From the Guidelines
For pregnant patients with sinusitis who are allergic to penicillin, the recommended treatment is to use oral antibiotics that do not harm the fetus, such as cephalosporin, when endoscopic evidence of purulence is present, while avoiding antibiotics that put the fetus at risk, such as tetracyclines, aminoglycosides, trimethoprim-sulfamethaxazole, and fluoroquinolones, as well as long-term macrolide or doxycycline use. When considering treatment options, it is essential to prioritize fetal and maternal safety, as emphasized by the expert panel recommendations 1. Some key points to consider in the management of sinusitis in pregnant patients allergic to penicillin include:
- The use of nasal saline irrigation and intranasal corticosteroids like fluticasone (1-2 sprays per nostril daily) for symptomatic relief, as supported by the european position paper on rhinosinusitis and nasal polyps 2020 1.
- The importance of reserving antibiotics for cases with symptoms lasting more than 10 days, severe symptoms, or worsening symptoms after initial improvement, to minimize unnecessary exposure to antibiotics.
- The need to avoid certain antibiotics that may pose a risk to the fetus, such as tetracyclines, aminoglycosides, trimethoprim-sulfamethaxazole, and fluoroquinolones, as well as long-term macrolide or doxycycline use, as recommended by the expert panel 1.
- The consideration of alternative treatments, such as azithromycin or clindamycin, for patients with a true penicillin allergy, while taking into account the potential risks and benefits of each option.
- The importance of consulting with the patient's obstetrician before initiating any treatment, especially if oral corticosteroids are being considered, due to the potential risks associated with their use during pregnancy 1.
From the FDA Drug Label
Pregnancy Category B Reproduction studies have been performed in rats and mice at doses up to moderately maternally toxic dose concentrations (i.e., 200 mg/kg/day). These doses, based on a mg/m2 basis, are estimated to be 4 and 2 times, respectively, the human daily dose of 500 mg. In the animal studies, no evidence of harm to the fetus due to azithromycin was found. There are, however, no adequate and well-controlled studies in pregnant women Because animal reproduction studies are not always predictive of human response, azithromycin should be used during pregnancy only if clearly needed. Acute Bacterial Sinusitis In a randomized, double blind, double-dummy controlled clinical trial of acute bacterial sinusitis, azithromycin (500 mg once daily for 3 days) was compared with amoxicillin/clavulanate (500/125 mg tid for 10 days).
Treatment of sinusitis in pregnant patients who are allergic to penicillin: Azithromycin can be used as an alternative treatment for acute bacterial sinusitis in pregnant patients who are allergic to penicillin.
- The recommended dose is 500 mg once daily for 3 days.
- Pregnancy Category B: Azithromycin should be used during pregnancy only if clearly needed, as there are no adequate and well-controlled studies in pregnant women.
- Key considerations:
- No evidence of harm to the fetus due to azithromycin was found in animal studies.
- Azithromycin should be used with caution in pregnant patients, as animal reproduction studies are not always predictive of human response.
- The benefits and risks of using azithromycin during pregnancy should be carefully weighed, and the drug should only be used if clearly needed 2.
From the Research
Treatment Options for Sinusitis in Pregnant Patients Allergic to Penicillin
- For pregnant patients allergic to penicillin, alternative antibiotics such as macrolides (e.g., clarithromycin, azithromycin) or doxycycline can be considered for the treatment of sinusitis 3, 4.
- A study comparing azithromycin and phenoxymethylpenicillin in the treatment of acute maxillary sinusitis found that azithromycin had a similar efficacy to penicillin, but with the advantage of a shorter treatment duration 5.
- Clarithromycin extended-release has been shown to be comparable to amoxicillin/clavulanate in the treatment of acute bacterial sinusitis, with a high clinical cure rate and tolerability 6.
- A comparative trial of ciprofloxacin and clarithromycin in the treatment of acute bacterial sinusitis found that both antibiotics were effective, but with a higher relapse rate in the clarithromycin group 7.
Macrolide Antibiotics
- Macrolide antibiotics, such as clarithromycin and azithromycin, have been shown to have adequate penetration into sinus fluid to eradicate erythromycin-sensitive strains of Streptococcus pneumoniae 3.
- Clarithromycin and azithromycin also have immunomodulatory properties, which can be beneficial in the treatment of chronic rhinosinusitis 4.