What is the treatment for bacterial sinusitis?

From the Guidelines

Bacterial sinusitis should be treated with amoxicillin alone or in combination with clavulanate as the first-line antibiotic choice, according to the most recent and highest quality study 1.

Treatment Approach

The treatment approach for bacterial sinusitis involves antibiotics, supportive care, and sometimes nasal corticosteroids.

• For children with severe, worsening, or persistent acute bacterial sinusitis, antibiotics should be prescribed 1.
• Amoxicillin alone or in combination with clavulanate is the preferred first-line treatment 1.
• For patients who are vomiting, cannot take oral medications, or are not likely to take the initial antibiotic doses as prescribed, intravenous or intramuscular ceftriaxone can be given 1.

Supportive Care

Supportive measures include:

• Saline nasal irrigation 2-3 times daily
• Oral decongestants like pseudoephedrine 30-60 mg every 4-6 hours (avoid in hypertension)
• Analgesics such as acetaminophen or ibuprofen for pain relief
• Intranasal corticosteroids like fluticasone 1-2 sprays per nostril daily can reduce inflammation

Diagnosis and Management

The diagnosis of acute bacterial sinusitis is made when a child with an acute upper respiratory tract infection presents with persistent illness, worsening course, or severe onset 1.

• Clinicians should not obtain imaging studies to distinguish acute bacterial sinusitis from viral URI, but a contrast-enhanced computed tomography scan of the paranasal sinuses should be obtained if orbital or central nervous system complications are suspected 1.
• The clinician should prescribe antibiotic therapy for acute bacterial sinusitis in children with severe onset or worsening course, and either prescribe antibiotic therapy or offer additional observation for 3 days to children with persistent illness 1.

Alternative Treatments

For patients with hypersensitivity to amoxicillin, alternative treatments include:

• Cefdinir
• Cefuroxime
• Cefpodoxime 1

From the FDA Drug Label

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)]. To evaluate the safety and efficacy of a high dose short course of levofloxacin, 780 outpatient adults with clinically and radiologically determined acute bacterial sinusitis were evaluated in a double-blind, randomized, prospective, multicenter study comparing levofloxacin 750 mg by mouth once daily for five days to levofloxacin 500 mg by mouth once daily for 10 days Clinical success rates (defined as complete or partial resolution of the pre-treatment signs and symptoms of ABS to such an extent that no further antibiotic treatment was deemed necessary) in the microbiologically evaluable population were 91.4% (139/152) in the levofloxacin 750 mg group and 88.6% (132/149) in the levofloxacin 500 mg group at the test-of-cure (TOC) visit (95% CI [-4. 2,10] for levofloxacin 750 mg minus levofloxacin 500 mg).

Levofloxacin is approved for the treatment of acute bacterial sinusitis (ABS) using either 750 mg by mouth x 5 days or 500 mg by mouth once daily x 10 to 14 days.

• The clinical success rate for levofloxacin 750 mg was 91.4%.
• The clinical success rate for levofloxacin 500 mg was 88.6%. The treatment of ABS with levofloxacin is effective, with high clinical success rates for both the 5-day and 10-14 day treatment regimens 2.

From the Research

Bacterial Sinusitis Treatment Overview

• Bacterial sinusitis is a common complication of acute rhinosinusitis, with most cases caused by viruses 3.
• Antibiotic therapy should be considered in patients with prolonged or more severe symptoms, with narrow-spectrum antibiotics such as amoxicillin recommended for 10 to 14 days 3.

Antibiotic Treatment Options

• Amoxicillin is a first-line treatment for acute bacterial rhinosinusitis, with amoxicillin-clavulanate also effective 3, 4.
• For patients with beta-lactam allergy, doxycycline or a respiratory fluoroquinolone may be used, with clindamycin plus a third-generation cephalosporin an option for children with non-type I hypersensitivity to beta-lactam antibiotics 4.
• Azithromycin has been shown to be as effective as amoxicillin/clavulanic acid in the treatment of acute sinusitis, with a simpler dosage regimen and faster clinical effect 5.

Supportive Care and Symptom Management

• Saline irrigation, nasal steroids or antihistamines, and decongestants may help reduce the severity of symptoms 3, 4, 6.
• Decongestants are often recommended, but should not be used for more than three days to avoid rebound congestion 3.
• Nasal corticosteroids may be beneficial in treating chronic sinusitis, but evidence for their use in acute bacterial sinusitis is limited 3.

Treatment Duration and Efficacy

• A 10-day course of amoxicillin is recommended for patients who fail to improve with symptomatic treatment, with second-line antibiotics initiated if improvement is not seen within 72 to 96 hours 6.
• High-dose amoxicillin/clavulanate may lead to more rapid improvement in symptoms, but is associated with a higher risk of severe diarrhea 7.
• The efficacy of antibiotic treatment may vary depending on the specific antibiotic and patient population, with further study needed to confirm findings 7.