Managing Acute Sinusitis: Bacterial vs. Viral and Treatment Strategies
Introduction
As a clinical pharmacist, you will be asked to distinguish between bacterial and viral acute sinusitis (AS), a key factor in determining treatment. Use clinical criteria "see table 1" to identify bacterial AS requiring antibiotics. Bacterial pathogens include: Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis.
Distinguishing between the common cold and AS is often a matter of symptom duration. Typical common colds are self-limited and last 7 to 10 days, whereas AS can persist for up to 4 weeks. Symptoms of AS are similar to those of the common cold and include: Nasal congestion and discharge, facial pain over the sinuses, decreased sense of smell and cough. The waxing and waning phenomenon sets AS apart from the common cold. Patients may experience mild symptom improvement after 5 to 7 days, followed by worsening symptoms, including new-onset fever, headache, and/or increased nasal discharge.
A bacterial origin is suspected if any of the following symptoms or signs are present: Purulent nasal discharge, maxillary tooth or facial pain, unilateral maxillary sinus tenderness, worsening symptoms after initial improvement. Diagnosis of acute bacterial sinusitis (ABS) can be made if a patient has 2 major markers or 1 major and 2 minor markers, and symptoms persist beyond 7 to 10 days, start out severe and last at least 3 to 4 consecutive days, or worsen after 5 to 7 days.
| Table (1). Signs and symptoms of acute bacterial sinusitis | |
|---|---|
| Major Markers | Minor Markers |
| Purulent nasal discharge | Headache |
| Purulent postnasal discharge | Ear pain/pressure/fullness |
| Nasal obstruction/congestion | Sore throat |
| Facial congestion/fullness | Halitosis |
| Focal facial pain/pressure | Dental pain |
| Hyposmia/anosmia | Cough |
| Fever (≥102°F [39°C]) | Fever (<102°F) |
| Fatigue | |
Pharmacotherapy
Select the right antibiotic to prevent complications "see table 2". First-line options include amoxicillin-clavulanate (Curam, Augmentin), recommended by the IDSA. Doxycycline (Vibramycin) can be an alternative for adults. Cephalosporins are not preferred due to resistance but may be combined with clindamycin (Dalacin) for children with non–type I penicillin allergy. Levofloxacin (Tavanic, Levon) is reserved for children with type I penicillin allergy. Trimethoprim-sulfamethoxazole (Septrin, Bactrim) is not recommended due to high resistance rates.
| Table (2). Antibiotic regimens for acute sinusitis | |||
|---|---|---|---|
| Class | Line | Dosage | Notes |
| Penicillin/amoxicillin/augmentin | First | Amoxicillin-clavulanate 875 mg/125 mg BID or 500 mg/125 mg TID for 5–7 days | Amoxicillin-clavulanate is recommended by the IDSA as the preferred empiric antimicrobial therapy for acute sinusitis. |
| Doxycycline | First | 100 mg BID for 5–7 days | Doxycycline may be used as an alternative regimen to amoxicillin-clavulanate for initial empiric antimicrobial therapy for ABRS in adults because it remains highly active against respiratory pathogens. |
| Cephalosporins | Second/third | Cefixime 400 mg QD or Cefpodoxime 200 mg BID + Clindamycin 300 mg TID for 10 days | Second- and third-generation oral cephalosporins are no longer recommended for empiric monotherapy for ABRS due to variable rates of resistance among Streptococcus pneumoniae. Combination therapy with a third-generation oral cephalosporin (cefixime or cefpodoxime) plus clindamycin may be used as second-line therapy for children with non–type I penicillin allergy or from geographic regions with high endemic rates of PNS S. pneumoniae. |
| Quinolone | Second/third | Levofloxacin 500 mg QD for 5–7 days | Levofloxacin is recommended for children older than 8 years with a history of type I hypersensitivity to penicillin. |
| Sulfa | Third | Trimethoprim-sulfamethoxazole (TMP-SMX) 160/800 mg BID for 10 days | Trimethoprim-sulfamethoxazole is not recommended for empiric therapy because of high rates of resistance among both S. pneumoniae and Haemophilus influenzae (~30%–40%). |
Duration of therapy? A 5–7 day course is effective for uncomplicated cases. No significant benefit was found with longer courses. Adjunct therapies "see table 3" may improve symptoms...
- Intranasal steroids (Avamays, Flixonase, etc) reduce nasal inflammation—strongly recommended.
- Oral decongestants reduce secretions but should be avoided in uncontrolled hypertension, hyperthyroidism, CAD, and certain other conditions.
- Topical decongestants (Otrivin, etc) work better than oral forms but should be used for no more than 3 days to prevent rebound congestion.
- Mucolytics (Bromhexine, Ambroxol) help thin nasal secretions.
- Saline irrigation (Neti pot) improves clearance and enhances comfort.
Additional supportive measures include staying hydrated, using warm facial packs, avoiding environmental triggers, elevating the head during sleep, and frequent hand washing. Tailor therapy based on severity, comorbidities, and resistance patterns to optimize outcomes.
| Table (3). Therapeutic options for acute sinusitis | ||
|---|---|---|
| Class of Drug/Modality | Efficacy | Notes |
| Intranasal steroids | Decreases nasal inflammation | Highly recommended |
| Antihistamines | Increases viscosity of nasal secretions | Not recommended |
| Oral decongestants | Decrease amount of nasal secretions and edema | Caution in patients with uncontrolled hypertension, hyperthyroidism, coronary artery disease, diabetes, glaucoma, and benign prostatic hypertrophy; not indicated for children <6 years old |
| Topical decongestants | Decrease amount of nasal secretions | Use for no more than 3 days to lessen the risk of rebound nasal congestion. Found to be more effective than oral decongestants |
| Mucolytics | Thin nasal secretions | Useful adjunctive therapy |
| Analgesics | Decrease headache and sinus pressure | Dose per manufacturer’s guidelines |
| Saline nasal irrigation/humidity and Neti pot | Thin nasal secretions/improve nasal clearance | Increases comfort |
References
- Chow AW, Benninger MS, Brook I, et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Dis. 2012;54(8):e72-e112.
- Falagas ME, Karageorgopoulos DE, Grammatikos AP, Matthaiou DK. Effectiveness and safety of short vs. long duration of antibiotic therapy for acute bacterial sinusitis: a meta-analysis of randomized trials. Br J Clin Pharmacol. 2009;67(2):161-171.
- Aring AM, Chan MM. Acute rhinosinusitis in adults. Am Fam Physician. 2011;83(9):1057-1063.
