What are the recommended antibiotics for acute sinusitis (sinus infection)?

From the Guidelines

Antibiotics should only be prescribed for bacterial sinus infections when symptoms are severe, last longer than 10 days, or worsen after initial improvement, with first-line treatment being amoxicillin-clavulanate (Augmentin) 875/125 mg twice daily for 5-7 days, as recommended by the American College of Physicians and the Centers for Disease Control and Prevention 1.

Key Considerations

• Most sinus infections are viral and will resolve without antibiotics within 7-10 days.
• Bacterial sinus infections typically present with facial pain/pressure, thick yellow-green nasal discharge, and symptoms persisting beyond 10 days or worsening after initial improvement.
• Antibiotics should be reserved for bacterial infections because overuse contributes to antibiotic resistance and may cause side effects like diarrhea or yeast infections.

Treatment Options

• Amoxicillin-clavulanate (Augmentin) 875/125 mg twice daily for 5-7 days is the preferred first-line treatment for bacterial sinus infections 1.
• Doxycycline 100 mg twice daily for 5-7 days may be used as an alternative for patients with penicillin allergies.
• Respiratory fluoroquinolones such as levofloxacin 750 mg daily for 5 days may be considered for patients with risk factors like recent antibiotic use or healthcare exposure.

Non-Antibiotic Management

• Nasal saline irrigation, intranasal corticosteroids like fluticasone, and over-the-counter pain relievers should be tried before starting antibiotics.
• These measures can help alleviate symptoms and reduce the need for antibiotics.

Diagnosis and Management

• The diagnosis of bacterial sinusitis is made when a patient presents with persistent illness, worsening course, or severe onset, as defined by the American Academy of Pediatrics 1.
• Clinicians should not obtain imaging studies to distinguish acute bacterial sinusitis from viral URI, as they do not contribute to the diagnosis.
• The appropriate duration of antibiotic therapy for sinusitis is not well defined, but a 10- to 14-day course of antibiotic may be adequate for most patients with acute disease 1.

From the FDA Drug Label

1. 4 Acute Bacterial Sinusitis: 5 Day and 10 to 14 Day Treatment Regimens Levofloxacin is approved for the treatment of acute bacterial sinusitis (ABS) using either 750 mg by mouth x 5 days or 500 mg by mouth once daily x 10 to 14 days To evaluate the safety and efficacy of a high dose short course of levofloxacin, 780 outpatient adults with clinically and radiologically determined acute bacterial sinusitis were evaluated in a double-blind, randomized, prospective, multicenter study comparing levofloxacin 750 mg by mouth once daily for five days to levofloxacin 500 mg by mouth once daily for 10 days Clinical success rates (defined as complete or partial resolution of the pre-treatment signs and symptoms of ABS to such an extent that no further antibiotic treatment was deemed necessary) in the microbiologically evaluable population were 91.4% (139/152) in the levofloxacin 750 mg group and 88.6% (132/149) in the levofloxacin 500 mg group at the test-of-cure (TOC) visit

Antibiotics for Sinus Infection:

• Levofloxacin is approved for the treatment of acute bacterial sinusitis (ABS) using either 750 mg by mouth x 5 days or 500 mg by mouth once daily x 10 to 14 days.
• Clinical success rates were 91.4% for the 750 mg group and 88.6% for the 500 mg group.
• Another option is Azithromycin, which has a recommended dose of 500 mg QD × 3 days for acute bacterial sinusitis 2.

From the Research

Antibiotics for Sinus Infection

• The use of antibiotics for sinus infections has been studied in several clinical trials, with various antibiotics showing efficacy in treating the condition 3, 4, 5, 6, 7.
• A study comparing azithromycin and amoxicillin/clavulanate found that a 3-day course of azithromycin was as effective and well-tolerated as a 10-day course of amoxicillin/clavulanic acid in adults with acute sinusitis 3.
• Another study comparing azithromycin extended release and amoxicillin/clavulanate found that more patients randomized to azithromycin extended release experienced symptom resolution at day 5 than those randomized to amoxicillin/clavulanate, without differences in second antibiotic use at 28 days 4.
• A review of short-course antibiotic therapy for acute sinusitis suggests that a 5-day course may be equivalent or superior to traditional 10-14 day therapies, offering advantages such as improved compliance and reduced risk of antibiotic resistance 5.
• Studies have also compared the efficacy of once-daily antibiotics, such as cefixime and clarithromycin extended-release, to twice-daily antibiotics, such as amoxicillin/clavulanate, with results showing that once-daily antibiotics can be effective and well-tolerated in treating sinus infections 6, 7.
• The choice of antibiotic and duration of treatment should be based on current guidelines and individual patient factors, such as the severity of symptoms and presence of underlying medical conditions 5, 7.
• Key symptoms of sinusitis, such as nasal congestion, sinus pressure, and purulent nasal discharge, can be effectively treated with antibiotics, with some studies showing rapid improvement in symptoms within 2-5 days of treatment 4, 7.