Treatment

The approach to therapy in acute sinusitis varies with the severity of the infection. Patients with uncomplicated sinusitis and mild symptoms can be managed on an outpatient basis with antimicrobials and decongestants. Failure to resolve after an adequate course of oral antibiotics may necessitate admission for intravenous antibiotics and possible surgical drainage.

Antibiotic therapy

The efficacy of antimicrobial therapy has been demonstrated in a number of studies including a controlled trial in children with acute sinusitis. The cure rate at 10 days was higher in children treated with amoxicillin or amoxicillin-clavulanate than in those who received a placebo (66 versus 43 percent). In these studies, a substantial number of patients improved without antibiotic treatment. There appears to be a natural rate of recovery, independent of antibiotic intervention. In a randomized controlled trial which compared the use of amoxicillin to placebo in 214 patients with radiographically corroborated maxillary sinusitis who were also treated with decongestants, there was no difference in outcome between the two groups at one and two weeks in patients with no concurrent medical problems and no history of chronic sinus complaints. The number of people with chronic complaints or acute relapses after one year was also the same in both groups. The inconsistent effect of antimicrobial therapy in these and other studies may be related in part to a viral etiology of the infection.

Two clinical findings suggestive of a bacterial etiology are prolonged symptoms or an acute severe presentation.Despite the uncertain efficacy, a

short course course of antimicrobial therapy is recommended in patients with uncomplicated acute sinusitis.

Choice of antibiotic

Antibiotics with activity against Pneumococcus and Haemophilus are the most widely used. "Narrower" spectrum agents such as amoxicillin are effective in many patients. There are, however, a substantial number of bacteria resistant to amoxicillin, including ß-lactamase producing H. influenzae and penicillin-resistant pneumococci.

There are only a limited number of agents approved by the Food and Drug Administration in the United States for the treatment of sinusitis, including inexpensive drugs, such as ampicillin and amoxicillin, as well as more costly agents, such as amoxicillin-clavulanate, and clarithromycin. Unapproved agents which have been used successfully in sinusitis include trimethoprim-sulfamethoxazole, cefaclor, cefuroxime, azithromycin, cefpodoxime, and cefixime.

Duration of therapy:

The customary duration of antimicrobial therapy in acute sinusitis is seven to fourteen days. However, a recent randomized, controlled trial of patients with maxillary sinusitis treated with oral trimethoprim-sulfamethoxazole showed no difference in outcome between a three and a ten day course of therapy.