What is the treatment for sinusitis?

Treatment for Sinusitis

Distinguishing Viral from Bacterial Sinusitis

Most cases of acute rhinosinusitis are viral and resolve without antibiotics within 7 days. 1 Antibiotics should only be initiated when acute bacterial sinusitis is confirmed by one of three clinical patterns: 1

• Persistent symptoms ≥10 days without clinical improvement (most common presentation) 1, 2
• Severe symptoms (fever >39°C, purulent nasal discharge, facial pain) for ≥3 consecutive days 1, 2
• "Double sickening" - worsening symptoms after initial improvement from a viral upper respiratory infection 1, 2

First-Line Antibiotic Treatment

Amoxicillin remains the first-line antibiotic for uncomplicated acute bacterial sinusitis in both adults and children. 1, 3

Adult Dosing

• Standard dose: 500 mg twice daily for mild disease 1
• High dose: 875 mg twice daily for moderate disease or areas with high prevalence of resistant S. pneumoniae 1
• Duration: 10-14 days (treat until symptom-free for 7 days) 1, 3

Pediatric Dosing

• Standard dose: 45 mg/kg/day in 2 divided doses 1
• High dose: 80-90 mg/kg/day in 2 divided doses for children with risk factors (age <2 years, daycare attendance, recent antibiotic use) or areas with high prevalence of resistant S. pneumoniae 1

Alternative First-Line Options for Penicillin Allergy

For patients with documented penicillin allergy, second- or third-generation cephalosporins are preferred alternatives, as the risk of cross-reactivity is negligible. 1

• Cefuroxime-axetil (second-generation cephalosporin) 1
• Cefpodoxime-proxetil (third-generation, superior activity against H. influenzae) 1
• Cefdinir (third-generation, excellent coverage) 1

Critical caveat: Azithromycin and other macrolides should NOT be used as first-line therapy due to 20-25% resistance rates among S. pneumoniae and H. influenzae. 1, 4

Second-Line Treatment for Treatment Failure

If no improvement occurs after 3-5 days of initial antibiotic therapy, switch to a different antibiotic. 1, 3

Second-Line Options

• Amoxicillin-clavulanate (high-dose: 875 mg/125 mg twice daily for adults; 80-90 mg/kg/day of amoxicillin component for children) provides better coverage against β-lactamase-producing H. influenzae and M. catarrhalis 1
• Respiratory fluoroquinolones (levofloxacin 500-750 mg once daily or moxifloxacin) should be reserved for treatment failures, complicated sinusitis (frontal, ethmoidal, or sphenoidal involvement), or multi-drug resistant S. pneumoniae 1

Important: Fluoroquinolones should NOT be used as routine first-line therapy to prevent resistance development. 1

Adjunctive Therapies

Intranasal corticosteroids are recommended as adjunctive therapy in both acute and chronic sinusitis to reduce inflammation and improve drainage. 5, 1

Additional Supportive Measures

• Analgesics (acetaminophen, NSAIDs) for pain relief 1
• Saline nasal irrigation for symptomatic relief 1
• Adequate hydration, warm facial packs, sleeping with head elevated 1
• Decongestants (systemic or topical) may be used, though evidence for efficacy is limited 5

Short-term oral corticosteroids (e.g., 4 mg dexamethasone for 5 days) may be considered for patients with severe pain (acute hyperalgic sinusitis), marked mucosal edema, or failure to respond to initial treatment, but should NOT be used as monotherapy. 1

Chronic Sinusitis Management

Chronic sinusitis is defined as symptoms lasting longer than 8 weeks. 3

• Intranasal corticosteroids are first-line therapy 3
• Daily high-volume saline irrigation 3
• Longer duration antibiotic therapy (minimum 3 weeks) may be required for chronic infectious sinusitis 5, 3
• Evaluate for underlying factors: allergic rhinitis, anatomical abnormalities, immunodeficiency 1, 3

When to Refer to a Specialist

Refer patients to an otolaryngologist or allergist/immunologist for: 1, 3

• Sinusitis refractory to usual antibiotic treatment
• Recurrent sinusitis (≥3 episodes per year)
• Suspected complications (orbital or intracranial involvement)
• Need to clarify allergic or immunologic basis
• Consideration for endoscopic sinus surgery when anatomic obstruction is present 5

Critical Pitfalls to Avoid

• Do not prescribe antibiotics for viral rhinosinusitis - most cases resolve spontaneously within 7 days 1
• Ensure adequate treatment duration - incomplete courses lead to relapse 1
• Avoid azithromycin as first-line therapy due to high resistance rates 1, 4
• Reserve fluoroquinolones for treatment failures or complicated disease to prevent resistance 1
• Complete the full antibiotic course even after symptoms improve 1
• Reassess at 3-5 days if no improvement to avoid treatment failure 1