Augmentin for Chronic Sinusitis
Augmentin (amoxicillin-clavulanate) has limited evidence supporting its use in chronic sinusitis, with studies showing only modest clinical improvement rates of approximately 56% compared to acute sinusitis where improvement reaches 86%. 1, 2
Evidence Quality and Treatment Efficacy
The evidence for Augmentin in chronic sinusitis is substantially weaker than for acute bacterial sinusitis:
Chronic sinusitis responds poorly to antibiotics overall, with clinical improvement occurring in only 56% of patients treated with either amoxicillin or cefaclor, compared to 86% improvement in acute sinusitis. 2
A comparative trial found amoxicillin/clavulanate achieved 51.2% clinical cure rates in chronic sinusitis, which was not significantly different from ciprofloxacin (58.6%). 3
The susceptibility of cultured organisms to antibiotics was unrelated to treatment outcome in chronic sinusitis, suggesting factors beyond bacterial resistance drive the disease. 2
When Augmentin May Be Considered
Augmentin can be used for acute exacerbations of chronic sinusitis rather than the chronic condition itself:
The most common bacteria in acute exacerbations are S. pneumoniae, H. influenzae, and M. catarrhalis, which Augmentin covers effectively. 1
Standard adult dosing is 500-875 mg twice daily for 10-14 days. 1
High-dose formulations (amoxicillin 2000 mg/clavulanate 125 mg twice daily) were developed for drug-resistant S. pneumoniae but showed no additional benefit over standard dosing in recent trials. 4, 5
Superior Treatment Approach for Chronic Sinusitis
Intranasal corticosteroids are more appropriate than antibiotics as primary therapy for chronic sinusitis:
Topical corticosteroids address the underlying inflammatory pathology that drives chronic disease. 1
When antibiotics are added to intranasal steroids, the combination shows only modest additional benefit. 1
Topical antibacterial therapy (such as mupirocin nasal irrigation) may be superior to oral Augmentin in post-surgical chronic sinusitis patients, showing significant improvement in endoscopic scores and near-significant SNOT-22 improvement. 1
Critical Pitfalls to Avoid
Do not prescribe Augmentin for uncomplicated chronic sinusitis without evidence of acute bacterial exacerbation, as antibiotic treatment of non-bacterial inflammation is inappropriate and strongly discouraged. 1
Recognize that chronic sinusitis is fundamentally an inflammatory disease, not primarily an infectious one, requiring anti-inflammatory rather than antimicrobial therapy. 1
Avoid prolonged or repeated antibiotic courses without addressing underlying factors such as allergic rhinitis, anatomic obstruction, or nasal polyps. 1
Severe diarrhea occurs in 7-16% of patients on high-dose formulations with no proven additional efficacy, making standard dosing preferable when antibiotics are indicated. 4, 5
When to Use Antibiotics in Chronic Sinusitis
Limit Augmentin to these specific scenarios:
Acute bacterial exacerbations with purulent discharge, facial pain, and fever lasting less than 4 weeks superimposed on chronic symptoms. 1
Post-surgical patients with positive bacterial cultures showing S. aureus, H. influenzae, or S. pneumoniae. 1
Duration should be 10-14 days, with clinical response expected within 3-5 days; if no improvement occurs, switch to respiratory fluoroquinolones (levofloxacin 500 mg daily or moxifloxacin 400 mg daily). 1, 6
Recommended Management Algorithm
For patients presenting with chronic sinusitis symptoms:
Initiate intranasal corticosteroids (mometasone 200 mcg twice daily or equivalent) as primary therapy. 1
Add saline irrigation to improve sinus drainage and mucociliary clearance. 7
Reserve Augmentin 875/125 mg twice daily for 10-14 days only when acute bacterial exacerbation is clinically evident (purulent discharge, facial pain, fever). 1, 7
Refer to ENT specialist if symptoms persist despite appropriate medical therapy, for evaluation of anatomic abnormalities, nasal polyps, or consideration of endoscopic sinus surgery. 6