Treatment of Chronic Sinusitis with 14 Days of Augmentin
For chronic rhinosinusitis with acute exacerbation presenting with green copious nasal discharge, 14 days of Augmentin (amoxicillin-clavulanate) is NOT recommended as it provides no additional benefit over placebo when combined with intranasal corticosteroids and saline irrigation. 1
Key Evidence Against Antibiotic Use in This Context
The most recent high-quality evidence directly addressing this clinical scenario demonstrates that:
A 2017 double-blind, placebo-controlled trial specifically evaluated amoxicillin-clavulanate 875/125 mg twice daily for 14 days in acute exacerbations of chronic rhinosinusitis (AECRS) and found no difference in clinical outcomes compared to placebo. 1
Both antibiotic and placebo groups showed identical improvement in symptoms, quality of life scores, and nasal endoscopic findings when combined with mometasone furoate and saline irrigation. 1
Despite 84% of cultured bacteria being sensitive to amoxicillin-clavulanate, antibiotic therapy did not alter the clinical course. 1
Distinction Between Acute and Chronic Sinusitis
This is a critical clinical distinction that changes management:
The evidence supporting amoxicillin-clavulanate applies primarily to acute bacterial sinusitis, NOT chronic rhinosinusitis or its acute exacerbations. 2, 3
European guidelines (EPOS 2020) show that in chronic rhinosinusitis without nasal polyps (CRSsNP), amoxicillin-clavulanate demonstrated no statistically significant differences compared to other antibiotics or alternative treatments in multiple randomized trials. 4
Studies comparing amoxicillin-clavulanate to cefuroxime in chronic rhinosinusitis patients showed no significant difference in clinical cure rates or bacteriologic eradication. 4
Recommended Treatment Approach
The appropriate management for chronic sinusitis with acute exacerbation should prioritize:
Intranasal corticosteroids (such as mometasone furoate) as the primary therapeutic intervention. 2, 1
Regular nasal saline irrigation to mechanically clear secretions and reduce inflammation. 1
Reserve antibiotics for true acute bacterial sinusitis or when there is evidence of bacterial superinfection with systemic symptoms (high fever, severe facial pain, periorbital complications). 2, 3
When Antibiotics ARE Indicated
If antibiotics are deemed necessary for acute bacterial sinusitis (not chronic disease):
Amoxicillin-clavulanate 875/125 mg twice daily for 10-14 days is appropriate for acute bacterial sinusitis with risk factors for resistant organisms. 2, 5
High-dose formulations (2000/125 mg twice daily) may be considered in areas with high prevalence of drug-resistant Streptococcus pneumoniae. 5
Duration should be 10-14 days or until symptom-free for 7 days. 4, 2
Common Pitfalls to Avoid
Do not confuse chronic rhinosinusitis with acute bacterial sinusitis—the bacterial pathogens, pathophysiology, and treatment responses differ significantly. 6
Green or purulent nasal discharge alone does not indicate bacterial infection requiring antibiotics in chronic sinusitis; this can occur with viral infections or inflammatory exacerbations. 1
In chronic sinusitis, anaerobic bacteria and Staphylococcus aureus predominate rather than the typical acute pathogens (S. pneumoniae, H. influenzae, M. catarrhalis). 6
Antibiotic overuse in chronic rhinosinusitis contributes to resistance without improving patient outcomes. 1
Alternative Considerations
If the patient fails to respond to intranasal corticosteroids and saline irrigation:
Consider short-term oral corticosteroids for marked mucosal edema or severe symptoms. 2
Evaluate for underlying allergic rhinitis, anatomic abnormalities, or immunodeficiency if symptoms are recurrent (≥3 episodes per year). 2
Refer to an otolaryngologist for nasal endoscopy, possible CT imaging, and consideration of surgical intervention if medical management fails. 2, 7