What is the best treatment option for a patient with a sinus infection, allergy to penicillin (PCN), presenting with nasal congestion, sinus pressure, and no fever?

From the Guidelines

For a sinus infection with a penicillin allergy, I recommend starting with a non-penicillin antibiotic like cefpodoxime or cefdinir, as they are suitable agents for acute bacterial sinusitis, according to the most recent and highest quality study 1.

Key Considerations

• The patient's symptoms, such as sound stuffiness and sinus pressure without fever, are consistent with acute rhinosinusitis, which can be caused by viral or bacterial infection 1.
• Given the penicillin allergy, it's essential to choose an alternative antibiotic that is effective against common respiratory pathogens, such as S pneumoniae and H influenzae.
• Cefpodoxime and cefdinir are third-generation cephalosporins that can be given orally once or twice daily and have suitable activity against S pneumoniae, including penicillin-resistant strains 1.

Symptom Relief

• For symptom relief, use a combination of pseudoephedrine (Sudafed) 30-60mg every 4-6 hours for congestion and nasal pressure, along with an intranasal steroid spray like fluticasone (Flonase) 1-2 sprays per nostril daily.
• Saline nasal irrigation with a neti pot or saline spray can help clear mucus.
• Over-the-counter pain relievers like acetaminophen (Tylenol) or ibuprofen (Advil) can reduce discomfort and inflammation.

Monitoring and Follow-up

• If symptoms don't improve within 7-10 days, worsen significantly, or if you develop fever or severe pain, consult a healthcare provider as you may need a different antibiotic or further evaluation 1.
• Patients started on antibiotic therapy for ABRS should be counseled on use of the medication, potential adverse effects, and the importance of adherence with dosing schedules.

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)]. 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).

Best option for sinus infection with allergy to PCN:

• Levofloxacin is a suitable option for the treatment of acute bacterial sinusitis, especially in patients with an allergy to penicillin (PCN) 2.
• The recommended dosage for levofloxacin in the treatment of acute bacterial sinusitis is 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 750 mg group and 88.6% for the 500 mg group 2.

From the Research

Sinus Infection Medicine Allergy to PCN

• For patients allergic to penicillin (PCN), alternative antibiotic options are available for the treatment of sinus infections.
• According to 3, in penicillin-allergic patients, amoxicillin-clavulanate is an appropriate option.
• Other alternatives include cefuroxime, cefpodoxime, or cefdinir, as stated in 3.
• In cases of serious drug allergy, clarithromycin or azithromycin may be prescribed, as mentioned in 3.

Treatment Options

• A study published in 4 compared the efficacy and tolerability of a 3-day course of azithromycin with a 10-day course of amoxicillin/clavulanic acid in the treatment of acute sinusitis in adults.
• The results showed that azithromycin was as effective and well tolerated as amoxicillin/clavulanic acid, with a significantly faster resolution of signs and symptoms of sinusitis.
• Another study 5 investigated the sinus fluid penetration of oral clarithromycin and azithromycin in patients with acute rhinosinusitis, finding that both drugs presented adequate penetration into sinus fluid to eradicate erythromycin-sensitive strains of Streptococcus pneumoniae.

Choosing the Best Option

• Considering the patient's symptoms, such as sound stuffiness and sinus pressure without fever, and allergy to PCN, azithromycin or clarithromycin may be a suitable option, as suggested by 3 and 4.
• The choice of antibiotic should be based on the severity of symptoms, the likelihood of bacterial infection, and the patient's medical history, as outlined in 6.