What is the treatment for sinus issues without allergies for more than four days?

Treatment for Acute Sinusitis (>4 Days, No Allergies)

For sinus symptoms lasting more than 4 days without allergies, start high-dose amoxicillin 875 mg twice daily for 10-14 days, combined with intranasal corticosteroids to reduce inflammation and promote drainage. 1

Confirm Bacterial vs. Viral Sinusitis First

Before prescribing antibiotics, verify the patient meets criteria for bacterial sinusitis rather than viral rhinosinusitis, which resolves spontaneously in 98-99.5% of cases within 7-10 days. 1

Bacterial sinusitis is diagnosed when ONE of these three patterns is present:

• Persistent symptoms ≥10 days without improvement (purulent rhinorrhea, nasal congestion, facial pain, postnasal drainage) 2, 1
• Severe symptoms for ≥3 consecutive days (fever ≥39°C with purulent nasal discharge and facial pain) 1, 3
• "Double sickening" - worsening symptoms after initial improvement from a viral upper respiratory infection 1, 3

Since your patient has symptoms for "more than four days," this falls into the acute sinusitis category (symptoms <4 weeks), but you should wait until day 10 unless severe symptoms are present. 2, 1

First-Line Antibiotic Treatment

Amoxicillin remains the gold standard first-line antibiotic:

• 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 drug-resistant Streptococcus pneumoniae 1
• Duration: 10-14 days, or until symptom-free for 7 days 1, 4

The rationale: Amoxicillin provides excellent coverage against the three most common bacterial pathogens (Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis). 1, 3

Essential Adjunctive Therapies (Not Optional)

Intranasal corticosteroids are strongly recommended as adjunctive therapy, not optional symptomatic treatment:

• Mometasone, fluticasone, or budesonide twice daily 1
• These reduce mucosal inflammation, promote drainage, and improve symptom resolution with strong evidence from multiple randomized controlled trials 1, 4

Additional supportive measures:

• Adequate hydration 1
• Analgesics (acetaminophen or NSAIDs) for pain 1
• Warm facial packs 1
• Sleep with head elevated 1
• Nasal saline irrigation to improve mucociliary clearance 4
• Decongestants (pseudoephedrine or topical) for symptomatic relief, though evidence is limited 1

When to Escalate Treatment

Reassess at 3-5 days: If no improvement, switch antibiotics or re-evaluate diagnosis. 1, 4

If treatment fails after 3-5 days, escalate to high-dose amoxicillin-clavulanate:

• Adult dose: 875 mg/125 mg twice daily for 10-14 days 1
• Pediatric dose: 90 mg/kg/day of amoxicillin component with 6.4 mg/kg/day clavulanate in 2 divided doses (max 2 g every 12 hours) 1, 4

The clavulanate component provides coverage against β-lactamase-producing H. influenzae and M. catarrhalis, which cause 30-40% of treatment failures. 1

If amoxicillin-clavulanate fails, switch to respiratory fluoroquinolone:

• Levofloxacin 500 mg once daily for 10-14 days 1
• Moxifloxacin 400 mg once daily for 10 days 1
• These provide 90-92% predicted clinical efficacy against drug-resistant S. pneumoniae and β-lactamase-producing organisms 1

Critical Pitfalls to Avoid

Do NOT prescribe antibiotics for viral rhinosinusitis lasting <10 days - this contributes to antimicrobial resistance without clinical benefit. 1 Wait the full 10 days unless severe symptoms (high fever, severe facial pain) are present. 1

Do NOT use azithromycin or other macrolides - resistance rates exceed 20-25% for both S. pneumoniae and H. influenzae, making them unsuitable for acute bacterial sinusitis. 1

Do NOT give systemic corticosteroids without antibiotics when bacterial sinusitis is suspected - this may suppress immune response and allow bacterial proliferation. 1 Short-term oral corticosteroids (typically 5 days) may be added as adjunctive therapy only when patients fail initial treatment or have marked mucosal edema. 1, 4

Do NOT use clindamycin as monotherapy - it lacks activity against H. influenzae and M. catarrhalis, causing failure in 30-40% of cases. 1

Complete the full antibiotic course even after symptoms improve to prevent relapse. 1

When to Refer to Specialist

Refer to otolaryngology if:

• Symptoms refractory to two courses of appropriate antibiotics 1
• Recurrent sinusitis (≥3 episodes per year) 2, 1
• Suspected complications (orbital cellulitis, meningitis, severe frontal/sphenoid sinusitis) 1
• Persistent symptoms after 21-28 days of appropriate treatment 4

Refer to allergist-immunologist if:

• Need to evaluate for underlying allergic factors (though patient reports no allergies) 4
• Evaluation for immunodeficiency in recurrent cases 4
• Unusual opportunistic infections 1

Special Anatomic Considerations

For maxillary sinusitis (most common type): Standard first-line antibiotics as outlined above. 1

For frontal, ethmoidal, or sphenoidal sinusitis: Consider fluoroquinolones (levofloxacin or moxifloxacin) earlier due to potential for serious complications from proximity to optic nerve, cavernous sinus, and carotid artery. 2, 1