What is the appropriate antibiotic (abx) choice for a patient with sinus pain, cough, and postnasal drip (PND) for one week?

From the Guidelines

For a patient with sinus pain, cough, and post-nasal drip (PND) for one week, I recommend watchful waiting without antibiotic therapy as initial management, as most cases of rhinosinusitis are viral in origin and self-limiting. According to the American Academy of Otolaryngology–Head and Neck Surgery 1, watchful waiting is emphasized as initial management for all patients with uncomplicated acute bacterial rhinosinusitis (ABRS), regardless of severity.

Key Considerations

• The patient's symptoms have persisted for one week, which is within the timeframe where viral causes are more likely than bacterial superinfection.
• The American College of Physicians and the Centers for Disease Control and Prevention recommend reserving antibiotic treatment for patients with persistent symptoms for more than 10 days, onset of severe symptoms, or worsening symptoms after initial improvement 1.
• Adjunctive therapy, such as intranasal saline irrigation or intranasal corticosteroids, can alleviate symptoms and potentially decrease antibiotic use 1.

Management Strategies

• Symptomatic relief can be achieved with saline nasal irrigation, intranasal corticosteroids like fluticasone 1-2 sprays per nostril daily, and over-the-counter analgesics such as acetaminophen or ibuprofen for pain.
• Oral decongestants like pseudoephedrine may help with congestion but should be avoided in patients with hypertension.
• Patients should be advised to follow up if symptoms worsen or fail to improve after 7-10 days of watchful waiting.

Antibiotic Use

• Antibiotics should be considered when symptoms have persisted beyond 7-10 days, are severe, or show worsening after initial improvement.
• Amoxicillin-clavulanate is the preferred agent, and doxycycline or a respiratory fluoroquinolone may be used as an alternative in patients with ABRS 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 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

• Levofloxacin is a suitable choice for the treatment of acute bacterial sinusitis.
• The recommended treatment regimens are 750 mg by mouth once daily for 5 days or 500 mg by mouth once daily for 10 to 14 days.
• Clinical success rates for levofloxacin in the treatment of acute bacterial sinusitis are 91.4% for the 5-day regimen and 88.6% for the 10-day regimen 2.

From the Research

ABX Choice for Sinus Pain, Cough, and PND

• The patient presents with sinus pain, cough, and postnasal drip (PND) for 1 week, which may indicate acute bacterial rhinosinusitis (ABRS) 3, 4, 5.
• According to the studies, the cardinal features of ABRS include unilateral facial pain or pressure, fever greater than 102°F (39°C), and purulent nasal discharge with obstruction of the nasal passages 5.
• Antibiotics should be considered for patients with 3 or more days of severe symptoms, significant worsening after 3 to 5 days of symptoms, or 7 or more days of symptoms 5.

First-Line Treatment Options

• Amoxicillin is a recommended first-line treatment for ABRS for those without a beta-lactam allergy 3, 5.
• Amoxicillin-clavulanate is also a suitable option, especially for patients with moderate disease or recent antibiotic use 3, 4.
• For patients with a beta-lactam allergy, doxycycline or a respiratory fluoroquinolone may be used as alternative treatments 3, 5.

Treatment Duration and Supportive Care

• The optimal duration of antibiotic therapy is unknown, but treatment may be continued until the patient becomes free of symptoms and then for an additional 7 days 4.
• Supportive care, including saline irrigation, nasal steroids or antihistamines, and decongestants, may help reduce the severity of symptoms 3, 5.
• Nasal corticosteroids and nasal irrigation with hypertonic and normal saline may also be beneficial in treating chronic sinusitis 3, 6.