Duration of Augmentin for Sinusitis
For adults with uncomplicated acute bacterial sinusitis, prescribe Augmentin (amoxicillin-clavulanate) 875 mg/125 mg twice daily for 5–7 days, which provides equivalent clinical cure rates to traditional 10-day courses while reducing adverse effects. 1
Confirming the Diagnosis Before Prescribing
Before initiating antibiotics, confirm that the patient meets at least one of three diagnostic criteria for acute bacterial rhinosinusitis (ABRS):
- Persistent symptoms ≥10 days without improvement—purulent nasal discharge plus either nasal obstruction or facial pain/pressure 1
- Severe symptoms ≥3–4 consecutive days—fever ≥39°C with purulent discharge and facial pain 1
- "Double sickening"—initial improvement from a viral URI followed by worsening within 10 days 1
Critical context: Approximately 98–99.5% of acute rhinosinusitis cases are viral and resolve spontaneously within 7–10 days without antibiotics. 1 Do not prescribe antibiotics for symptoms lasting <10 days unless the severe criteria above are met. 1
Standard Treatment Duration: 5–7 Days
The evidence strongly supports shorter courses:
- Randomized controlled trials demonstrate that 5–7 day courses achieve clinical cure rates of 74–80%, comparable to 10-day regimens, with no difference in microbiological eradication or relapse. 1
- A multicenter trial comparing 5-day vs 10-day therapy found equivalent clinical success rates (74% vs 80%, 95% CI for difference: -15.2% to 5.1%). 2
- Shorter courses result in fewer adverse effects—particularly important given that diarrhea occurs in 40–43% of patients on amoxicillin-clavulanate, with severe diarrhea in 7–8%. 1
Practical dosing:
- Adults: Augmentin 875 mg/125 mg orally twice daily for 5–7 days 1
- Alternative phrasing: Continue until symptom-free for 7 consecutive days (typically totaling 10–14 days) 1
High-Dose Regimen for Risk Factors
Escalate to high-dose Augmentin (2 g amoxicillin/125 mg clavulanate twice daily) when any of the following risk factors are present: 1
- Recent antibiotic use within the past 4–6 weeks 1
- Age >65 years 1
- Daycare exposure 1
- Moderate-to-severe symptoms 1
- Comorbidities (diabetes, chronic cardiac/hepatic/renal disease) 1
- Immunocompromised state 1
- High local prevalence of penicillin-resistant Streptococcus pneumoniae 1
This high-dose regimen provides 90–92% predicted clinical efficacy against drug-resistant S. pneumoniae and β-lactamase-producing Haemophilus influenzae and Moraxella catarrhalis. 1
Pediatric Dosing: Longer Duration Required
Children require 10–14 days of therapy—shorter courses are not supported by current evidence. 1
- Standard dose: Amoxicillin 45 mg/kg/day divided twice daily 1
- High-dose (for risk factors): Amoxicillin 80–90 mg/kg/day + clavulanate 6.4 mg/kg/day divided twice daily 1
Risk factors requiring high-dose in children: age <2 years, daycare attendance, recent antibiotic use, or high local resistance rates. 1
Reassessment Protocol: When to Switch Antibiotics
Early reassessment is critical to prevent treatment failure and complications:
Day 3–5 Reassessment (Adults)
- If no clinical improvement (persistent purulent drainage, unchanged facial pain, or worsening), switch immediately to: 1
- High-dose amoxicillin-clavulanate (if not already used), or
- Respiratory fluoroquinolone (levofloxacin 500 mg daily or moxifloxacin 400 mg daily) 1
72-Hour Reassessment (Children)
- If no improvement or worsening, switch to high-dose amoxicillin-clavulanate 1
Day 7 Reassessment (All Patients)
- Persistent or worsening symptoms require: 1
- Confirmation of diagnosis
- Exclusion of complications (orbital cellulitis, meningitis, intracranial abscess)
- Consider imaging (CT) only if complications suspected
- ENT referral if appropriate
Essential Adjunctive Therapies (Add to All Patients)
These therapies improve outcomes regardless of antibiotic choice:
- Intranasal corticosteroids (mometasone, fluticasone, or budesonide) twice daily—significantly reduce mucosal inflammation and accelerate symptom resolution; supported by strong evidence from multiple randomized controlled trials 1
- Saline nasal irrigation 2–3 times daily—provides symptomatic relief and aids mucus clearance 1
- Analgesics (acetaminophen or ibuprofen)—for pain and fever control 1
Common Pitfalls to Avoid
- Do not extend treatment beyond 7 days without clinical justification—this increases severe diarrhea incidence (≈7–8%) without improving outcomes 1
- Do not prescribe antibiotics for symptoms <10 days unless severe features (fever ≥39°C with purulent discharge for ≥3 consecutive days) are present 1
- Maintain a minimum 5-day course even if symptoms improve earlier, to prevent relapse and resistance development 1
- Do not wait beyond 3–5 days to change therapy in non-responders—delayed escalation increases complication risk 1
Watchful Waiting: An Alternative Approach
For uncomplicated ABRS with reliable follow-up, initial observation without antibiotics is appropriate. 1
- Start antibiotics only if no improvement by day 7 or symptoms worsen at any time 1
- The number needed to treat (NNT) with antibiotics is 10–15 to achieve one additional cure compared with placebo, reflecting the high spontaneous recovery rate 1
When to Refer to ENT
Immediate referral is indicated for: 1
- No improvement after 7 days of appropriate second-line antibiotic therapy
- Worsening symptoms at any point during treatment
- Suspected complications (severe headache, visual changes, periorbital swelling, altered mental status, cranial nerve deficits)
- Recurrent sinusitis (≥3 episodes per year) requiring evaluation for underlying allergic rhinitis, immunodeficiency, or anatomic abnormalities
Evidence Strength Summary
The recommendation for 5–7 day courses in adults is supported by:
- IDSA guideline (weak recommendation, low-moderate quality evidence) 1
- Multiple RCTs demonstrating comparable efficacy with fewer adverse effects 1, 2
- Predicted clinical efficacy of 90–92% against major pathogens 1
The key takeaway: Shorter is better for uncomplicated adult ABRS—5–7 days provides equivalent cure rates with less diarrhea, while children still require the full 10–14 days. 1