What is the best treatment for sinusitis in a patient with a penicillin (PCN) allergy?

From the Guidelines

For patients with sinusitis who are allergic to penicillin, the best treatment option is to use folate inhibitors such as trimethoprim-sulfamethoxazole as a cost-effective alternative to amoxicillin, or consider the macrolide class of antibiotics 1. When managing acute bacterial rhinosinusitis (ABRS) in patients allergic to penicillin, it's crucial to consider the severity of illness, patient preference, and local resistance patterns.

• The diagnosis of ABRS should be based on clinical criteria, including symptoms or signs of acute rhinosinusitis that are present 10 days or more beyond the onset of upper respiratory symptoms, or worsening within 10 days after an initial improvement 1.
• For patients with nonsevere illness, the observation option, which involves deferring antibiotic treatment for up to 7 days and managing symptoms, can be considered 1.
• However, for patients with severe illness or those who are penicillin-allergic, antibiotics such as trimethoprim-sulfamethoxazole or macrolides should be initiated promptly 1.
• Symptomatic relief measures, including hydration, analgesics, and other supportive therapies, should also be provided to aid in symptom management 1.
• It's essential to counsel patients on the importance of adherence to the prescribed antibiotic regimen and potential adverse effects, as well as the natural history of ABRS to set realistic expectations regarding treatment outcomes 1.
• If the patient worsens or fails to improve with the initial management option, reassessment and consideration of alternative treatments or referral to a specialist may be necessary 1.

From the FDA Drug Label

In the second study, 264 patients were enrolled in a prospective, multi-center, non-comparative trial of 500 mg levofloxacin administered orally or intravenously once daily for 7 to 14 days. Clinical success for clinically evaluable patients was 93% For both studies, the clinical success rate in patients with atypical pneumonia due to Chlamydophila pneumoniae, Mycoplasma pneumoniae, and Legionella pneumophila were 96%, 96%, and 70%, respectively. 14. 4 Acute Bacterial Sinusitis: 5 Day and 10 to 14 Day Treatment Regimens 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 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

The best treatment for sinusitis in a patient allergic to PCN is levofloxacin. The recommended dosage is either 750 mg by mouth x 5 days or 500 mg by mouth once daily x 10 to 14 days. Clinical success rates for levofloxacin in the treatment of acute bacterial sinusitis are 91.4% for the 5-day regimen and 88.6% for the 10-14 day regimen 2.

Alternatively, moxifloxacin can also be used to treat acute bacterial sinusitis, with a clinical success rate of 90% at the 7 to 21 day post-therapy test of cure visit 3.

Another option is azithromycin, which has been shown to be effective in the treatment of acute bacterial sinusitis in pediatric patients, but its use in adults is supported by evidence from adequate and well-controlled studies 4.

From the Research

Treatment Options for Sinusitis in Patients Allergic to PCN

• For patients allergic to Penicillin (PCN), alternative antibiotics can be used to treat sinusitis, as suggested by 5.
• Amoxicillin-clavulanate is an appropriate option for patients who are allergic to PCN or unresponsive to amoxicillin, according to 5.
• Other alternatives include cefuroxime, cefpodoxime, or cefdinir, as mentioned in 5.
• In cases of serious drug allergy, clarithromycin or azithromycin may be prescribed, as stated in 5.
• A study comparing azithromycin and amoxicillin/clavulanate found that azithromycin had a faster resolution of signs and symptoms of sinusitis, with a cure rate of 95% by the end of therapy, as reported in 6.
• Moxifloxacin has also been shown to be effective in treating acute rhinosinusitis, with a shorter treatment duration and lower risk of treatment failure and recurrence compared to levofloxacin, as found in 7.

Antibiotic Duration and Efficacy

• The optimal duration of therapy for sinusitis is unknown, but some recommend treatment until the patient becomes free of symptoms and then for an additional 7 days, as suggested in 5.
• A 3-day course of azithromycin was found to be as effective as a 10-day course of amoxicillin/clavulanic acid in treating acute sinusitis, with a significantly simpler dosage regimen and faster clinical effect, as reported in 6.
• Moxifloxacin has been shown to have a shorter treatment duration and lower total treatment charges compared to levofloxacin, while resulting in better outcomes, as found in 7.