What are the treatment options for a sinus infection?

Treatment of Sinus Infection

For acute bacterial sinusitis, start with amoxicillin 500 mg twice daily (or 875 mg twice daily for severe infections) for 10-14 days, combined with intranasal corticosteroids and supportive care measures. 1

First-Line Antibiotic Therapy

Amoxicillin is the antibiotic of choice for most patients with acute bacterial sinusitis due to its effectiveness, low cost, and good tolerability. 1, 2

• Standard dosing for adults: 500 mg twice daily for mild-to-moderate infections 1
• High-dose for severe infections: 875 mg twice daily 1
• Treatment duration: 10-14 days until symptom-free for 7 days 1, 2

For penicillin-allergic patients, use cephalosporins as first-line alternatives: 1

• Cefuroxime, cefpodoxime, cefprozil, or cefdinir 1
• Trimethoprim-sulfamethoxazole is an alternative in adults (though resistance is more common in children) 2

Second-Line Therapy for Treatment Failure

If no improvement after 3-5 days, switch to amoxicillin-clavulanate for better coverage against resistant bacteria. 1

• Adult dosing: 875 mg/125 mg every 12 hours or 500 mg/125 mg every 8 hours 3
• High-dose option: 90 mg/kg amoxicillin component with 6.4 mg/kg clavulanate (not exceeding 2g every 12 hours) 2

Location-Specific Antibiotic Selection

For maxillary sinusitis (most common type), use standard first-line antibiotics as above. 1

For frontal, ethmoidal, or sphenoidal sinusitis, consider fluoroquinolones active against pneumococci: 1, 2

• Levofloxacin or moxifloxacin 1
• These locations require broader coverage and antibiotic therapy is definitely indicated 2

Essential Adjunctive Therapies

Intranasal corticosteroids should be added as adjunct to antibiotic therapy in both acute and chronic sinusitis. 1, 2

Short-term oral corticosteroids (such as dexamethasone 4 mg) may be used when: 1

• Patient fails to respond to initial treatment 1
• Marked mucosal edema is present 1
• Severe pain (acute hyperalgic sinusitis) 1

Supportive care measures include: 2

• Adequate hydration 1
• Analgesics for pain relief 2
• Warm facial packs 2
• Sleeping with head elevated 1
• Nasal decongestants (oxymetazoline) for up to 5 days only to avoid rebound congestion 2

Pediatric Dosing Considerations

For children above 8 years: 1

• Standard therapy: 45 mg/kg/day amoxicillin in 2 divided doses 1
• High-dose for resistant S. pneumoniae areas: 80-90 mg/kg/day in 2 divided doses 1

For children with risk factors (age <2 years, daycare attendance, recent antibiotic use), use amoxicillin-clavulanate 80-90 mg/kg/day of amoxicillin component. 1

Critical Pitfalls to Avoid

Do not use extended nasal decongestants beyond 5 days, as this leads to rebound congestion (rhinitis medicamentosa). 2

Do not substitute two 250 mg/125 mg amoxicillin-clavulanate tablets for one 500 mg/125 mg tablet, as they contain the same amount of clavulanic acid (125 mg) and are not equivalent. 3

Do not use systemic corticosteroids as monotherapy for bacterial sinusitis—antibiotics are necessary to treat the underlying infection. 1

Do not overdiagnose bacterial sinusitis in viral upper respiratory infections or overuse antibiotics for viral sinusitis. 2

Complete the full antibiotic course even after symptoms improve to prevent relapse. 1

When to Refer to Specialist

Refer to a specialist when: 1

• Sinusitis is refractory to usual antibiotic treatment 1
• Recurrent sinusitis (≥3 episodes per year) 1
• Need to clarify allergic or immunologic basis 1
• Associated with unusual opportunistic infections 1