Treatment of Sinusitis

Amoxicillin-clavulanate is the preferred first-line treatment for acute bacterial sinusitis due to increasing bacterial resistance patterns. 1

Diagnosis and Classification

Acute sinusitis is defined as symptoms and signs lasting less than 4 weeks 2
Three clinical presentations of acute sinusitis include: persistent symptoms (>10 but <30 days without improvement), severe symptoms (high fever and purulent nasal discharge for 3-4 consecutive days), or worsening symptoms (respiratory symptoms that worsen after initial improvement) 3

Amoxicillin-clavulanate is the preferred first-line treatment due to increasing bacterial resistance patterns 1
For less severe cases, high-dose amoxicillin (90 mg/kg/day in 2 divided doses, maximum 1g every 12 hours) may be considered 1
Treatment duration should be 7-10 days for acute bacterial sinusitis 1
Some experts recommend continuing antibiotics until the patient is symptom-free plus an additional 7 days 1

Second-generation cephalosporins (cefuroxime axetil) and third-generation cephalosporins (cefpodoxime proxetil, cefdinir) are recommended for patients with penicillin allergy 1, 2
Pristinamycin is an option for patients with beta-lactam allergy 1
Clindamycin may be used for suspected anaerobic pathogens 1, 4

First-line antibiotics are recommended for maxillary sinusitis, which is the most common type 2
For frontal, ethmoidal, or sphenoidal sinusitis, fluoroquinolones active against pneumococci (levofloxacin, moxifloxacin) may be considered 2
Levofloxacin (750 mg orally once daily for 5 days) is FDA-approved for acute bacterial sinusitis due to Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis 5

Intranasal corticosteroids are recommended as an adjunct to antibiotic therapy in both acute and chronic sinusitis 1, 2
Short-term systemic corticosteroids may be considered for acute hyperalgic sinusitis (sinusitis with severe pain) 1, 2
Topical and oral decongestants may help decrease nasal resistance and improve sinus ventilation, but should be used cautiously to avoid rebound congestion (rhinitis medicamentosa) 1, 6
Saline irrigation helps improve mucociliary clearance and reduce nasal congestion 4, 6

Patients with chronic or recurrent sinusitis should be evaluated for underlying inflammation, allergies, immunodeficiency, and anatomic abnormalities 1, 2
Intranasal corticosteroids are particularly useful in chronic hyperplastic eosinophilic rhinosinusitis 1
Antihistamines are not recommended for acute bacterial sinusitis but may be beneficial in chronic sinusitis if the underlying risk factor is allergic rhinitis 1, 7

If no improvement after 3-5 days of treatment, switch to a different antibiotic 2
For partial response, continue antibiotic treatment for another 10-14 days or consider second-line antibiotic options 2

Recurrent sinusitis (≥3 episodes per year) requires evaluation of underlying risk factors and consideration of consultation with an allergist-immunologist or otolaryngologist 1, 2
Complicated sinusitis requires hospitalization, bacteriological testing, and parenteral antibiotic therapy 1
For patients with chronic kidney disease, antibiotic selection and dosing should be adjusted based on kidney function 4

Treating viral rhinosinusitis with antibiotics 1
Using fluoroquinolones as first-line therapy, which should be reserved for specific situations 1, 8
Prolonged use of topical decongestants leading to rhinitis medicamentosa 1, 6
Failing to evaluate for underlying causes in chronic or recurrent sinusitis 1, 2