What is given for a sinus infection when a person has had antibiotics twice in the last year?

Antibiotic Selection for Sinus Infection After Recent Antibiotic Exposure

For a patient with acute bacterial sinusitis who has received antibiotics twice in the last year, high-dose amoxicillin-clavulanate (875 mg/125 mg twice daily for 5-10 days) is the preferred first-line treatment, as recent antibiotic exposure is a risk factor for resistant organisms. 1

Confirming the Diagnosis First

Before prescribing antibiotics, verify the patient meets criteria for acute bacterial rhinosinusitis rather than viral rhinosinusitis 1:

• Persistent symptoms ≥10 days without improvement 1
• Severe symptoms (fever ≥39°C with purulent nasal discharge) for ≥3-4 consecutive days 1
• "Double sickening" - worsening after initial improvement from a viral upper respiratory infection 1

Most acute rhinosinusitis (98-99.5%) is viral and resolves spontaneously within 7-10 days without antibiotics 1. Do not prescribe antibiotics for symptoms <10 days unless severe features are present 1.

First-Line Treatment: High-Dose Amoxicillin-Clavulanate

Recent antibiotic use within the past year places this patient at higher risk for resistant organisms, specifically β-lactamase-producing Haemophilus influenzae and Moraxella catarrhalis, and potentially drug-resistant Streptococcus pneumoniae. 1

Dosing Specifications

• Amoxicillin-clavulanate 875 mg/125 mg twice daily for 5-10 days 1
• For patients with additional risk factors (age >65, moderate-to-severe symptoms, comorbidities, or immunocompromised state), consider high-dose amoxicillin-clavulanate 2 g/125 mg twice daily 1
• Treatment duration of 5-7 days has comparable efficacy to 10-day regimens with fewer adverse effects 1
• Continue treatment until symptom-free for 7 days (typically 10-14 days total) 1

Why Amoxicillin-Clavulanate Over Plain Amoxicillin

The clavulanate component provides essential coverage against β-lactamase-producing organisms, which have become increasingly prevalent 1. Recent antibiotic exposure increases the likelihood of encountering these resistant pathogens 1.

Alternative Options for Penicillin Allergy

Non-Severe (Non-Type I) Penicillin Allergy

For patients with non-anaphylactic penicillin allergy (rash, mild reactions), second- or third-generation cephalosporins are safe and effective 1, 2:

• Cefuroxime-axetil (second-generation cephalosporin) 1
• Cefpodoxime-proxetil 200 mg twice daily for 10 days 1, 2
• Cefdinir 300 mg twice daily or 600 mg once daily for 10 days 1

Recent evidence shows the risk of serious allergic reactions to second- and third-generation cephalosporins in penicillin-allergic patients is negligible 1.

Severe (Type I) Penicillin Allergy

For patients with documented anaphylaxis to penicillin, respiratory fluoroquinolones are the first-line choice 1, 2:

• Levofloxacin 500 mg once daily for 10-14 days 1, 3
• Moxifloxacin 400 mg once daily for 10 days 1

These provide 90-92% predicted clinical efficacy against drug-resistant S. pneumoniae and β-lactamase-producing H. influenzae 1.

Avoid cephalosporins in patients with anaphylaxis to penicillin due to potential cross-reactivity (1-10% risk with true IgE-mediated allergy). 2

What NOT to Use

Azithromycin and Other Macrolides

Azithromycin should not be used for acute bacterial sinusitis due to resistance rates exceeding 20-25% for both S. pneumoniae and H. influenzae. 1 French guidelines explicitly exclude macrolides from recommended therapy due to resistance prevalence 1.

Trimethoprim-Sulfamethoxazole (Bactrim/Septra)

Do not use trimethoprim-sulfamethoxazole due to 50% resistance rate for S. pneumoniae and 27% resistance for H. influenzae. 1

First-Generation Cephalosporins

Avoid cephalexin and other first-generation cephalosporins due to inadequate coverage against H. influenzae, with nearly 50% of strains being β-lactamase producing. 1

Treatment Monitoring and Reassessment

Critical Timepoints

• Reassess at 3-5 days: If no improvement, switch to second-line therapy 1
• Reassess at 7 days: If symptoms persist or worsen, reconfirm diagnosis and consider complications 1

When to Switch Antibiotics

If the patient fails initial therapy with amoxicillin-clavulanate after 3-5 days 1:

• Switch to a respiratory fluoroquinolone (levofloxacin 500 mg once daily or moxifloxacin 400 mg once daily) 1
• These provide 90-92% predicted clinical efficacy against resistant organisms 1

Essential Adjunctive Therapies

All patients should receive adjunctive therapies regardless of antibiotic choice to improve symptom resolution 1:

• Intranasal corticosteroids (mometasone, fluticasone, or budesonide twice daily) - strongly recommended to reduce mucosal inflammation 1
• Saline nasal irrigation - provides symptomatic relief and removes mucus 1
• Analgesics (acetaminophen or ibuprofen) - for pain and fever 1
• Adequate hydration 1

Watchful Waiting as an Alternative

For adults with uncomplicated acute bacterial sinusitis, watchful waiting without immediate antibiotics is an appropriate initial strategy when reliable follow-up can be assured. 1 Start antibiotics only if no improvement by 7 days or symptoms worsen at any time 1.

However, given this patient's history of two antibiotic courses in the past year, immediate antibiotic therapy with high-dose amoxicillin-clavulanate is more appropriate to prevent treatment failure 1.

Critical Pitfalls to Avoid

• Do not wait beyond 7 days to change therapy in non-responders - this delays effective treatment and may allow complications to develop 1
• Do not use fluoroquinolones as first-line therapy in patients without documented β-lactam allergies - reserve them for treatment failures or severe allergies to prevent resistance development 1
• Ensure adequate treatment duration (minimum 5 days for adults) to prevent relapse 1
• Do not prescribe antibiotics for viral rhinosinusitis lasting <10 days unless severe symptoms are present 1

When to Refer

Refer to otolaryngology or consider imaging (CT scan) if 1:

• No improvement after 7 days of appropriate second-line antibiotic therapy
• Worsening symptoms at any time
• Suspected complications (orbital cellulitis, meningitis, brain abscess)
• Recurrent sinusitis (≥3 episodes per year) requiring evaluation for underlying allergic rhinitis, immunodeficiency, or anatomic abnormalities