What is the recommended treatment for sinus infections?

Treatment of Sinus Infections

Antibiotic therapy is indicated for acute bacterial sinusitis when symptoms persist beyond 7-10 days or are severe with high fever and purulent nasal discharge. 1, 2

Diagnosis and Classification

• Acute sinusitis is defined as symptoms lasting less than 3-4 weeks 3, 1
• Clinical diagnosis is based on symptoms including purulent rhinorrhea (often unilateral), pain upon pressure over the infected sinus, and facial pain that increases when bending forward 3, 4
• Three clinical presentations suggest bacterial sinusitis: persistent symptoms >10 days without improvement, severe symptoms with high fever and purulent discharge for 3-4 consecutive days, or worsening symptoms after initial improvement 4

First-Line Antibiotic Treatment

• Amoxicillin is the first-line antibiotic for most patients with acute bacterial sinusitis, with standard dosing of 500 mg twice daily for adults 1
• For more severe infections, higher doses (875 mg twice daily) of amoxicillin or amoxicillin-clavulanate are recommended 1, 4
• The duration of antibiotic treatment is generally 10-14 days for acute disease, though some cephalosporins have been shown to be effective in 5-day regimens 3, 1, 5

Alternative First-Line Options

• For patients allergic to or intolerant of amoxicillin, alternative options include:
  • Second and third-generation cephalosporins: cefuroxime-axetil, cefpodoxime-proxetil, cefotiam-hexetil 3, 1
  • Pristinamycin (for cases of allergy to beta-lactams) 3
  • Macrolides (clarithromycin, azithromycin) in cases of serious drug allergy 4

Treatment Based on Sinusitis Type

• For maxillary sinusitis (most common type), first-line antibiotics as listed above are recommended 3, 1
• For frontal, ethmoidal, or sphenoidal sinusitis, fluoroquinolones active against pneumococci (levofloxacin, moxifloxacin) should be considered due to higher risk of complications 3, 1
• Fluoroquinolones should be reserved for situations where major complications are likely or when first-line therapy fails 3, 1

Specific Antibiotic Dosing

• Azithromycin: 500 mg once daily for 3 days 6
• Clarithromycin extended-release: 1 gram once daily for 14 days 7
• Amoxicillin-clavulanate: typically 875 mg twice daily 1, 4

Adjunctive Therapies

• Intranasal corticosteroids are recommended as an adjunct to antibiotic therapy in both acute and chronic sinusitis 1, 2, 8
• Saline irrigation helps prevent crusting of secretions and facilitates mechanical removal of mucus 2, 9
• First-generation antihistamine/decongestant combinations may be helpful specifically for cough associated with sinusitis due to postnasal drip 3, 2
• Short-term oral corticosteroids may be considered for patients with marked mucosal edema or who fail to respond to initial treatment 1

Treatment Failure Protocol

• If no improvement after 3-5 days of initial therapy, switch to a different antibiotic 1
• For partial response, continue antibiotic treatment for another 10-14 days or consider second-line options 1
• Consider referral to a specialist for sinusitis refractory to standard treatment or recurrent episodes (more than 3-4 per year) 1, 2

Special Considerations

• Complete the full course of antibiotics even after symptoms improve to prevent relapse 1
• Antihistamines are indicated for acute sinusitis only when a patient has concomitant allergies that are symptomatic 9
• Evaluate for underlying inflammation, allergy, immunodeficiency, and anatomic abnormalities in patients with recurrent sinusitis 1

Common Pitfalls

• Acute bacterial sinusitis is often over-diagnosed and over-treated in primary care practice 8
• Most cases of acute sinusitis are viral in origin and resolve without antibiotics 8
• Sinus imaging studies are not recommended for routine diagnosis but may be helpful in selected cases 8
• Antibiotics should be reserved for symptoms lasting more than 7-10 days or severe symptoms with high fever and purulent nasal discharge 1, 8