What is the management of acute sinusitis?

From the Guidelines

Acute sinusitis is best managed with supportive care for 7-10 days in most cases, as 90-98% of cases are viral and resolve without antibiotics. Initial treatment should focus on symptom relief with analgesics like acetaminophen or ibuprofen (400-600mg every 6-8 hours), intranasal saline irrigation, and intranasal corticosteroids such as fluticasone (1-2 sprays per nostril daily) or mometasone 1. The use of nasal saline has been shown to provide minor improvements in nasal symptom scores, as reported in a Cochrane review 1.

Some key points to consider in the management of acute sinusitis include:

• The use of oral or topical decongestants like pseudoephedrine (30-60mg every 4-6 hours) may provide short-term relief but should be limited to 3-5 days to avoid rebound congestion 1.
• Antibiotics should only be considered if symptoms persist beyond 10 days, worsen after initial improvement, or present with severe symptoms (high fever ≥39°C, purulent discharge, facial pain) from the outset 1.
• When antibiotics are necessary, amoxicillin (500mg three times daily or 875mg twice daily for 5-7 days) is the first-line choice, with amoxicillin-clavulanate (875/125mg twice daily) for those at risk of resistant organisms 1.
• Doxycycline (100mg twice daily) or levofloxacin (500mg daily) are alternatives for penicillin-allergic patients 1.

It's essential to note that the management of acute sinusitis should prioritize symptom relief and avoid unnecessary antibiotic use, which can contribute to resistance and potential side effects 1. By following this approach, patients can experience improved symptom management and reduced risk of complications.

From the FDA Drug Label

1.1 Lower Respiratory Tract Infections – caused by beta-lactamase–producing isolates of Haemophilus influenzae and Moraxella catarrhalis.

1. 2 Acute Bacterial Otitis Media – caused by beta-lactamase–producing isolates of H. influenzae and M. catarrhalis. 1.3 Sinusitis – caused by beta-lactamase–producing isolates of H. influenzae and M. catarrhalis. Patients Aged 12 weeks (3 months) and Older: See dosing regimens provided in Table 1. Table 1: Dosing in Patients Aged 12 weeks (3 months) and Older INFECTIONDOSING REGIMEN Every 12 hoursEvery 12 hours 200 mg/5 mL or 400 mg/5 mL oral suspension a125 mg/5 mL or 250 mg/5 mL oral suspension a Otitis media b, sinusitis, lower respiratory tract infections, and more severe infections45 mg/kg/day every 12 hours40 mg/kg/day every 8 hours Less severe infections25 mg/kg/day every 12 hours20 mg/kg/day every 8 hours

Acute Sinusitis Management: Amoxicillin-clavulanate is indicated for the treatment of sinusitis caused by beta-lactamase–producing isolates of Haemophilus influenzae and Moraxella catarrhalis.

• The recommended dose for patients aged 12 weeks and older is 45 mg/kg/day every 12 hours or 40 mg/kg/day every 8 hours for more severe infections, and 25 mg/kg/day every 12 hours or 20 mg/kg/day every 8 hours for less severe infections 2.
• For adults, the usual dose is one 500 mg/125 mg amoxicillin and clavulanate potassium tablet every 12 hours or one 250 mg/125 mg amoxicillin and clavulanate potassium tablet every 8 hours 2.
• Amoxicillin-clavulanate should be used only to treat infections that are proven or strongly suspected to be caused by susceptible bacteria 2.

From the Research

Diagnosis of Acute Sinusitis

• Acute sinusitis is defined pathologically by transient inflammation of the mucosal lining of the paranasal sinuses lasting less than 4 weeks 3, 4.
• Clinically, it is characterized by nasal congestion, rhinorrhoea, facial pain, hyposmia, sneezing, and, if more severe, additional malaise and fever 3, 4.
• The challenge lies in distinguishing between the symptoms of bacterial and viral sinusitis, with cardinal features of acute bacterial rhinosinusitis including unilateral facial pain or pressure, fever greater than 102°F (39°C), and purulent nasal discharge with obstruction of the nasal passages 5.

Treatment of Acute Sinusitis

• Antibiotics should be considered for patients with 3 or more days of severe symptoms, significant worsening after 3 to 5 days of symptoms, or 7 or more days of symptoms 5.
• 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.
• Supportive care for rhinosinusitis, including use of saline irrigation, nasal steroids or antihistamines, and decongestants, may help reduce the severity of symptoms 5, 3, 4.

Management Strategies

• Computed tomography and referral to an otolaryngologist should be considered for patients with recurrent rhinosinusitis or concern about complications 5.
• Treatment algorithms are presented for adult and pediatric sinusitis, taking into account variable patterns of microbial resistance and antibiotic susceptibility 6.
• Best practices for clinical diagnoses and the most up-to-date management strategies are outlined in recent medical literature reviews 7.