From the Guidelines
For acute bacterial rhinosinusitis in the NYC metropolitan area, amoxicillin with or without clavulanate is the recommended first-line antibiotic therapy for 5 to 10 days, as stated in the clinical practice guideline update for adult sinusitis 1. This recommendation is based on randomized controlled trials with heterogeneity and noninferiority design, showing a preponderance of benefit over harm. The choice of amoxicillin with or without clavulanate as first-line therapy is due to its effectiveness in covering common causative organisms, including Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. Some key points to consider when treating acute bacterial rhinosinusitis include:
- The use of amoxicillin-clavulanate (Augmentin) at a dose of 875/125 mg twice daily for 5-7 days as a first-line treatment option
- Considering doxycycline (100 mg twice daily for 5-7 days) or a respiratory fluoroquinolone like levofloxacin (750 mg daily for 5 days) as alternative options for patients with penicillin allergy
- Switching to a respiratory fluoroquinolone or high-dose amoxicillin-clavulanate (2000/125 mg twice daily) in cases of treatment failure or suspected resistant organisms
- Only treating bacterial rhinosinusitis with antibiotics when symptoms persist beyond 10 days, worsen after initial improvement, or are severe from onset with high fever and purulent discharge
- Using adjunctive treatments such as intranasal corticosteroids, saline irrigation, and analgesics to manage symptoms while antibiotics address the underlying infection.
From the FDA Drug Label
In an open label, noncomparative study requiring baseline transantral sinus punctures the following outcomes were the clinical success rates at the Day 7 and Day 28 visits for the modified intent to treat patients administered 500 mg of azithromycin once daily for 3 days with the following pathogens: PathogenAzithromycin (500 mg per day for 3 Days) Day 7Day 28 S. pneumoniae23/26 (88%)21/25 (84%) H influenzae28/32 (87%)24/32 (75%) M. catarrhalis14/15 (93%)13/15 (87%)
Rates of clinical success by pathogen in the microbiologically evaluable population who had specimens obtained by antral tap at study entry showed comparable results for the five- and ten-day regimens at the test-of-cure visit 22 days post treatment.
Antibiotics that cover common organisms found in acute bacterial rhinosinusitis in the NYC metropolitan area include:
- Azithromycin: effective against S. pneumoniae, H. influenzae, and M. catarrhalis 2
- Levofloxacin: effective against S. pneumoniae, including multi-drug resistant S. pneumoniae, and other common pathogens 3
From the Research
Antibiotic Coverage for Acute Bacterial Rhinosinusitis in the NYC Metropolitan Area
The common organisms found in acute bacterial rhinosinusitis (ABRS) include:
- Streptococcus pneumoniae
- Haemophilus influenzae
- Moraxella catarrhalis
Recommended Antibiotics
The following antibiotics are recommended for the treatment of ABRS:
- Amoxicillin/clavulanate 4, 5, 6
- High-dose amoxicillin 5, 7
- Cefuroxime, cefpodoxime, or cefdinir 5
- Clarithromycin or azithromycin for patients with serious drug allergies 5
Efficacy of Antibiotics
The efficacy of amoxicillin/clavulanate has been demonstrated in several studies:
- Bacteriologic success was achieved in 87.8% of patients with ABRS 4
- Amoxicillin/clavulanate was effective against penicillin-resistant S. pneumoniae and beta-lactamase-positive pathogens 4, 6
- Clavulanic acid/amoxicillin (1:14) dry syrup was effective in treating children with ABRS, with a cure rate of 88.5% 8
Considerations for Antibiotic Resistance
The increasing prevalence of antimicrobial resistance among common respiratory pathogens, including S. pneumoniae and H. influenzae, should be considered when selecting antibiotics 5, 6. The use of pharmacokinetically enhanced formulations of amoxicillin/clavulanate may help to improve activity against resistant organisms 6.