What are the antibiotic (abx) treatment options for sinusitis?

From the Guidelines

Antibiotics for sinusitis should be prescribed with amoxicillin with or without clavulanate as first-line therapy for 5 to 10 days for most adults. This recommendation is based on the most recent and highest quality study, which suggests that amoxicillin with or without clavulanate is the preferred choice for treating acute bacterial rhinosinusitis (ABRS) in adults 1. The study found that this treatment has a preponderance of benefit over harm, and it is recommended for 5 to 10 days.

Key Considerations

• The choice of antibiotic should be based on the likelihood of bacterial infection, which is typically considered after symptoms persist beyond 10 days, worsen after initial improvement, or are severe from onset with high fever and purulent discharge.
• For penicillin-allergic patients, alternative treatments such as doxycycline or respiratory fluoroquinolones like levofloxacin may be considered 1.
• In areas with high pneumococcal resistance or for treatment failures, high-dose amoxicillin-clavulanate may be considered.
• Patients should continue therapy for the full course even if symptoms improve and should use supportive measures like saline irrigation, intranasal steroids, and analgesics.

Additional Options

• Other antibiotics such as cefpodoxime and cefdinir may be suitable agents, but their use should be guided by local resistance patterns and patient-specific factors 1.
• The use of macrolides like azithromycin and clarithromycin is not recommended due to concerns about resistance and efficacy 1.
• Fluoroquinolones like ciprofloxacin, levofloxacin, and moxifloxacin may be used in adults, but their use should be guided by local resistance patterns and patient-specific factors 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 [see Clinical Studies (14.4)].

Levofloxacin is indicated for the treatment of acute bacterial sinusitis due to Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis.

• The recommended treatment regimens are 750 mg by mouth x 5 days or 500 mg by mouth once daily x 10 to 14 days.
• Clinical success rates in the microbiologically evaluable population were 91.4% in the levofloxacin 750 mg group and 88.6% in the levofloxacin 500 mg group at the test-of-cure (TOC) visit 2.

From the Research

Diagnosis and Treatment of Sinusitis

• Acute bacterial sinusitis (ABS) is a common problem in both children and adults, with three clinical presentations: onset with persistent symptoms, onset with severe symptoms, and onset with worsening symptoms 3.
• The diagnosis of acute sinusitis can be confirmed with images, and the predominant bacterial species implicated are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis in children 3.
• Therapy for ABS may be initiated with high-dose amoxicillin or amoxicillin-clavulanate, with alternatives including cefuroxime, cefpodoxime, or cefdinir 3.

Antibiotic Treatment Duration

• The optimal duration of antibiotic therapy for ABS is unknown, but some recommend treatment until the patient becomes free of symptoms and then for an additional 7 days 3.
• A meta-analysis of randomized trials found that short-course antibiotic treatment (up to 7 days) has similar effectiveness to longer-course treatment (> or =2 days longer than short-course) for patients with acute uncomplicated bacterial sinusitis 4.
• Short-course antibiotic treatment may lead to fewer adverse events, better patient compliance, lower rates of resistance development, and fewer costs 4.

Treatment Options

• Amoxicillin is as effective as amoxicillin-clavulanate as a first-line treatment for acute bacterial rhinosinusitis for those without a beta-lactam allergy 5.
• For patients with a beta-lactam allergy, appropriate antibiotics include doxycycline or a respiratory fluoroquinolone; clindamycin plus a third-generation cephalosporin is an option for children with non-type I hypersensitivity to beta-lactam antibiotics 5.
• High-dose amoxicillin/clavulanate may lead to more rapid improvement in symptoms compared to standard-dose amoxicillin/clavulanate, but may also increase the risk of severe diarrhea 6.
• A combination of amoxicillin and clavulanate given every 12 hours is as effective and safe as administration every 8 hours for the treatment of acute bacterial maxillary sinusitis 7.