What are the treatment options for acute sinusitis?

From the Guidelines

Treatment for acute sinusitis should begin with supportive care, including nasal saline irrigation, over-the-counter pain relievers, and intranasal corticosteroids, with antibiotics reserved for patients with persistent symptoms or severe disease, as recommended by the American College of Physicians and the Centers for Disease Control and Prevention 1. The goal of treatment is to alleviate symptoms, reduce morbidity, and improve quality of life.

• Supportive care measures include:
  • Nasal saline irrigation to help clear nasal passages and reduce congestion
  • Over-the-counter pain relievers like acetaminophen (325-650mg every 4-6 hours) or ibuprofen (400-600mg every 6-8 hours) to manage pain and fever
  • Intranasal corticosteroids such as fluticasone (1-2 sprays per nostril daily) to reduce inflammation
• Decongestants like pseudoephedrine (30-60mg every 4-6 hours) can help with nasal congestion but should be limited to 3-5 days to avoid rebound congestion. Most cases of acute sinusitis are viral and resolve within 7-10 days without antibiotics. However, if symptoms persist beyond 10 days, worsen after initial improvement, or include high fever and severe facial pain, antibiotics may be necessary. First-line antibiotic therapy is typically amoxicillin-clavulanate (875/125mg twice daily for 5-7 days) or, for penicillin-allergic patients, doxycycline (100mg twice daily for 5-7 days) 1. During treatment, it is essential to stay hydrated, rest adequately, and avoid irritants like cigarette smoke. If symptoms worsen despite treatment or if you develop visual changes, severe headache, or mental status changes, seek immediate medical attention as these could indicate complications. The American Academy of Otolaryngology-Head and Neck Surgery emphasizes watchful waiting (without antibiotic therapy) as initial management for all patients with uncomplicated ABRS, regardless of severity 1. Adjunctive therapy, such as intranasal saline irrigation or intranasal corticosteroids, has been shown to alleviate symptoms and potentially decrease antibiotic use 1. Patients who are seriously ill, who deteriorate clinically despite antibiotic therapy, or who have recurrent episodes should be referred to a specialist (for example, an otolaryngologist, infectious disease specialist, or allergist) 1.

From the FDA Drug Label

Levofloxacin tablets are indicated for the treatment of acute bacterial sinusitis due to Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis [see Clinical Studies (14.4)]. To evaluate the safety and efficacy of a high dose short course of levofloxacin, 780 outpatient adults with clinically and radiologically determined acute bacterial sinusitis were evaluated in a double-blind, randomized, prospective, multicenter study comparing levofloxacin 750 mg by mouth once daily for five days to levofloxacin 500 mg by mouth once daily for 10 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).

Treatment for Acute Sinusitis:

• 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.
• The clinical success rates for levofloxacin 750 mg and 500 mg were 91.4% and 88.6%, respectively.
• The treatment is effective against Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 2.

From the Research

Treatment Options for Acute Sinusitis

• Antibiotics are considered for patients with severe symptoms, significant worsening after 3 to 5 days of symptoms, or 7 or more days of symptoms 3
• First-line treatment for acute bacterial rhinosinusitis includes amoxicillin or amoxicillin-clavulanate 4, 3
• Alternatives for patients with beta-lactam allergy include doxycycline or a respiratory fluoroquinolone 3
• Supportive care, such as saline irrigation, nasal steroids or antihistamines, and decongestants, may help reduce symptom severity 3

Duration of Antibiotic Therapy

• The optimal duration of therapy is unknown, but some recommend treatment until the patient becomes free of symptoms and then for an additional 7 days 4
• Short-course antibiotic therapy (less than or equal to 5 days) may have equivalent or superior efficacy compared to traditional longer therapies 5
• A 10- to 14-day treatment course is commonly recommended, but there is no strong scientific or medical rationale for this duration 5

Diagnosis and Confirmation

• Acute sinusitis is a clinical diagnosis, and distinguishing between bacterial and viral sinusitis can be challenging 3
• Images to confirm the presence of acute sinusitis are necessary in older children and adults to enhance the certainty of diagnosis 4
• Diagnostic testing, such as antral puncture, is impractical due to its invasiveness, and point-of-care testing for elevated C-reactive protein may be helpful but is not widely available 3

Complications and Special Considerations

• Complications of acute and chronic sinusitis include intraorbital and intracranial sepsis, which require urgent evaluation and treatment 6
• Special consideration needs to be paid to sinusitis in children, in relation to dental disease, and in the immunosuppressed 6