What is the recommended treatment for a patient with acute sinusitis, considering their medical history and severity of symptoms?

Treatment of Acute Sinusitis

Distinguish Viral from Bacterial Sinusitis First

Most acute sinusitis (98-99.5%) is viral and resolves spontaneously within 7-10 days without antibiotics—prescribe antibiotics only when bacterial infection is confirmed by one of three specific patterns. 1, 2, 3

Diagnose acute bacterial rhinosinusitis (ABRS) when:

• Persistent symptoms: Nasal congestion, purulent discharge, or facial pain lasting ≥10 days without improvement 1, 2, 3
• Severe symptoms: Fever ≥39°C (101°F) with purulent nasal discharge for ≥3 consecutive days 1, 2, 3
• "Double sickening": Worsening symptoms after initial improvement from a viral upper respiratory infection 1, 2, 3

First-Line Antibiotic Treatment

For confirmed ABRS, prescribe amoxicillin-clavulanate 875 mg/125 mg twice daily for 5-10 days as first-line therapy, providing superior coverage against β-lactamase-producing organisms. 1, 2, 3

Standard dosing options:

• Amoxicillin-clavulanate 875/125 mg twice daily for uncomplicated cases 1, 2
• High-dose amoxicillin-clavulanate (2 g/125 mg twice daily) for patients with recent antibiotic use within past month, age >65 years, moderate-to-severe symptoms, comorbidities, or immunocompromised state 2
• Plain amoxicillin 500 mg twice daily (mild disease) or 875 mg twice daily (moderate disease) is acceptable for uncomplicated cases without recent antibiotic exposure 2, 3

Treatment duration:

• 5-10 days for adults, with most guidelines recommending treatment until symptom-free for 7 days (typically 10-14 days total) 1, 2
• Recent evidence supports 5-7 day courses for uncomplicated cases with comparable efficacy and fewer adverse effects 2

Penicillin-Allergic Patients

For non-severe penicillin allergy (rash, delayed reactions), prescribe second- or third-generation cephalosporins as the risk of cross-reactivity is negligible. 1, 2

Recommended alternatives:

• Cefuroxime-axetil (second-generation cephalosporin) 1, 2
• Cefpodoxime-proxetil or cefdinir (third-generation cephalosporins with superior H. influenzae coverage) 1, 2

For severe penicillin allergy (anaphylaxis/Type I hypersensitivity), prescribe levofloxacin 500 mg once daily for 10-14 days as first-line therapy. 1, 2

Critical antibiotics to avoid:

• Never use azithromycin or macrolides due to resistance rates exceeding 20-25% for both S. pneumoniae and H. influenzae 1, 2, 4
• Never use trimethoprim-sulfamethoxazole due to 50% resistance rates for S. pneumoniae 1, 2
• Never use first-generation cephalosporins (cephalexin) due to inadequate H. influenzae coverage 1, 2

Second-Line Treatment for Treatment Failure

If no improvement occurs after 3-5 days of initial therapy, switch to a respiratory fluoroquinolone (levofloxacin 500-750 mg once daily or moxifloxacin 400 mg once daily) for 10-14 days. 1, 2

Fluoroquinolones achieve 90-92% clinical efficacy and provide excellent coverage against multi-drug resistant S. pneumoniae and β-lactamase-producing H. influenzae 1, 2

Alternative second-line options include:

• High-dose amoxicillin-clavulanate (2 g/125 mg twice daily) if not used initially 2
• Third-generation cephalosporins (cefpodoxime, cefdinir) for superior H. influenzae activity 2

Essential Adjunctive Therapies

Prescribe intranasal corticosteroids (mometasone, fluticasone, or budesonide) twice daily for all patients with ABRS to reduce mucosal inflammation and improve drainage. 1, 2

Intranasal corticosteroids provide clinically important benefits with a number needed to treat of 14, though the magnitude of effect is modest (73% improvement with steroids vs 66% with placebo at 14-21 days) 1

Additional symptomatic measures:

• Analgesics (acetaminophen or NSAIDs) for pain management based on severity 1, 2
• Saline nasal irrigation to promote mucus clearance and reduce tissue edema 1, 2
• Oral decongestants (pseudoephedrine) for symptomatic relief, barring contraindications like hypertension 1
• Topical decongestants for no more than 3-5 days to avoid rebound congestion 1

Consider short-term oral corticosteroids (prednisone 24-80 mg daily for 5 days) for marked mucosal edema or failure to respond to initial antibiotic therapy. 1, 2, 5

Oral corticosteroids as adjunctive therapy to antibiotics show modest benefit: RR 1.3 (95% CI 1.0-1.7) for symptom improvement at Days 4-10, though evidence quality is limited 5

Critical Monitoring and Reassessment

Reassess patients at 3-5 days: if no improvement, switch antibiotics or re-evaluate the diagnosis. 1, 2

At 7 days: confirm the diagnosis of ABRS if symptoms persist or worsen, and consider complications or alternative diagnoses. 1, 2, 3

Approximately 90% of patients with acute rhinosinusitis improve naturally within 7-15 days without antibiotics, so watchful waiting without immediate antibiotics is appropriate for uncomplicated cases when reliable follow-up can be assured 2, 3

When to Refer to a Specialist

Refer to otolaryngology or infectious disease if:

• No improvement after 7 days of appropriate second-line therapy 1, 2
• Worsening symptoms at any time 1, 2
• Suspected complications (orbital cellulitis, meningitis, abscess formation) 1, 2
• Recurrent sinusitis (≥3 episodes per year) 1, 2
• Need for sinus aspiration/culture in immunocompromised patients 1

Pediatric Considerations

For children, prescribe amoxicillin 45 mg/kg/day in 2 divided doses for standard therapy, or high-dose amoxicillin 80-90 mg/kg/day in 2 divided doses for high-risk children. 2

High-risk factors include age <2 years, daycare attendance, antibiotic use within past 4-6 weeks, or high local resistance rates 2

For treatment failure at 72 hours, switch to high-dose amoxicillin-clavulanate (80-90 mg/kg/day of amoxicillin component with 6.4 mg/kg/day clavulanate in 2 divided doses). 2

Treatment duration for children is 10-14 days 2

Common Pitfalls to Avoid

• Do not prescribe antibiotics for symptoms lasting <10 days unless severe symptoms are present (fever ≥39°C with purulent discharge for ≥3 consecutive days) 1, 2
• Do not use mucus color alone to determine antibiotic need, as color reflects neutrophils, not bacteria 2
• Do not use fluoroquinolones as first-line therapy in patients without documented β-lactam allergies to prevent resistance development 1, 2
• Do not obtain radiographic imaging for uncomplicated acute rhinosinusitis unless complications or alternative diagnoses are suspected 1, 3
• Do not continue ineffective therapy beyond 3-5 days without reassessment 1, 2