Augmentin Duration for Acute Sinusitis in an Elderly Man
For an elderly man with acute sinusitis and acute bronchitis, prescribe amoxicillin-clavulanate (Augmentin) 875 mg/125 mg twice daily for 5–7 days. 1
Standard Treatment Duration
- The American Academy of Otolaryngology–Head and Neck Surgery establishes 5–10 days as the recommended duration for amoxicillin-clavulanate in uncomplicated acute bacterial sinusitis, with recent evidence supporting shorter 5–7 day courses as equally effective and associated with fewer adverse effects. 1
- Treatment should continue until the patient is symptom-free for 7 consecutive days, which typically results in a 10–14 day total course in patients who respond more slowly. 1, 2
- A 2021 randomized controlled trial in JAMA Network Open found no additional benefit from high-dose amoxicillin-clavulanate (1750 mg amoxicillin twice daily) compared to standard-dose (875 mg twice daily) in adults with acute sinusitis, with both groups showing similar clinical improvement by day 3 (44.3% vs 36.4%, p=0.35). 3
Dosing Specifications for This Patient
- Standard-dose amoxicillin-clavulanate 875 mg/125 mg twice daily is appropriate for this elderly patient with normal renal function and no recent antibiotic exposure. 1, 2
- High-dose amoxicillin-clavulanate (2 g/125 mg twice daily) should be reserved for patients with recent antibiotic use within the past month, age >65 years with moderate-to-severe symptoms, comorbid conditions, or immunocompromised state. 1
- Since this patient is elderly but has normal renal function and no mention of severe symptoms or recent antibiotic use, standard dosing is sufficient. 1
Reassessment Timeline
- Reassess at 3–5 days: If no improvement occurs, switch to high-dose amoxicillin-clavulanate or a respiratory fluoroquinolone (levofloxacin 500 mg once daily or moxifloxacin 400 mg once daily for 10 days). 1
- Reassess at 7 days: If symptoms persist or worsen, reconfirm the diagnosis, exclude complications (orbital cellulitis, meningitis), and consider imaging (CT scan) or ENT referral. 1
- Waiting beyond 7 days to change therapy in non-responders delays effective treatment and may allow complications to develop. 1
Essential Adjunctive Therapies (Add to All Patients)
- Intranasal corticosteroids (mometasone, fluticasone, or budesonide) twice daily reduce mucosal inflammation and improve symptom resolution; this recommendation is backed by multiple randomized controlled trials. 1
- Saline nasal irrigation 2–3 times daily provides symptomatic relief and aids mucus clearance. 1
- Analgesics (acetaminophen or ibuprofen) for pain and fever control. 1
Why Not Longer Courses?
- A 2005 randomized controlled trial in Antimicrobial Agents and Chemotherapy demonstrated that a 5-day course of high-dose amoxicillin-clavulanate (2000/125 mg twice daily) was as effective clinically as a 7-day course of standard-dose (875/125 mg twice daily) in acute exacerbations of chronic bronchitis, with clinical success rates of 93.0% vs 91.2% and similar tolerability. 4
- A 2003 placebo-controlled trial in Archives of Internal Medicine found that amoxicillin-clavulanate 875/125 mg twice daily for 6 days provided no advantage over placebo in adults with clinically diagnosed acute rhinosinusitis (adjusted hazard ratio 0.99,95% CI 0.68–1.45), though patients with positive rhinoscopy findings may benefit more. 5
- A 2017 placebo-controlled trial in International Forum of Allergy & Rhinology showed that amoxicillin-clavulanate 875/125 mg twice daily for 14 days did not change the clinical course of acute exacerbation of chronic rhinosinusitis compared with placebo when both groups received intranasal corticosteroids and saline irrigation. 6
Common Pitfalls to Avoid
- Do not prescribe antibiotics for symptom duration <10 days unless severe features are present (fever ≥39°C with purulent discharge for ≥3 consecutive days). 1
- Gastrointestinal adverse effects are more common with amoxicillin-clavulanate, particularly diarrhea (reported in 40–43% of patients, with severe diarrhea in 7–8%). 1
- Stopping antibiotics prematurely when symptoms improve can lead to incomplete eradication and potential relapse. 7
- Do not use high-dose amoxicillin-clavulanate routinely in elderly patients without risk factors, as the 2021 JAMA trial showed no additional benefit and similar rates of severe diarrhea (7.0% vs 7.7%). 3
When to Refer to ENT
- No improvement after 7 days of appropriate second-line antibiotic therapy. 1
- Any worsening of symptoms at any stage of treatment. 1
- Suspicion of serious complications (severe headache, visual changes, altered mental status, periorbital swelling). 1
- Recurrent sinusitis (≥3 episodes per year), warranting evaluation for underlying allergic rhinitis, immunodeficiency, or anatomic abnormalities. 1