What is the treatment for a worsening sinus infection with postnasal drip (PND) and cough?

From the Guidelines

For a sinus infection with worsening post-nasal drip (PND) and cough, I recommend a conservative, multi-faceted treatment approach, reserving antibiotics for severe cases or those that worsen over time, as most cases are self-limiting and may not require antibiotic therapy 1.

Treatment Approach

• For symptom relief, use saline nasal irrigation with a Neti pot or squeeze bottle twice daily to help clear out mucus and debris.
• Consider pseudoephedrine 30-60 mg every 4-6 hours (maximum 240 mg daily) for congestion, and guaifenesin (Mucinex) 600-1200 mg twice daily to thin mucus.
• Add an intranasal steroid like fluticasine propionate (Flonase) 1-2 sprays per nostril daily to reduce inflammation.
• For cough and post-nasal drip, a first-generation antihistamine like diphenhydramine 25-50 mg at bedtime may help with nighttime symptoms.
• Stay well-hydrated with 2-3 liters of fluid daily to thin secretions, and elevate your head while sleeping using extra pillows.

Antibiotic Use

• Antibiotics should be reserved for patients with persistent symptoms for more than 10 days, onset of severe symptoms or signs of high fever (>39 °C) and purulent nasal discharge or facial pain lasting for at least 3 consecutive days, or onset of worsening symptoms following a typical viral illness that lasted 5 days that was initially improving (double sickening) 1.
• If antibiotics are necessary, amoxicillin-clavulanate (Augmentin) 875/125 mg twice daily for 7-10 days, or if penicillin-allergic, doxycycline 100 mg twice daily for the same duration, may be considered.

Monitoring and Follow-up

• If symptoms don't improve within 7-10 days of treatment, or if you develop fever over 101°F, severe headache, or visual changes, seek medical attention as these could indicate complications requiring more aggressive treatment or imaging studies 1.

From the FDA Drug Label

1. 4 Acute Bacterial Sinusitis: 5 Day and 10 to 14 Day Treatment Regimens 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 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 Sinus Infection and PND (Post-Nasal Drip) and Cough:

• Levofloxacin can be used to treat acute bacterial sinusitis.
• The recommended treatment regimens are 750 mg by mouth x 5 days or 500 mg by mouth once daily x 10 to 14 days.
• Clinical success rates for these regimens are 91.4% and 88.6%, respectively.
• It is essential to note that levofloxacin should only be used to treat bacterial infections and not viral infections such as the common cold, which may also cause PND and cough 2.

From the Research

Sinus Infection Treatment

• The treatment of sinus infections often involves the use of antibiotics, with amoxicillin-clavulanate being a commonly prescribed option 3, 4, 5, 6.
• Studies have shown that amoxicillin-clavulanate is effective in treating acute sinusitis, with success rates ranging from 84% to 96% 3, 4.
• However, the use of amoxicillin-clavulanate may be associated with a higher risk of gastrointestinal-related adverse events compared to amoxicillin alone 6.

Postnasal Drip and Cough

• Postnasal drip (PND) is a common complaint in primary care and ear-nose-throat offices, and is often associated with chronic cough 7.
• The pathophysiology of PND-related cough is not fully understood, but may be related to airway sensory hypersensitivity rather than actual irritation from inflamed nasal secretions 7.
• Treatment of PND and PND-related cough may involve the use of intranasal corticosteroids, which have been shown to be effective in controlling postnasal drip and decreasing inflammatory response 3.

Treatment Options

• Amoxicillin-clavulanate and levofloxacin are both effective treatment options for acute sinusitis, with similar success rates 4.
• Amoxicillin may be a viable alternative to amoxicillin-clavulanate, with similar efficacy and fewer gastrointestinal-related adverse events 6.
• The choice of treatment should be based on individual patient factors, including the presence of comorbidities and the risk of treatment failure 6.