What is the next course of treatment for a patient with a lingering sinus infection and persistent symptoms despite previous treatment with amoxicillin/clavulanic (Augmentin) tablets?

Treatment Recommendation for Persistent Sinusitis After Amoxicillin/Clavulanate

Switch to high-dose amoxicillin-clavulanate (875 mg/125 mg twice daily) for 10-14 days and add intranasal corticosteroids. 1, 2

Rationale for Treatment Change

Your patient has failed initial therapy with amoxicillin/clavulanate, which constitutes treatment failure after 3 weeks of persistent symptoms including facial pain/pressure and ear involvement. 2 The American Academy of Allergy, Asthma, and Immunology defines this as a "poor response" requiring escalation of antibiotic therapy. 2

The key issue here is that standard-dose amoxicillin-clavulanate may have been insufficient for resistant organisms. 1, 2

Specific Treatment Algorithm

Primary Antibiotic Recommendation

• Prescribe amoxicillin-clavulanate 875 mg/125 mg twice daily for 10-14 days (or until symptom-free for 7 days, whichever is longer). 1, 2
• This higher dose provides enhanced coverage against β-lactamase-producing H. influenzae and M. catarrhalis, which are increasingly prevalent causes of treatment failure. 1
• The clavulanate component specifically targets resistant organisms that may have caused the initial treatment failure. 1

Essential Adjunctive Therapy

• Add intranasal corticosteroid spray (mometasone furoate or fluticasone propionate) twice daily to reduce mucosal inflammation and improve sinus drainage. 2, 3
• This combination of antibiotic plus intranasal steroid is superior to antibiotics alone for persistent symptoms. 2

Consider Short-Term Oral Corticosteroids

• If severe facial pain/pressure persists or there is marked nasal obstruction, add oral prednisone 20-40 mg daily for 5-7 days as adjunctive therapy. 1, 2
• This is particularly helpful when mucosal edema is blocking sinus drainage. 2

Alternative Options If Penicillin Allergy

If the patient had a true penicillin allergy (which they don't based on tolerating amoxicillin/clavulanate):

• Second-line: Levofloxacin 500-750 mg once daily for 10-14 days provides excellent coverage against resistant S. pneumoniae and other common pathogens. 1, 4, 5
• Levofloxacin achieves 90-92% clinical efficacy and is specifically indicated for acute bacterial sinusitis. 1, 4
• Alternative cephalosporins: Cefuroxime-axetil or cefpodoxime-proxetil for 10-14 days. 1

Critical Pitfall to Avoid

Do NOT prescribe azithromycin or other macrolides. 1, 6 Despite the patient's tolerance of the initial medication, azithromycin has 20-25% resistance rates among S. pneumoniae and H. influenzae and is explicitly not recommended for sinusitis treatment failure. 1 While one older study showed azithromycin efficacy 7, current guidelines uniformly reject macrolides due to widespread resistance. 1

When to Escalate Further

• If no improvement after 3-5 days on the new regimen, consider switching to levofloxacin 500-750 mg daily or moxifloxacin 400 mg daily. 1, 2
• If symptoms persist beyond 4 weeks total, obtain sinus CT imaging to evaluate for anatomic abnormalities, nasal polyps, or complications. 2
• Consider ENT referral if symptoms fail to resolve after appropriate second-line therapy or if imaging reveals structural abnormalities. 2

Additional Supportive Measures

• Nasal saline irrigation (high-volume, isotonic) twice daily improves mucociliary clearance. 2
• Adequate hydration, analgesics for pain, warm facial compresses, and sleeping with head elevated provide symptomatic relief. 1
• Assess for underlying allergic rhinitis as a contributing factor, particularly given the chronicity of symptoms. 2

Treatment Duration Specifics

• Continue antibiotics until symptom-free for 7 days, typically requiring 10-14 days total. 1, 2
• Shorter 5-day courses are only appropriate for uncomplicated acute sinusitis, not treatment failures. 1, 8
• Reassess at 3-5 days to ensure clinical improvement is occurring. 1