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Guidelines

Acute Sinusitis – Treatment

The goal of treatment is to promote adequate drainage of the sinuses. This in turn will provide relief of symptoms associated with sinusitis. This may require a combination of home care and medical treatments.

Symptomatic Care

Many patient sources discuss the benefits of comfort measures even though few studies have been conducted on the sinusitis population to document the actual effects of these measures on the treatment of sinusitis. Therefore, non-pharmacologic measures are aimed at symptom relief and providing comfort. There is no evidence to determine whether the use of antihistamines, decongestants or nasal irrigation is efficacious in children with acute sinusitis (Shaikh, 2014). The sections below discuss the evidence for adults.

  • Comfort measures. See the “Viral Upper-Respiratory Infections” section for information on comfort measures.
  • Topical decongestants. One randomized controlled trial that included 60 patients evaluated the effects of topical agents of fluticasone propionate, oxymetazoline, and 3% and 0.9% sodium chloride solutions on mucociliary clearance in the therapy of acute bacterial rhinosinusitis in vivo. It found that oxymetazoline and 3% NaCl solution groups seemed to be more effective in mucociliary clearance, but there was no significant difference in improvement among the groups including those not receiving any treatment (Inanli, 2002). Topical decongestants should not be used for longer than 72 hours, owing to the potential for rebound congestion (Aring, 2016).
  • Oral decongestants. No controlled trials have assessed the efficacy of oral decongestants for the treatment of acute sinusitis (Aring, 2016). The IDSA guideline does not recommend their use (Chow, 2012), while the AAP guideline states the data is insufficient, and the AAO guideline (Rosenfeld, 2015) supports their use while agreeing there is little data to document benefit. If used, oral decongestants should be recommended with caution to patients with hypertension or cardiovascular disease.
  • Intranasal corticosteroids. Intranasal corticosteroid sprays are a reasonable option either alone or as adjunct to antibiotics. Evidence has shown modest benefit but low risk.

A 2012 systematic review and meta-analysis of six studies (five studies prescribed an antibiotic with the nasal steroid and one study did not) found modest benefit with a NNT of 13. The benefit was more pronounced with longer durations of treatment (21 days) and higher doses of medication. No serious adverse events were noted (Hayward, 2012).

Similarly, a 2013 systematic review found that patients receiving intranasal corticosteroids were more likely to experience symptom improvement after 15 to 21 days compared with those receiving placebo. Higher doses of intranasal corticosteroids had a greater effect on symptom relief than lower doses. Additionally, no significant adverse events were reported, and there was no significant difference in dropout or recurrence rates for those receiving intranasal corticosteroids or placebo and for those receiving higher doses of intranasal corticosteroids (Zalmanovici Trestioreanu, 2013).

A different systematic review looked for evidence of benefit in patients with recurrent sinusitis (four or more episodes per year) and found only three trials, of which two had bias risks. That trial did find mild improvement in length of symptoms and possibly decreased recurrence, but more study is needed (van Loon, 2013).

  • Systemic corticosteroids. Systemic corticosteroids have also been studied and have some advantage of lower cost and easier administration, but higher risk of adverse events. A 2014 systematic review of five trials studying oral steroids – one as monotherapy and four as adjunctive therapy – found in the monotherapy study no benefit while the adjunctive studies found modest benefit with a NNT of seven without significant adverse events. However, this review recommended against using oral steroids until more data are available (Venekamp, 2014). Due to high risk of side effects, systemic corticosteroids should be used judiciously.
  • Antihistamines
    Antihistamines are not recommended for the treatment of sinusitis in the absence of known allergic disease, because they cause further thickening of secretions (Willett, 1994).

Antibiotics

The controversy around use of antibiotics in sinusitis relates to the often self-limited nature of the disease and the relatively small benefits found in studies. It is currently controversial whether to start antibiotics at the time of diagnosis or use watchful waiting to determine if they are needed.

Since antral puncture on all patients suspected of bacterial sinusitis is clinically impractical, the diagnosis rests on clinical impression, and antibiotic therapy is empiric.

In reference to other guidelines, Infectious Diseases Society of America (IDSA) Clinical Practice Guideline for Acute Bacterial Rhinosinusitis in Children and Adults (Chow, 2012) recommends starting an antibiotic at the time of diagnosis. American Academy of Otolaryngology (AAO) Clinical Practice Guideline (Update): Adult Sinusitis (Rosenfeld, 2015), and the American Academy of Pediatrics (AAP) Clinical Practice Guideline for the Diagnosis and Management of Acute Bacterial Sinusitis in Children Aged 1 to 18 Years (Wald, 2013) recommend considering watchful waiting using shared decision-making.

Overall, the literature shows consensus that immediate antibiotic use has small benefits in resolving acute rhinosinusitis symptoms or reducing clinical failure within approximately two weeks of treatment, although follow-up times vary across the included randomized controlled trials. Serious complications associated with acute rhinosinusitis were rare. Evidence on delayed treatment with antibiotics is small. More studies are needed on delayed strategies. Overall, the benefits of treating the symptoms of acute rhinosinusitis with antibiotics may not outweigh the harms of treatment such as serious side effects of antibiotic use and antibiotic resistance. One limitation of literature in general is that literature evaluated patients with clinical signs and symptoms and not definitive diagnosis of acute bacterial sinusitis. Finally, there is no conclusive evidence on merits of antibiotic use in children with acute rhinosinusitis. Individual studies have had the following findings:

  • A 2016 systematic review including 6 randomized controlled trials (randomized controlled trials) that compared treatment of any antibiotic with placebo found a benefit of antibiotic treatment compared to placebo for the rate of improvement after 3 (odds ratio 2.78) and 7 days (odds ratio 2.29) after initiation of antibiotics in patients with symptoms and signs of acute rhinosinusitis lasting for seven or more days. After 10 days, improvement rates did not differ significantly between patients treated with or without antibiotics (odds ratio 1.36). Compared to placebo, antibiotic treatment relieves symptoms in a significantly higher proportion of patients within the first days of treatment (Burgstaller, 2016).
  • A 2015 systematic review of 31 randomized controlled trials on efficacy and side effects of antibiotics in the treatment of acute rhinosinusitis found only slight added benefit in the usage of antibiotics over placebo in the treatment of ARS (Sng, 2015).
  • A 2014 systematic review of 63 studies (nine placebo-controlled trials with 1,915 participants) and 54 studies comparing different classes of antibiotics (10 different comparisons) (the trials in the review included clinically diagnosed acute sinusitis, confirmed or not by imaging or bacterial culture) found moderate-quality evidence that antibiotics provide a small benefit for clinical outcomes in immunocompetent primary care patients with uncomplicated acute sinusitis. However, about 80% of participants treated without antibiotics improved within two weeks (Ahovuo-Saloranta, 2014). In five studies at low risk of bias, penicillin or amoxicillin decreased the risk of clinical failure (a lack of full recovery or improvement for participants with symptoms lasting at least seven days) rate at 7 to 15 days follow-up (risk ratio 0.66) compared to placebo. After 15 days, there were no differences in clinical failure between the two groups. Cure or improvement rates, as opposed to clinical failure, at 7 to 15 days were 86% among placebo patients and 91% among antibiotic patients, indicating no differences between the two groups. When clinical failure was defined as a lack of full recovery, results were similar: antibiotics decreased the risk of failure (risk ratio 0.73) at 7 to 15 days follow-up. Adverse effects in seven of the nine placebo-controlled studies (comparing penicillin, amoxicillin, azithromycin or moxicillin to placebo) were more common in antibiotic than in placebo groups. However, dropouts due to adverse effects were rare in both groups (Ahovuo-Saloranta, 2014).
  • A 2012 systematic review of 10 randomized controlled trials with 2,450 participants comparing antibiotic treatment to placebo in adult participants with uncomplicated acute rhinosinusitis-like signs and symptoms found that given antibiotic resistance and low incidence of serious complications, antibiotics should not be used in adult patients with clinically diagnosed, uncomplicated acute rhinosinusitis. The findings are not applicable to children, patients with a suppressed immune system and patients with severe disease since the trials did not include these populations (Lemiengre, 2012). Specifically, the findings showed that 47% of participants were cured after one week and 71% after 14 days irrespective of the treatment group; antibiotics shortened the time to cure, but only five more participants per 100 will cure faster at any time point between 7 and 14 days if they receive antibiotics instead of placebo (number needed to treat to benefit [NNTB]) 18); purulent secretion resolved faster with antibiotics (odds ratio [OR] 1.58; NNTB 11) (Lemiengre, 2012). Participants who received antibiotics (7%) and those who received placebo (15%) experienced adverse events (OR 2.10; number needed to treat to harm [NNTH] 8). More participants in the placebo group needed to start antibiotic therapy because of an abnormal course of rhinosinusitis (OR 0.49; NNTH 20). Only one disease-related complication (brain abscess) occurred in a patient treated with antibiotics (Lemiengre, 2012).

More studies are needed on the merits of antibiotic use in children with acute rhinosinusitis. A 2013 systematic review and meta-analysis of four randomized controlled trials on efficacy of antibiotics in the treatment of acute rhinosinusitis in children found symptoms improved at 10-14 days of antibiotic use (odds ratio 2.0). There were substantial methodological differences between the included randomized controlled trials to conclusively determine whether antibiotic use in children is merited (Cronin, 2013).

Delayed vs. immediate antibiotic prescription strategies. A 2016 randomized controlled trial involving 405 adults with acute, uncomplicated respiratory infections compared the efficacy and safety of two delayed antibiotic prescription strategies (a delayed patient-led prescription strategy and a delayed prescription collection strategy requiring patients to collect their prescription from the primary care center) with immediate prescription and no antibiotic strategies. In this trial 19.8% of the participants had uncomplicated acute rhinosinusitis, while the rest had other uncomplicated acute respiratory tract infections. It found that use of antibiotics does not lead to a clinically significant improvement in symptom resolution compared to the placebo group. But for patients who do want antibiotics, a delayed prescription approach may be more appropriate as it significantly reduces antibiotic use (de la Poza Abad, 2016).

Antibiotic Considerations

A 2014 systematic review of 63 randomized controlled trials of patients with clinically diagnosed acute sinusitis, confirmed or not by imaging or bacterial culture that included 54 studies comparing different classes of antibiotics (10 different comparisons), found that in the 10 head-to-head comparisons, none of the antibiotic preparations was superior to another. However, amoxicillin-clavulanate had significantly more dropouts due to adverse effects than cephalosporins and macrolides (Ahovuo-Saloranta, 2014).

The ICSI work group did not specifically search for primary literature on first-line vs. alternative antibiotic treatments for acute bacterial sinusitis. Instead, the IDSA (Chow, 2012), AAO (Rosenfeld, 2015) and AAP (Wald, 2013) antibiotic recommendations are listed.

First-line treatment. The IDSA recommends amoxicillin-clavulanate combination. Per the IDSA, high-dose amoxicillin-clavulanate should be considered in situations where the patient has higher risk of resistance: age < 2 or > 65, day care participation, hospitalization within the past five days, prior antibiotics within the past month, immunocompromised, comorbidities, a local rate of S. pneumoniae resistance > 10%, or severe disease (Chow, 2012). The AAO and AAP recommend amoxicillin with or without clavulanate.

Alternatives to first-line

  • Doxycycline is an alternative in adults who are allergic to penicillin. It is not suitable for children (IDSA and AAO).
  • Respiratory fluoroquinolone (Levofloxacin or Moxifloxacin) in children and adults who are allergic to penicillin (IDSA, AAO and AAP) – FDA warns fluoroquinolones should be used only in serious bacterial infections and reserved for use in patients who have no other treatment options for acute bacterial sinusitis. There may be serious adverse events associated with these medications that outweigh the benefits. The warning can be found at https://www.fda.gov/Drugs/DrugSafety/ucm511530.htm.
  • Second- or third-generation cephalosporins as monotherapy or in combination

– The IDSA does not recommend it as monotherapy due to lack of coverage of penicillin-resistant S. pneumoniae.

– The IDSA recommends combination therapy with a third-generation oral cephalosporin (cefixime or cefpodoxime) plus clindamyacin as second-line therapy for children with non-type I penicillin allergy or from geographic regions with high endemic rates of PNS S. pneumoniae.

– The AAO recommends combination therapy with a third-generation oral cephalosporin (cefixime or cefpodoxime) plus clindamyacin in adults with a history of non-type I hypersensitivity to penicillin.

– The AAP recommends their use if allergic to penicillin or amoxicillin or combination of clindamycin (or linezolid) and cefixime in young children (age < 2) with a serious type 1 hypersensitivity to penicillin and moderate or more severe sinusitis.

– Trimethoprim-sulfamethoxazole and macrolides are no longer recommended as alternatives due to increasing resistance (IDSA, AAO and AAP).

Duration of initial antibiotic treatment

A 2014 systematic review involving adult patients found that penicillin or amoxicillin decreased the risk of clinical failure rate at 7 to 15 days follow-up compared to placebo (Ahovuo-Saloranta, 2014). Another systematic review involving adult patients found that antibiotics can shorten the time to cure, but only five more participants per 100 will cure faster at any time point between 7 and 14 days if they receive antibiotics instead of placebo. Number needed to treat to benefit was 18 (Lemiengre, 2012).

A 2013 systematic review and meta-analysis of 4 randomized controlled trials on efficacy of antibiotics in the treatment of acute rhinosinusitis in children found symptoms improved at 10-14 days of antibiotic use (Cronin, 2013).

IDSA, AAO and AAP recommendations:

  • 5-7 days in adults; 10-14 days in children (IDSA)
  • 5-10 days for most adults (AAO)
  • No recommendation (AAP)

Antibiotic Treatment Response

Complete response. Patient is symptomatically improved to near normal.

Failure or no response. IDSA, AAO and AAP guidelines on acute bacterial rhinosinusitis all agree that patients who worsen in 48-72 hours after starting treatment or who are not responsive within seven days warrant reevaluation. During reevaluation, consider whether the diagnosis is correct and if there is an underlying abnormality (Rosenfeld, 2015; Wald, 2013; Chow, 2012). They recommend the following for these patients:

  • Consider switching to an alternative antibiotic
  • Consider referral to a specialist (e.g., ENT or ID)
  • Consider imaging with sinus CT

An antibiotic that offers better coverage-resistant bacteria, such as high-dose amoxicillin/clavulanate, should be prescribed if ABRS is confirmed as the diagnosis (Chow, 2012). A substantial minority of patients will have infection from bacteria that are resistant in vitro to first-line therapy. Several studies have suggested that failure of therapy may be due to ß-lactamase-producing organisms, anaerobes or staphylococci. It would seem reasonable, therefore, to give a trial of a broader spectrum antibiotic in the setting of clinical failure (Rosenfeld, 2015).

ICSI

ICSI