Treatment for Bacterial Sinusitis
Amoxicillin-clavulanate is recommended as the first-line empiric antimicrobial therapy for acute bacterial sinusitis in both adults and children, rather than amoxicillin alone. 1, 2
First-Line Treatment Options
- For adults with uncomplicated acute bacterial sinusitis, amoxicillin-clavulanate is recommended over amoxicillin alone, though this recommendation is based on low-quality evidence 1
- For children with acute bacterial sinusitis, amoxicillin-clavulanate is strongly recommended over amoxicillin alone based on moderate-quality evidence 1
- High-dose amoxicillin-clavulanate (2g orally twice daily for adults or 90 mg/kg/day orally twice daily for children) should be used in areas with high prevalence of resistant S. pneumoniae (>10%) 1
- The recommended duration of therapy for uncomplicated acute bacterial sinusitis in adults is 5-7 days 1, 2
- For children with acute bacterial sinusitis, a longer treatment duration of 10-14 days is recommended 1
Alternative Treatment Options for Penicillin-Allergic Patients
- For patients with non-type 1 penicillin allergy, cephalosporins such as cefdinir, cefuroxime, or cefpodoxime are appropriate alternatives 2
- For adults with true type 1 penicillin allergy, respiratory fluoroquinolones (levofloxacin, moxifloxacin) are recommended 2, 3
- Levofloxacin is FDA-approved for acute bacterial sinusitis at doses of either 750 mg once daily for 5 days or 500 mg once daily for 10-14 days 3
- Doxycycline may be considered in adults with β-lactam allergies, but has lower efficacy (77-81% predicted clinical success) compared to first-line agents (87-91%) 2
Adjunctive Therapies
- Intranasal saline irrigation with either physiologic or hypertonic saline is recommended as an adjunctive treatment in adults with acute bacterial sinusitis 1
- Intranasal corticosteroids are recommended as an adjunct to antibiotics, particularly in patients with a history of allergic rhinitis 1
- Neither topical nor oral decongestants and/or antihistamines are recommended as adjunctive treatment 1
Treatment Failure and Follow-up
- If symptoms worsen after 48-72 hours of initial empiric antimicrobial therapy or fail to improve despite 3-5 days of treatment, an alternative management strategy is recommended 1
- Cultures should be obtained by direct sinus aspiration rather than by nasopharyngeal swab when treatment fails 1
- Patients who continue to deteriorate clinically despite extended courses of antimicrobial therapy should be referred to a specialist such as an otolaryngologist, infectious disease specialist, or allergist 1
Special Considerations
- For patients with orbital or intracranial complications, high-dose amoxicillin-clavulanate is recommended for comprehensive coverage 1
- In severe cases with complications, hospitalization and consultation with specialists may be necessary 1
- Routine antimicrobial coverage for Staphylococcus aureus or MRSA during initial empiric therapy is not recommended 1
Recent Research and Controversies
- A 2021 randomized clinical trial found no significant benefit of high-dose amoxicillin-clavulanate over standard-dose for adults with acute bacterial sinusitis 4
- However, an earlier 2018 study suggested that immediate-release high-dose amoxicillin-clavulanate may lead to more rapid improvement compared to standard-dose, though with increased risk of severe diarrhea 5
- Shorter courses of newer antibiotics (like 5-day gatifloxacin) have shown comparable efficacy to standard 10-day regimens in some studies 6