Antimicrobial Treatment of Acute Sinusitis

Treatment is aimed at establishing good drainage by using decongestants, nasal saline irrigation/ spray, humidification, and mucolytic agents. Systemic decongestants or antihistamines may be helpful, especially in allergic individuals. Anatomic deformities should be corrected.

Appropriate antibiotic therapy is of paramount importance. Antimicrobial therapy has been shown to be beneficial and effective in preventing septic complications (49,73). Endoscopic examination and culture can assist in the selection of antimicrobials in the treatment of patients who fail to respond (3).

Amoxicillin can be appropriate for the initial treatment of acute uncomplicated mild sinusitis. (Table 6). However, antimicrobials that are more effective against the major bacterial pathogens (including those that are resistant to multiple antibiotics) may be indicated as initial therapy and for the re-treatment of those who have risk factors prompting a need for more effective antimicrobials (Table 7) and those who had failed amoxicillin therapy. These agents include amoxicillin and clavulanic acid, the "newer" or "respiratory" quinolones (e.g., levofloxacin, gatifloxacin, and moxifloxacin), and some of the 2nd & 3rd generation cephalosporins (cefdinir, cefuroxime-axetil, and cefpodoxime proxetil).

These agents should be administered to patients where bacterial resistance is likely (i.e., recent antibiotic therapy, winter season, increased resistance in the community), the presence of a moderate-to-severe infection, the presence of co-morbidity (diabetes, chronic renal, hepatic or cardiac pathology), and when penicillin allergy is present. Agents that may be less effective because of growing bacterial resistance may however be considered for patients with antimicrobial allergy. These include the macrolides, trimethoprim-sulfamethoxazole (TMP-SMX), tetracyclines, and clindamycin (74).

A number of antimicrobial agents have been studied in the therapy of acute sinusitis over the past 25 years, with the use of pre- and post-treatment aspirate cultures. Those studied were ampicillin, amoxicillin, amoxicillin-clavulanic acid, cefuroxime axetil, cefprozil, loracarbef, levofloxacin, gatifloxacin, moxifloxacin, and gemifloxacin. For a 10-day course of therapy, the success rate was a bacteriological cure over 80% to 90%. Appropriate antibiotic therapy is of paramount importance, even though it is estimated that spontaneous recovery occurs in about half of patients (73,74).

The recommended length of therapy for acute sinusitis is at least 14 days, or seven days beyond the resolution of symptoms, whichever is longer. However, no controlled studies have established the duration of therapy sufficient to resolve the infection.

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