What are the antibiotic (abx) choices for acute sinusitis?

From the Guidelines

For acute bacterial sinusitis, first-line antibiotic treatment is typically amoxicillin with or without clavulanate as first-line therapy for 5 to 10 days for most adults. This recommendation is based on the most recent and highest quality study available, which suggests that amoxicillin with or without clavulanate is the preferred agent for treating acute bacterial rhinosinusitis (ABRS) 1.

Key Considerations

• The American Academy of Otolaryngology–Head and Neck Surgery emphasizes watchful waiting (without antibiotic therapy) as initial management for all patients with uncomplicated ABRS, regardless of severity 1.
• Alternatives for penicillin-allergic patients include doxycycline or a respiratory fluoroquinolone like levofloxacin 1.
• For patients with risk factors for resistant organisms (recent antibiotic use, healthcare exposure), consider high-dose amoxicillin-clavulanate 1.
• Most cases of sinusitis are viral and should not receive antibiotics initially, and antibiotics should only be considered if symptoms persist beyond 10 days, are severe, or worsen after initial improvement 1.

Supportive Care

• Supportive care with saline irrigation, intranasal corticosteroids, and analgesics should be recommended regardless of whether antibiotics are prescribed 1.
• Patients should follow up if symptoms worsen or don't improve within 3-5 days of starting antibiotics.

Pathogens and Treatment

• Antibiotics target common pathogens like Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 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 (95% CI [-4. 2,10] for levofloxacin 750 mg minus levofloxacin 500 mg).

Levofloxacin is an option for the treatment of acute bacterial sinusitis, with two possible regimens:

• 750 mg by mouth once daily for 5 days
• 500 mg by mouth once daily for 10 to 14 days Clinical success rates were 91.4% and 88.6%, respectively 2.

1. 6 Acute Bacterial Sinusitis Moxifloxacin hydrochloride tablets are indicated in adult patients (18 years of age and older) for the treatment of acute bacterial sinusitis (ABS) caused by susceptible isolates of Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis

Moxifloxacin is also an option for the treatment of acute bacterial sinusitis, for patients 18 years of age and older, caused by susceptible isolates of Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis 3.

From the Research

Antibiotic Choices for Acute Sinus Infection

• The choice of antibiotics for acute sinus infection depends on various factors, including the severity of symptoms, patient's medical history, and susceptibility of the causative pathogens 4.
• Amoxicillin-clavulanate is a commonly recommended antibiotic for acute sinusitis, with a dosage of 875 mg twice daily for 7-10 days 5, 4.
• Alternative antibiotics include moxifloxacin, levofloxacin, cefuroxime, cefpodoxime, and cefdinir 6, 7.
• For patients with penicillin allergy, clarithromycin or azithromycin may be prescribed 4.

Efficacy of Antibiotics

• A study comparing high-dose amoxicillin-clavulanate with standard-dose amoxicillin-clavulanate found no significant difference in efficacy between the two groups 5.
• Moxifloxacin has been shown to be as effective as amoxicillin-clavulanate in treating acute sinusitis, with more rapid symptomatic relief 6.
• Levofloxacin has also been found to be as effective as amoxicillin-clavulanate, with better tolerability 7.

Distribution of Antibiotics in Sinus Tissue

• A study on the distribution of amoxicillin-clavulanate in sinus tissue found that the antibiotic reaches effective concentrations in the tissue, even in patients with chronic rhinosinusitis 8.
• The study suggested that a dosage of 1 g twice daily of amoxicillin-clavulanate may be clinically effective for acute episodes of chronic rhinosinusitis 8.