What are the recommended antibiotics for sinusitis?

From the Guidelines

Antibiotics should be reserved for patients with acute rhinosinusitis who have persistent symptoms for more than 10 days, severe symptoms, or worsening symptoms after initial improvement, as most cases are self-limited and resolve without antibiotics. The American College of Physicians and the Centers for Disease Control and Prevention recommend watchful waiting as initial management for all patients with uncomplicated acute bacterial rhinosinusitis (ABRS), regardless of severity 1.

Key Considerations

• Most patients diagnosed with acute rhinosinusitis have more adverse effects than benefits from antibiotics 1.
• A meta-analysis of adults with acute rhinosinusitis showed that the number needed to treat was 18 for 1 patient to be cured rapidly, but the number needed to harm from adverse effects from antibiotics was 8 1.
• First-line treatment for ABRS is usually amoxicillin-clavulanate (Augmentin) 875/125 mg twice daily for 5-7 days, or amoxicillin 500 mg three times daily for adults 1.
• For penicillin-allergic patients, alternatives include doxycycline 100 mg twice daily, levofloxacin 500 mg daily, or trimethoprim-sulfamethoxazole 1.

Management Strategies

• Patients with severe, worsening, or persistent acute bacterial sinusitis should be prescribed antibiotics 1.
• Outpatient observation for three days is also an option in patients with persistent illness 1.
• Adjunctive therapy, such as intranasal saline irrigation or intranasal corticosteroids, has been shown to alleviate symptoms and potentially decrease antibiotic use 1.
• Patients who are seriously ill, who deteriorate clinically despite antibiotic therapy, or who have recurrent episodes should be referred to a specialist 1.

From the FDA Drug Label

1.4 Acute Bacterial Sinusitis: 5 Day and 10 to 14 Day Treatment Regimens Levofloxacin tablets are indicated for the treatment of acute bacterial sinusitis due to Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis [see Clinical Studies (14.4)]. 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

• Levofloxacin is indicated for the treatment of acute bacterial sinusitis due to Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis.
• The recommended treatment regimens are 750 mg by mouth once daily for 5 days or 500 mg by mouth once daily for 10 to 14 days.
• Clinical success rates were 91.4% in the levofloxacin 750 mg group and 88.6% in the levofloxacin 500 mg group at the test-of-cure visit 2 2.

From the Research

Sinusitis Antibiotics

• The use of antibiotics for sinusitis is a common practice, with amoxicillin and amoxicillin-clavulanate being the most frequently prescribed antibiotics 3, 4, 5.
• The diagnosis of acute bacterial sinusitis is typically based on clinical presentation, with cardinal features including unilateral facial pain or pressure, fever, and purulent nasal discharge 3, 4.
• Studies have shown that amoxicillin is as effective as amoxicillin-clavulanate as a first-line treatment for acute bacterial rhinosinusitis in patients without a beta-lactam allergy 4.
• For patients with a beta-lactam allergy, alternative antibiotics such as doxycycline or a respiratory fluoroquinolone may be prescribed 4.
• The optimal duration of antibiotic therapy for sinusitis is unknown, but treatment is typically continued until the patient becomes free of symptoms and then for an additional 7 days 3.
• High-dose amoxicillin-clavulanate has been shown to be more effective than standard-dose amoxicillin-clavulanate in some studies, but may also increase the risk of side effects such as severe diarrhea 6.
• The distribution of amoxicillin-clavulanate in sinusal mucosa and serum has been studied, with results showing that tissue levels of both amoxicillin and clavulanic acid are higher than the Minimum Inhibitory Concentration (MIC) for common causative pathogens of sinus bacterial infections 7.
• Trends in antibiotic prescriptions for acute sinusitis have been analyzed, with results showing that amoxicillin-clavulanate is the most commonly prescribed antibiotic, and that otolaryngologists are more likely to engage in watchful waiting and prescribe recommended first-line therapy than non-otolaryngologists 5.