From the Guidelines
For a patient with a sinus infection for 2 weeks who doesn't want oral antibiotics, I recommend starting with saline nasal irrigation 2-3 times daily and intranasal corticosteroids like fluticasone (Flonase) 1-2 sprays per nostril daily, as these non-antibiotic approaches can effectively reduce inflammation and promote drainage, according to the most recent and highest quality study 1.
Key Considerations
- Most patients with acute rhinosinusitis can be managed with supportive care, including analgesics for pain and antipyretics for fever, as stated in 1.
- 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 mentioned in 1.
- The European Position Paper on Rhinosinusitis and Nasal Polyps 2020 1 provides evidence that intranasal corticosteroids can significantly reduce major symptom scores and improve quality of life in patients with acute post-viral rhinosinusitis.
Management Strategy
- Patients with mild symptoms can be offered symptomatic treatment and reassurance, as the degree of benefit from antibiotics is relatively small, and most patients improve without antibiotic therapy, as stated in 1.
- For those with severe symptoms, initial antibiotic therapy should be with narrow-spectrum agents, such as amoxicillin, doxycycline, and trimethoprim-sulfamethoxazole, but only if symptoms persist or worsen, as recommended in 1 and 1.
- It is essential to educate patients about worsening signs and symptoms that should prompt them to contact a physician, such as fever, severe headache, or visual changes, as mentioned in 1.
Monitoring and Follow-up
- Patients should be monitored for symptom improvement and potential complications, such as worsening symptoms, fever, or severe headache, as stated in 1 and 1.
- If symptoms persist beyond 7-10 more days, worsen significantly, or if fever, severe headache, or visual changes develop, antibiotics may become necessary, as recommended in 1 and 1.
From the FDA Drug Label
Acute bacterial sinusitis 500 mg QD × 3 days
The patient has a sinus infection and does not want oral antibiotics, but azithromycin (PO) is an oral antibiotic.
- Azithromycin can be used to treat acute bacterial sinusitis with a recommended dose of 500 mg once daily for 3 days 2. However, the patient's reluctance to take oral antibiotics must be considered, and alternative treatments or further discussion may be necessary to address the patient's concerns.
- The efficacy of azithromycin in treating acute bacterial sinusitis has been demonstrated in clinical trials, with a clinical cure rate of 88% at Day 10 and 71.5% at Day 28 2. It is essential to weigh the benefits and risks of treatment and consider the patient's preferences and values when making a decision.
- The safety profile of azithromycin is generally favorable, with the most common side effects being diarrhea, nausea, and abdominal pain 2.
From the Research
Treatment Options for Acute Sinusitis
The patient has a sinus infection that has lasted for 2 weeks and does not want to take oral antibiotics. There are several alternative treatment options that can be considered:
- Azithromycin: A 3-day course of azithromycin has been shown to be as effective as a 10-day course of amoxicillin/clavulanate in treating acute sinusitis 3.
- Clarithromycin extended-release: Once daily clarithromycin extended-release has been compared to twice-daily amoxicillin/clavulanate in patients with acute bacterial sinusitis, and the results showed that clarithromycin ER was comparable, and for selected measures superior, to amoxicillin/clavulanate 4.
- Azithromycin extended release: A single 2-g dose of azithromycin extended release has been compared to 10 days of amoxicillin/clavulanate, and the results showed that more patients randomized to azithromycin extended release experienced symptom resolution at day 5 than those randomized to amoxicillin/clavulanate 5.
Efficacy of Treatment Options
The efficacy of these treatment options has been studied in several clinical trials:
- A randomized, double-blind, multicenter study compared the efficacy and safety of two azithromycin regimens, 500 mg/day once daily for 3 days or 6 days, to the efficacy and safety of an amoxicillin-clavulanate regimen of 500-125 mg three times daily for 10 days, and the results showed that clinical success rates were equivalent among per-protocol subjects at the end of therapy and at the end of the study 6.
- A prospective, randomized, open-label, observational study compared early symptom resolution with a single 2-g dose of azithromycin extended release or 10 days of amoxicillin/clavulanate, and the results showed that more patients randomized to azithromycin extended release experienced symptom resolution at day 5 than those randomized to amoxicillin/clavulanate 5.
Considerations for Treatment
When considering treatment options for acute sinusitis, it is essential to take into account the patient's medical history, allergy status, and previous response to antibiotics:
- Patients who are allergic to penicillin may be treated with azithromycin or clarithromycin 7.
- Patients who have experienced treatment failure with amoxicillin/clavulanate may be treated with azithromycin or clarithromycin 7.
- 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 7.