What antibiotic (abx) can be used to treat a sinus infection in a patient with no relief from Zithromax (azithromycin) and allergies to amoxicillin, cefdinir, and doxycycline?

From the Guidelines

For a sinus infection not responding to Z-Pak (azithromycin) in someone allergic to amoxicillin, cefdinir, and doxycycline, I would recommend levofloxacin 750mg once daily for 5-7 days as the most effective treatment option. This recommendation is based on the study by 1, which ranks respiratory fluoroquinolones, such as levofloxacin, as having a predicted clinical efficacy of 90-92% for adults with acute bacterial rhinosinusitis.

Key Considerations

• Levofloxacin provides excellent coverage against common sinus pathogens, including resistant strains, as noted in the study by 1.
• It is essential to take levofloxacin with plenty of water and at least 2 hours before or after antacids or supplements containing magnesium, aluminum, iron, or zinc.
• Patients should be aware of the risk of tendon inflammation associated with levofloxacin and avoid strenuous exercise during treatment.
• If symptoms do not improve within 3 days or worsen at any point, it is crucial to seek medical attention immediately.

Alternative Options

• Although clarithromycin is another macrolide that may be effective when azithromycin fails, its predicted clinical efficacy is lower, ranging from 77-81% according to 1.
• Other alternatives, such as telithromycin or ciprofloxacin, may also be considered, but levofloxacin is the preferred choice due to its high efficacy and targeted spectrum of activity against common respiratory pathogens, including macrolide and penicillin-resistant strains, as mentioned in 1.

From the FDA Drug Label

Levofloxacin is approved for the treatment of acute bacterial sinusitis (ABS) using either 750 mg by mouth x 5 days or 500 mg by mouth once daily x 10 to 14 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 (95% CI [-4. 2,10] for levofloxacin 750 mg minus levofloxacin 500 mg)

Alternative Antibiotic Option:

• Levofloxacin may be considered for the treatment of acute bacterial sinusitis in patients allergic to amoxicillin, cefdinir, and doxycycline.
• The recommended dosage is either 750 mg by mouth x 5 days or 500 mg by mouth once daily x 10 to 14 days.
• Clinical success rates with levofloxacin are 91.4% and 88.6% for the 5-day and 10-14 day regimens, respectively 2

From the Research

Alternatives to Amoxicillin, Cefdinir, and Doxycycline for Sinus Infection

Given the allergies to amoxicillin, cefdinir, and doxycycline, alternative antibiotics can be considered for the treatment of sinus infections.

• Azithromycin is a potential option, as it has been shown to be effective in treating acute sinusitis, especially in patients with penicillin allergy or those unresponsive to amoxicillin 3, 4.
• Clarithromycin is another alternative, which has immunomodulatory properties and can be used in the management of chronic rhinosinusitis 5.
• Cefuroxime and cefpodoxime are other options that can be considered, as they are effective against the predominant bacterial species implicated in acute sinusitis, including Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 3.
• Erythromycins/macrolides, although not the first-line treatment due to high rates of S. Pneumoniae resistance, were commonly prescribed in some studies 6.

Considerations for Antibiotic Choice

When choosing an antibiotic, it is essential to consider the patient's allergy history, the severity of symptoms, and the potential for antibiotic resistance.

• The optimal duration of therapy is unknown, but treatment until the patient becomes free of symptoms and then for an additional 7 days is recommended 3.
• Images to confirm the presence of acute sinusitis are necessary in older children and adults to enhance the certainty of diagnosis 3.
• Future use of cultures to direct antibiotic therapy, such as nasopharyngeal swabs in adults with ARS or endoscopically guided cultures, may aid in targeting antibiotic therapy more effectively 7.