What are the treatment recommendations for acute sinusitis?

Treatment Recommendations for Acute Sinusitis

Amoxicillin is the first-line antibiotic for acute bacterial sinusitis in both children and adults, given for 10-14 days, but antibiotics should only be initiated when symptoms persist for ≥10 days without improvement OR when severe symptoms (high fever with purulent discharge and facial pain) are present from onset. 1

Distinguishing Viral from Bacterial Sinusitis

The critical first step is determining whether antibiotics are warranted:

• Viral rhinosinusitis (VRS) accounts for most cases and does NOT require antibiotics 1
• Acute bacterial rhinosinusitis (ABRS) requires antibiotics only when: 1
  • Symptoms persist ≥10-14 days without improvement (persistent presentation)
  • Severe symptoms at onset: high fever (≥39°C/102°F) with purulent nasal discharge and facial pain for ≥3-4 consecutive days
  • Worsening symptoms after initial improvement ("double-worsening" pattern)

Common pitfall: Prescribing antibiotics for symptoms <7 days duration—these patients are unlikely to have bacterial infection and will improve without antibiotics 1

First-Line Antibiotic Therapy

Standard-Dose Amoxicillin

• Amoxicillin is the drug of choice: effective, inexpensive, and well-tolerated 1
• Dosing: Adults receive standard dosing; children receive weight-based dosing 1
• Duration: 10-14 days, or continue until symptom-free then 7 additional days 1

Alternative for Penicillin Allergy

• Trimethoprim-sulfamethoxazole for adults (though resistance is increasing in children) 1
• Cephalosporins (cefuroxime, cefpodoxime, cefdinir) for true penicillin allergy 1
• Macrolides (azithromycin, clarithromycin) or quinolones (levofloxacin) for serious drug allergy 1, 2

Escalation for Treatment Failure

Reassess at 3-5 days: If no improvement or worsening occurs, switch antibiotics 1

High-Dose Amoxicillin-Clavulanate

• Indicated for: 1
  • Non-response to amoxicillin after 3-5 days
  • Regions with high antibiotic resistance
  • Recent antibiotic use (<30 days)
  • Daycare attendance
• Dosing: 90 mg/kg amoxicillin + 6.4 mg/kg clavulanate (not exceeding 2g every 12 hours) 1

Second-Line Alternatives

• Cefuroxime axetil, cefpodoxime, cefprozil, cefdinir 1
• Respiratory fluoroquinolones (levofloxacin 500-750mg daily) for adults 1, 3
• Azithromycin 500mg day 1, then 250mg days 2-5 (FDA-approved 3-day regimen also available) 4

Symptomatic Relief (Essential for All Patients)

Recommended Adjunctive Therapies

• Analgesics/antipyretics: Acetaminophen or ibuprofen for pain and fever 1
• Nasal saline irrigation: Low risk, provides cleansing and modest symptom relief 1
• Topical intranasal corticosteroids: Modest benefit (NNT=14), minimal adverse effects; consider mometasone or fluticasone 1
• Oral decongestants: May provide relief if no contraindications (hypertension, anxiety) 1
• Topical decongestants: Limit to 3-5 days maximum to avoid rebound congestion 1

Therapies with Questionable Efficacy

• Antihistamines: No proven benefit in non-atopic patients 1
• Guaifenesin/dextromethorphan: Lack evidence but may be used based on patient preference 1

Corticosteroid Adjunctive Therapy

Intranasal Corticosteroids

• May be helpful as adjunct to antibiotics in acute and chronic sinusitis 1
• Increases symptom resolution from 66% to 73% at 15-21 days 1

Oral Corticosteroids

• Consider when: 1, 5
  • Patient fails initial antibiotic treatment
  • Nasal polyposis present
  • Marked mucosal edema demonstrated
• Short-term use (prednisone 24-80mg daily) shows benefit as adjunct to antibiotics 5
• Evidence: RR 1.4 for symptom improvement at days 3-7, though risk of bias exists 5

When to Escalate Care

Indications for Specialist Referral

• Failure to improve after 21-28 days of appropriate antibiotic therapy 1
• Recurrent sinusitis: ≥3 episodes per year 1, 6
• Complicated sinusitis: Orbital swelling, diplopia, forehead swelling, severe headache, high fever 1
• Underlying conditions: Immunodeficiency, cystic fibrosis, aspirin sensitivity, nasal polyps 1

Consider CT Imaging

• Not recommended for uncomplicated acute sinusitis 1
• Indicated for: Treatment failures, suspected complications, recurrent disease, or surgical planning 1

Pediatric-Specific Considerations

• Diagnosis: Children may present with irritability, vomiting with mucus, and prolonged cough 1
• First-line: Amoxicillin remains drug of choice 1
• Reassessment: Critical at 72 hours—51% of placebo patients improve by day 3 1
• High-dose amoxicillin-clavulanate for non-responders or high-resistance areas 1

Patient Education and Follow-Up

Comfort Measures

• Adequate rest and hydration 1
• Warm facial packs, steamy showers 1
• Sleep with head elevated 1

Warning Signs Requiring Immediate Contact

• Worsening symptoms: Especially severe headache or high fever 1
• No improvement within 3-5 days of antibiotic treatment 1
• Orbital symptoms: Swelling, pain, vision changes 1

Prevention

• Treat underlying allergic rhinitis appropriately 1
• Avoid cigarette smoke and environmental irritants 1
• Manage viral upper respiratory infections promptly 1