What is the first line therapy for acute sinusitis?

From the Guidelines

The first-line therapy for acute sinusitis is typically watchful waiting for 7-10 days in mild to moderate cases, as most cases are viral and resolve spontaneously. If symptoms persist beyond this period or are severe from the outset, amoxicillin 500 mg three times daily for 5-10 days is the recommended antibiotic treatment, as suggested by the American College of Physicians and the Centers for Disease Control and Prevention 1. For patients with penicillin allergy, doxycycline 100 mg twice daily or a respiratory fluoroquinolone like levofloxacin 500 mg daily can be used. In areas with high prevalence of penicillin-resistant bacteria or for patients who have failed initial therapy, amoxicillin-clavulanate 875/125 mg twice daily is preferred.

Key Considerations

• Symptomatic relief can be achieved with:
  • Analgesics like acetaminophen or ibuprofen
  • Intranasal saline irrigation
  • Intranasal corticosteroids such as fluticasone 1-2 sprays per nostril daily
• Decongestants may provide short-term relief but should be limited to 3-5 days to avoid rebound congestion
• Antibiotics are recommended when bacterial infection is suspected, characterized by symptoms lasting more than 10 days, severe symptoms with purulent discharge and facial pain, or worsening symptoms after initial improvement, as indicated by the American Academy of Otolaryngology–Head and Neck Surgery 1.

Rationale

The rationale behind watchful waiting and selective use of antibiotics is based on the fact that most cases of acute sinusitis are viral and resolve without antibiotic treatment, and the potential for adverse effects from antibiotics outweighs the benefits in many cases, as highlighted in a meta-analysis of adults with acute rhinosinusitis 1. However, when bacterial infection is suspected, prompt antibiotic treatment can help alleviate symptoms and prevent complications.

Additional Therapies

Additional therapies that may provide symptomatic relief include systemic or topical decongestants, saline nasal irrigation, mucolytics, intranasal corticosteroids, and antihistamines tailored to the patient's symptoms, as suggested by the American Academy of Allergy, Asthma & Immunology and the American Academy of Family Physicians 1.

From the FDA Drug Label

1.4 Acute Bacterial Sinusitis: 5 Day and 10 to 14 Day Treatment Regimens 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

• First line therapy for acute bacterial sinusitis includes levofloxacin 750 mg by mouth once daily for 5 days or levofloxacin 500 mg by mouth once daily for 10 to 14 days 2 2.
• The clinical success rates for levofloxacin 750 mg and 500 mg are 91.4% and 88.6%, respectively.
• The treatment is effective against Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis.

From the Research

First Line Therapy for Acute Sinusitis

• The first line therapy for acute sinusitis typically involves the use of antibiotics, with amoxicillin-clavulanate being a commonly recommended option 3, 4, 5.
• Studies have shown that amoxicillin is as effective as amoxicillin-clavulanate as a first-line treatment for acute bacterial rhinosinusitis for those without a beta-lactam allergy 5.
• For patients with a beta-lactam allergy, appropriate antibiotics include doxycycline or a respiratory fluoroquinolone; clindamycin plus a third-generation cephalosporin is an option for children with non-type I hypersensitivity to beta-lactam antibiotics 5.
• Other antibiotics such as moxifloxacin and levofloxacin have also been shown to be effective in the treatment of acute sinusitis, with some studies suggesting they may be associated with more rapid symptomatic relief and better tolerability compared to amoxicillin-clavulanate 6, 7.

Treatment Considerations

• The choice of antibiotic should be based on the severity of symptoms, patient allergies, and local resistance patterns 3, 5.
• Supportive care, including the use of saline irrigation, nasal steroids or antihistamines, and decongestants, may help reduce the severity of symptoms 5.
• Most episodes of rhinosinusitis are self-limited, lasting 7 to 10 days, and complications are rare but may include orbital cellulitis, meningitis, and abscess 5.

Antibiotic Efficacy

• Studies have compared the efficacy of different antibiotics in the treatment of acute sinusitis, with results showing that moxifloxacin and levofloxacin are as effective as amoxicillin-clavulanate 6, 7.
• High-dose amoxicillin-clavulanate has been shown to be more effective than standard-dose amoxicillin-clavulanate in some studies, but may also be associated with a higher risk of side effects such as severe diarrhea 3.