What is the best treatment for sinusitis?

From the Guidelines

The best treatment for sinusitis typically begins with supportive care, including nasal saline irrigation, over-the-counter pain relievers, and decongestants, with antibiotics reserved for bacterial cases that last over 10 days or worsen after initial improvement, as recommended by the American College of Physicians and the Centers for Disease Control and Prevention 1.

Key Considerations

• For most cases of viral sinusitis, treatment includes:
  • Nasal saline irrigation
  • Over-the-counter pain relievers like acetaminophen or ibuprofen (400-600mg every 6-8 hours)
  • Decongestants such as pseudoephedrine (30-60mg every 4-6 hours)
  • Nasal steroid sprays like fluticasone (1-2 sprays per nostril daily) to reduce inflammation
• For bacterial sinusitis, which is suspected when symptoms last over 10 days or worsen after initial improvement, antibiotics are appropriate, with:
  • Amoxicillin (500mg three times daily for 5-7 days) as the first-line treatment
  • Amoxicillin-clavulanate (875/125mg twice daily for 5-7 days) for more severe cases or those with risk factors for resistance

Additional Recommendations

• Staying hydrated, using a humidifier, and applying warm compresses can provide additional relief
• Patients who are seriously ill, who deteriorate clinically despite antibiotic therapy, or who have recurrent episodes should be referred to a specialist, such as an otolaryngologist, infectious disease specialist, or allergist 1
• For chronic sinusitis, consideration should be given to systemic corticosteroids, and evaluation should include coronal sinus CT with extra cuts through the ostiomeatal complex to clarify the extent of disease and specific location or locations 1

Important Notes

• Acute uncomplicated rhinosinusitis is a self-limited infection that usually resolves without antibiotics, even in patients with a bacterial cause, and most patients diagnosed with acute rhinosinusitis have more adverse effects than benefits from antibiotics 1
• Clinicians should reserve antibiotic treatment for acute rhinosinusitis for patients with persistent symptoms for more than 10 days, onset of severe symptoms or signs of high fever (>39 °C) and purulent nasal discharge or facial pain lasting for at least 3 consecutive days, or onset of worsening symptoms following a typical viral illness that lasted 5 days that was initially improving (double sickening) 1

From the FDA Drug Label

Acute bacterial sinusitis 500 mg QD × 3 days The best treatment for sinusitis, according to the provided drug label, is azithromycin 500 mg once daily for 3 days 2.

• Key points:
  • The dosage is for adults.
  • The treatment is for acute bacterial sinusitis.
  • The recommended dose is 500 mg once daily for 3 days.

From the Research

Treatment Options for Sinusitis

• The treatment for acute bacterial sinusitis in adults includes antibiotics such as amoxicillin with clavulanate 3
• A study compared the efficacy of a 3-day course of azithromycin with a 10-day course of amoxicillin/clavulanic acid in the treatment of acute sinusitis in adults, and found that azithromycin was as effective and well tolerated as amoxicillin/clavulanic acid 4
• Another study compared early symptom resolution with a single 2-g dose of azithromycin extended release or 10 days of amoxicillin/clavulanate 875 mg/125 mg every 12 hours in patients with acute sinusitis, and found that more patients randomized to azithromycin extended release experienced symptom resolution at day 5 than those randomized to amoxicillin/clavulanate 5

Medical Management of Sinusitis

• The medical management of sinusitis involves drainage of the congested sinuses and elimination of the pathogenic bacteria 6
• Treatment can be accomplished medically by opening the sinus ostia through the use of decongestants and topical corticosteroids, and bacteria can be effectively eliminated by washing the sinuses with saline and through use of appropriate antibiotics 6
• The mainstay of medical treatment of sinusitis is antibiotics, with adjuvant treatments such as saline irrigation, decongestants, mucolytics, and antiinflammatory agents playing a more secondary role 7

Comparison of Treatment Outcomes

• A study found that adults with clinically diagnosed acute bacterial sinusitis were more likely to improve rapidly when treated with high-dose immediate-release amoxicillin/clavulanate than with standard-dose amoxicillin/clavulanate, but were also more likely to suffer severe diarrhea 3
• Another study found that a 3-day course of azithromycin was as effective and well tolerated as a 10-day course of amoxicillin/clavulanic acid in the treatment of acute sinusitis in adults 4