In acute bacterial sinusitis not improving on amoxicillin‑clavulanate, can I add a corticosteroid and the product 'Thessalon perles'?

Can Steroids and Benzonatate (Tessalon Perles) Be Added to Amoxicillin-Clavulanate for Acute Bacterial Sinusitis?

Yes, you should add intranasal corticosteroids to amoxicillin-clavulanate for acute bacterial sinusitis not improving after several days, but benzonatate (Tessalon Perles) is not indicated for sinusitis treatment and should not be added.

Intranasal Corticosteroids: Strongly Recommended as Adjunctive Therapy

Adding intranasal corticosteroids to antibiotic therapy significantly improves symptom resolution in acute bacterial sinusitis. 1

• The European Position Paper on Rhinosinusitis 2020 demonstrates that intranasal corticosteroids combined with antibiotics provide modestly beneficial effects in acute and chronic sinusitis 2
• A randomized controlled trial showed that amoxicillin plus fluticasone propionate nasal spray achieved significantly higher cure rates and lower symptom scores compared to amoxicillin alone in children with post-viral sinusitis 2
• Multiple studies confirm that intranasal corticosteroids reduce mucosal inflammation, improve nasal congestion, and enhance overall symptom resolution when added to antibiotics 1

Preferred Agents and Dosing

• Mometasone furoate, fluticasone propionate, or budesonide are the preferred intranasal corticosteroids due to negligible systemic bioavailability 1
• Standard dosing: 2 sprays per nostril twice daily (200-400 µg per day depending on formulation) 1
• Duration: Continue for 15-21 days concurrent with antibiotic therapy for acute bacterial sinusitis 1

Evidence for Efficacy

• A study of 200 patients with acute recurrent sinusitis showed that adding mometasone furoate nasal spray 400 µg twice daily to amoxicillin-clavulanate produced significantly greater reduction in total symptom scores, particularly for headache, facial pain, and congestion, compared to antibiotic alone 3
• The benefit was most pronounced for inflammatory symptoms associated with obstruction (headache, congestion, facial pain) rather than secretory symptoms 3

Oral Corticosteroids: Consider Only in Specific Situations

Short-term oral corticosteroids may be added for 5-7 days in specific clinical scenarios, but are not routinely recommended for all cases of acute bacterial sinusitis. 2, 1

When to Consider Oral Steroids

• Marked mucosal edema on examination 1
• Failure to respond to initial antibiotic treatment with intranasal corticosteroids after 3-5 days 1
• Severe symptoms with significant facial pain (acute hyperalgic sinusitis) 4

Important Limitations

• The European Position Paper on Rhinosinusitis 2020 found that systemic corticosteroids in post-viral rhinosinusitis showed only modest short-term benefit (resolution of facial pain at 4-7 days) with no sustained effect at 10-14 days 2
• Approximately two-thirds of patients improved with placebo treatment alone, indicating high spontaneous recovery rates 2
• Oral corticosteroids should never be used as monotherapy—they must always be combined with antibiotics when bacterial infection is suspected 4

Dosing for Oral Steroids (If Indicated)

• Typical regimen: Prednisone 40-60 mg daily for 5-7 days, then taper over 7-14 days 1
• Shorter courses of 3-7 days have been studied with modest benefit 2

Benzonatate (Tessalon Perles): Not Indicated for Sinusitis

Benzonatate is a non-narcotic antitussive used for symptomatic relief of cough and has no role in treating acute bacterial sinusitis. 2

Why Benzonatate Should Not Be Added

• Benzonatate works by anesthetizing stretch receptors in the respiratory passages and lungs, reducing the cough reflex 2
• Acute bacterial sinusitis is characterized by purulent nasal discharge, facial pain/pressure, and nasal obstruction—not primarily by cough 4
• When cough is present in sinusitis, it is typically due to postnasal drip, which is better addressed by treating the underlying inflammation with intranasal corticosteroids and antibiotics 2
• No evidence supports the use of antitussives like benzonatate in the treatment of acute bacterial sinusitis 2, 1, 4

Appropriate Cough Management in Sinusitis

• First-generation antihistamine/decongestant combinations may help with postnasal drip-related cough in upper airway cough syndrome secondary to rhinosinusitis 2
• These work through anticholinergic properties to reduce secretions 2
• Improvement in cough typically occurs within days to 2 weeks of initiating appropriate therapy for the underlying sinusitis 2

Reassessment Timeline for Treatment Failure

If your patient is not improving on amoxicillin-clavulanate, you need to reassess at specific timepoints. 1, 4

• At 3-5 days: If no improvement, switch to high-dose amoxicillin-clavulanate (2 g/125 mg twice daily) or a respiratory fluoroquinolone (levofloxacin 500 mg daily or moxifloxacin 400 mg daily) 4
• At 7 days: If symptoms persist or worsen, reconfirm the diagnosis, exclude complications, and consider ENT referral 4
• Waiting beyond 7 days to change therapy in non-responders delays effective treatment and may allow complications to develop 4

Complete Treatment Algorithm

1. Confirm diagnosis of acute bacterial sinusitis using one of three criteria: persistent symptoms ≥10 days, severe symptoms ≥3-4 consecutive days, or "double sickening" (worsening after initial improvement) 4

2. Start amoxicillin-clavulanate 875 mg/125 mg twice daily for 5-10 days 4

3. Add intranasal corticosteroid (mometasone, fluticasone, or budesonide) 2 sprays per nostril twice daily 1

4. Add saline nasal irrigation for mechanical clearance of secretions 1

5. Provide analgesics (acetaminophen or NSAIDs) for pain control 1

6. Consider short-term oral corticosteroids (prednisone 40-60 mg daily for 5 days) only if marked mucosal edema or severe symptoms are present 1, 4

7. Reassess at 3-5 days: Switch antibiotics if no improvement 4

8. Do NOT add benzonatate—it has no role in sinusitis treatment 2

Common Pitfalls to Avoid

• Do not use oral corticosteroids without concurrent antibiotics when bacterial sinusitis is suspected, as this may suppress immune response and allow bacterial proliferation 4
• Do not add antitussives like benzonatate for sinusitis-related symptoms—treat the underlying inflammation instead 2
• Do not continue ineffective antibiotic therapy beyond 3-5 days without reassessment and potential switch to second-line agents 4
• Ensure proper intranasal corticosteroid technique: patients should direct sprays away from the nasal septum to minimize local side effects like nasal irritation and bleeding 1