What alternative antibiotic can be given to a patient with acute bacterial sinusitis and suspected pneumonia, who has a penicillin allergy and is already on doxycycline (doxy)?

From the Guidelines

For a patient with acute bacterial sinusitis and concern for pneumonia who has a penicillin allergy and has already been on doxycycline for over a week without improvement, I recommend switching to a respiratory fluoroquinolone such as levofloxacin 750 mg orally once daily for 5-7 days. This recommendation is based on the most recent and highest quality study available, which suggests that respiratory fluoroquinolones are effective against a broad range of pathogens, including Streptococcus pneumoniae, Haemophilus influenzae, and atypical organisms 1.

The patient's treatment failure with doxycycline suggests either resistant organisms or inadequate coverage of the causative pathogens. Given the patient's penicillin allergy, alternative antibiotics such as cefdinir, clarithromycin, or azithromycin may be considered. However, cefdinir should be used with caution in patients with a severe penicillin allergy due to the risk of cross-reactivity.

• Key considerations for alternative antibiotics include:
  • Cefdinir 300 mg twice daily for 7 days, which may be suitable for patients with non-severe penicillin allergy 1
  • Clarithromycin 500 mg orally twice daily for 7 days, which provides coverage for atypical organisms but may have limited activity against certain strains of Streptococcus pneumoniae 1
  • Azithromycin 500 mg on day 1, then 250 mg daily for 4 more days, which provides coverage for atypical organisms and has been shown to be effective against Haemophilus influenzae 1

The patient should be advised to seek immediate medical attention if symptoms worsen, particularly if they develop high fever, severe shortness of breath, or chest pain. Reassessment within 48-72 hours is recommended to ensure clinical improvement. It is essential to note that the choice of antibiotic should be guided by local resistance patterns and susceptibility testing, if available 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

Adults Acute bacterial sinusitis due to Haemophilus influenzae, Moraxella catarrhalis or Streptococcus pneumoniae

The patient has acute bacterial sinusitis and is allergic to penicillin.

• Levofloxacin is indicated for the treatment of acute bacterial sinusitis due to Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis.
• Azithromycin is also indicated for the treatment of acute bacterial sinusitis due to Haemophilus influenzae, Moraxella catarrhalis, or Streptococcus pneumoniae. Since the patient is already on doxy (likely doxycycline) and has a penicillin allergy, levofloxacin or azithromycin could be considered as alternative antibiotic options for the treatment of acute bacterial sinusitis and possible pneumonia, but the choice of antibiotic should be based on the specific causative organisms and local susceptibility patterns 2 3.

From the Research

Patient with Acute Bacterial Sinusitis and Penicillin Allergy

• The patient has acute bacterial sinusitis and is concerned about pneumonia, but has a penicillin allergy and is already on doxycycline (doxy) for over one week 4, 5.
• Given the patient's penicillin allergy, alternative antibiotics such as cefuroxime, cefpodoxime, or cefdinir can be considered 4.
• For patients with a beta-lactam allergy, doxycycline or a respiratory fluoroquinolone can be prescribed 6.
• Since the patient is already on doxycycline, a fluoroquinolone can be considered as an alternative 5, 6.

Treatment Duration and Considerations

• The optimal duration of therapy is unknown, but some recommend treatment until the patient becomes free of symptoms and then for an additional 7 days 4.
• In patients with mild disease who have beta-lactam allergy, trimethoprim/sulfamethoxazole or doxycycline are options 5.
• Second-line antibiotics should be considered if the patient has moderate disease, recent antibiotic use (past six weeks), or no response to treatment within 72 hours 5.

Diagnosis and Management

• Acute bacterial sinusitis is a clinical diagnosis, and the challenge lies in distinguishing between the symptoms of bacterial and viral sinusitis 6.
• Cardinal features of acute bacterial rhinosinusitis include unilateral facial pain or pressure, fever greater than 102°F (39°C), and purulent nasal discharge with obstruction of the nasal passages 6.
• Diagnostic testing for acute rhinosinusitis with antral puncture is impractical due to its invasiveness, and point-of-care testing for elevated C-reactive protein may be helpful but is not widely available 6.