Management of Acute Sinusitis in a 35-Year-Old Woman
Confirm the Diagnosis Before Prescribing Antibiotics
Most acute sinus infections (98–99.5%) are viral and resolve spontaneously within 7–10 days without antibiotics—reserve antibiotics only for confirmed bacterial sinusitis. 1, 2
Diagnose acute bacterial rhinosinusitis (ABRS) when at least one of the following patterns is present:
- Persistent symptoms ≥10 days without improvement: purulent nasal discharge plus either nasal obstruction or facial pain/pressure/fullness 1, 2
- Severe symptoms ≥3–4 consecutive days: fever ≥39°C (102.2°F) with purulent nasal discharge and facial pain 1, 2
- "Double sickening": initial improvement from a cold followed by worsening symptoms within 10 days 1, 2
Do not prescribe antibiotics for symptoms lasting <10 days unless severe features are present. 1, 2
First-Line Antibiotic Therapy
Amoxicillin-clavulanate 875 mg/125 mg orally twice daily for 5–10 days is the preferred first-line antibiotic for confirmed bacterial sinusitis in otherwise healthy adults. 1, 2
- This regimen provides 90–92% predicted clinical efficacy against the three major pathogens: Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 1
- The clavulanate component is essential because 30–40% of H. influenzae and 90–100% of M. catarrhalis produce β-lactamase, rendering plain amoxicillin ineffective 1, 3
- Treatment duration: continue for 5–10 days or until symptom-free for 7 consecutive days (typically 10–14 days total) 1, 2
- Recent evidence supports shorter 5–7 day courses with comparable efficacy and fewer adverse effects 1
When to Use High-Dose Amoxicillin-Clavulanate
Use high-dose amoxicillin-clavulanate (2 g/125 mg twice daily) if the patient has any of these risk factors for resistant organisms 1:
- Recent antibiotic use (within past 4–6 weeks)
- Age >65 years
- Moderate-to-severe symptoms
- Comorbidities (diabetes, chronic cardiac/hepatic/renal disease)
- Immunocompromised state
- Daycare attendance or close contact with daycare children
Alternatives for Penicillin Allergy
Non-Severe Penicillin Allergy (e.g., Mild Rash)
Use a second- or third-generation cephalosporin for 10 days—cross-reactivity is negligible. 1, 2
- Cefuroxime-axetil (second-generation) 1
- Cefpodoxime-proxetil, cefdinir, or cefprozil (third-generation) 1, 2
Severe Penicillin Allergy (Type I/Anaphylactic)
Use a respiratory fluoroquinolone: 1, 2
- Levofloxacin 500 mg once daily for 10–14 days 1, 4
- Moxifloxacin 400 mg once daily for 10 days 1
- Both provide 90–92% predicted efficacy against multidrug-resistant S. pneumoniae 1, 4
Doxycycline 100 mg once daily for 10 days is an acceptable but suboptimal alternative (predicted efficacy 77–81% with a 20–25% bacteriologic failure rate). 1
Essential Adjunctive Therapies (Add to All Patients)
Intranasal corticosteroids (e.g., mometasone, fluticasone, budesonide) twice daily significantly reduce mucosal inflammation and accelerate symptom resolution—supported by strong evidence from multiple randomized controlled trials. 1, 2
- Saline nasal irrigation 2–3 times daily provides symptomatic relief and helps clear mucus 1, 2
- Analgesics (acetaminophen or ibuprofen) for pain and fever control 1, 2
- Decongestants (oral or topical); limit topical agents to ≤3 days to avoid rebound congestion 1
Watchful Waiting Strategy
For uncomplicated cases with reliable follow-up, initial observation without antibiotics is appropriate—initiate antibiotics only if no improvement by day 7 or if symptoms worsen at any time. 1, 2
- The number needed to treat (NNT) with antibiotics is 10–15 to achieve one additional cure, reflecting the high rate of spontaneous recovery 1
- During observation, provide symptomatic treatment with intranasal corticosteroids, saline irrigation, and analgesics 1, 2
Monitoring and Reassessment
Reassess at 3–5 days: If no clinical improvement, switch to high-dose amoxicillin-clavulanate or a respiratory fluoroquinolone 1, 2
Reassess at 7 days: If symptoms persist or worsen 1, 2:
- Reconfirm the diagnosis of bacterial sinusitis
- Exclude complications (orbital cellulitis, meningitis, brain abscess)
- Consider imaging (CT) only when complications are suspected—routine imaging is not recommended 1, 2
Antibiotics to Avoid
Macrolides (e.g., azithromycin): 20–25% resistance rates in S. pneumoniae and H. influenzae make them unsuitable 1, 2
Trimethoprim-sulfamethoxazole: 50% resistance in S. pneumoniae and 27% in H. influenzae 1
First-generation cephalosporins (e.g., cephalexin): inadequate against H. influenzae because ~50% of strains produce β-lactamase 1
When to Refer to Otolaryngology
Refer if any of the following occur 1, 2:
- No improvement after 7 days of appropriate second-line antibiotics
- Worsening symptoms at any time during treatment
- Suspected complications: severe headache, visual changes, periorbital swelling, altered mental status, proptosis, abnormal extraocular movements 5, 1
- Recurrent sinusitis (≥3 episodes per year) requiring evaluation for underlying allergic rhinitis, immunodeficiency, or anatomic abnormalities 5, 1, 2
Common Pitfalls to Avoid
Gastrointestinal adverse effects with amoxicillin-clavulanate are common (diarrhea in 40–43% of patients; severe diarrhea in 7–8%)—counsel patients accordingly 1
Fluoroquinolones should not be used as first-line therapy in patients without documented β-lactam allergy to avoid promoting resistance 1, 2
Ensure minimum treatment duration (≥5 days for adults) to prevent relapse 1, 2
Do not obtain routine imaging (X-ray or CT) for uncomplicated acute rhinosinusitis—87% of viral upper-respiratory infections show sinus abnormalities on imaging, leading to unnecessary interventions 1, 2