What are the next steps for treating persistent sinus drainage that has not responded to prescribed medication for 2 weeks?

Management of Persistent Sinus Drainage After 2 Weeks of Failed Treatment

Switch to high-dose amoxicillin-clavulanate (875-1000 mg twice daily) for 10-14 days and add intranasal corticosteroids with daily saline irrigation. 1

Reassess the Initial Treatment

The initial medication prescribed was likely inadequate in either spectrum of coverage, duration, or dosing:

• If azithromycin was used initially, this explains the treatment failure—azithromycin has weak activity against penicillin-resistant Haemophilus influenzae and Streptococcus pneumoniae, the most common bacterial pathogens in sinusitis 1
• A 5-day course is insufficient; bacterial sinusitis requires 10-14 days of antibiotic therapy for complete eradication 1
• Most acute sinusitis cases not treated with antibiotics resolve spontaneously within 7-10 days, so persistence at 2 weeks suggests either bacterial infection or progression to chronic inflammation 2, 3

Recommended Antibiotic Regimen

First-line therapy for treatment failure:

• High-dose amoxicillin-clavulanate: 875 mg twice daily (or 90 mg/kg amoxicillin component, not to exceed 2 g every 12 hours) for 10-14 days 1, 4
• This provides superior coverage against resistant S. pneumoniae and β-lactamase-producing H. influenzae 1
• Continue treatment until symptoms resolve to near-normal, typically requiring the full 10-14 day course 1

Alternative options if penicillin-allergic:

• Second-generation cephalosporins (if no anaphylactic penicillin allergy): cefuroxime, cefpodoxime, or cefdinir for 10-14 days 1, 4
• Respiratory fluoroquinolones (adults only): levofloxacin or moxifloxacin 1

Essential Adjunctive Therapies

Intranasal corticosteroids are mandatory:

• Start fluticasone propionate nasal spray (2 sprays per nostril daily) or equivalent 4, 5, 6
• Reduces mucosal inflammation, promotes sinus drainage, and improves antibiotic penetration 4, 6
• Should be continued for at least 3 months even after symptom resolution 4, 7

Daily saline irrigation:

• Use isotonic saline (preferred over hypertonic based on evidence) via nasal douche or squeeze bottle 8
• Mechanically clears secretions and improves mucociliary function 4, 7
• Perform 2-3 times daily during acute phase 8

Supportive Measures

• Adequate hydration and rest 1
• Analgesics (acetaminophen or NSAIDs) for facial pain/pressure 4
• Warm facial packs and steamy showers 1
• Sleep with head of bed elevated 1
• Avoid topical decongestants beyond 3 days to prevent rebound congestion 3

Red Flags Requiring Immediate Escalation

Obtain CT imaging if:

• Symptoms fail to improve after 10-14 days of appropriate antibiotic therapy 1, 4
• Severe symptoms develop (high fever >101°F, severe facial pain, periorbital swelling) 3
• Concern for complications (orbital involvement, intracranial extension) 3

Do not order plain radiographs—they have significant false-positive and false-negative rates 1

Evaluate for Underlying Factors

Consider these predisposing conditions:

• Allergic rhinitis: Present in up to 50% of patients with recurrent sinusitis 6, 7
• Poor oro-dental condition: Patients with dental disease derive the most benefit from antibiotics 2
• Anatomic abnormalities: Septal deviation, concha bullosa, or osteomeatal complex obstruction 9, 7
• Recent antibiotic use: Patients who used antibiotics in the previous 2 months have better response to retreatment 2

When to Refer to ENT

Refer if:

• Symptoms persist after completing 10-14 days of high-dose amoxicillin-clavulanate plus intranasal steroids 4, 7
• Recurrent sinusitis (≥3 episodes per year) 4
• CT shows extensive disease or anatomic abnormalities requiring surgical consideration 9, 7
• Suspicion of chronic rhinosinusitis (symptoms >12 weeks) 7, 10

Critical Pitfalls to Avoid

• Do not use azithromycin or other macrolides as first-line therapy for acute bacterial sinusitis due to inadequate coverage 1
• Do not prescribe antibiotics for <10 days—shorter courses lead to relapse 1, 4
• Do not omit intranasal corticosteroids—antibiotics alone are insufficient for persistent symptoms 4, 6, 7
• Do not assume viral etiology at 2 weeks—symptoms persisting beyond 10 days suggest bacterial infection 2, 3
• Do not use topical antibiotics (tobramycin, mupirocin)—evidence shows no benefit in acute sinusitis 8