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REF: ACP Online PIER 2007

Antibiotic Drug Rx for Bacterial Sinusitis

Amoxicillin

• Adults: 1.5-3.5 g/d divided bid-tid
  Children: 45 mg/kg·d divided bid × 10-21 days or 7 days symptom free
  High-risk children: 80-90 mg/kg·d divided bid × 10-21 days or 7 days symptom free

• Side Effects: Rash, hypersensitivity reaction (rare), gastrointestinal symptoms

• Notes: One randomized controlled study suggests that amoxicillin and amoxicillin-clavulanate are no more effective than placebo in children with sinusitis (52)

Amoxicillin-clavulanate (Augmentin)

• Dose based on amoxicillin component

• Similar side effects as with amoxicillin

Trimethoprim-sulfamethoxazole (Bactrim DS or Septra DS)  

• 800/160 mg bid × 3-10 days

• Hematologic (rare), rash, gastrointestinal symptoms, toxic epidermal necrolysis (rare)

• Consider in penicillin-allergic patients. Up to 20% pneumococcal resistance

Azithromycin

• Adults: 500 mg/d on day 1, then 250 mg × 4 days
  Children: 10 mg/kg·d on day 1, then 5 mg/kg·d × 4 days

• Similar side effects as with amoxicillin

• Consider in penicillin-allergic patients. No proven benefit over other agents

Doxycycline

• 100 mg bid × 7-10 days

• Photosensitivity, neutropenia

• Not recommended in children 8 years old

What role for antibiotics in otitis media and sinusitis?

Gurpreet S. Ahuja, MD Josette Thompson, MD (UC Irvine)
VOL 104 / NO 3 / SEPTEMBER 1998 / POSTGRADUATE MEDICINE

Otitis media and sinusitis are caused by essentially the same bacterial species.   Antibiotics are often dispensed for viral rhinosinusitis, which is 20 to 200 times more common than bacterial sinusitis .

Sinusitis                       RX

Causative organisms
Streptococcus pneumoniae, 30% to 40%;
Haemophilus influenzae, 20% to 30%; and
Moraxella (Branhamella) catarrhalis, 12% to 20%.
Streptococcus pyogenes accounts for up to 3% of the isolates, found typically in older children.
Viruses - rarely isolated.

In chronic suppurative otitis media :
Pseudomona aeruginosa, Enterobacter species, S aureus, and anaerobes that may be seen in high proportions in polymicrobial infections. The principal anaerobes include peptostreptococci and species of Bacteroides, Fusobacterium, Prevotella, and Porphyromonas . Staphylococcus epidermidis should also be considered a potential pathogen in a chronically draining ear.

Chronic sinusitis is caused by the same organisms associated with acute sinusitis. In addition, higher incidences of staphylococci and anaerobes are seen in chronically inflamed sinuses.

Antimicrobial therapy
Treatment recommendations for both otitis media and sinusitis

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If the patient has received antibiotics in the past month or if resistant organisms are common within the community, use of a second-line agent should be considered, such as amoxicillin and clavulanate potassium (Augmentin), an extended-spectrum macrolide (azithromycin [Zithromax], clarithromycin [Biaxin]), or a second- or third-generation cephalosporin (eg, cefprozil [Cefzil], cefuroxime axetil [Ceftin], cefpodoxime proxetil [Vantin]). Also, switching to a second-line antibiotic may be necessary in patients who do not have a response to first-line treatment or those who have a breakthrough infection during antibiotic prophylaxis.

Quinolones (eg, ciprofloxacin [Cipro]) are not approved for use in children, and data on their efficacy in the treatment of acute otitis media in adults are equivocal. Some of the newer quinolones show increased activity against pneumococci.

Other studies (16,17) have shown that a single dose of intramuscular ceftriaxone sodium (Rocephin) may be as effective as a 10-day course of a common oral antimicrobial. However, its routine use as firstline therapy is not advisable.

Otitis media with effusion
Middle ear effusion may persist for a variable period after an episode of acute otitis media. After treatment, 50% of patients may still exhibit fluid at 4 weeks and 10% at 12 weeks. Effusions in the absence of a recent history of acute otitis media are less likely to resolve spontaneously. Meta-analyses have shown a small (albeit statistically significant) benefit of antibiotic therapy on the short-term resolution of otitis media with effusion, especially in patients with no recent history of acute otitis media (18).

Tympanostomy tubes are an alternative to antimicrobial prophylaxis (22). The principal indications for their use are: (1) chronic middle ear effusions that have not resolved with medical therapy after 3 months (both ears) or 6 months (one ear), especially when accompanied by hearing loss; (2) recurrent acute otitis media, particularly in patients in whom antibiotic prophylaxis has failed; (3) persistent eustachian tube dysfunction that may variably be associated with the development of a retraction pocket, hearing loss, tinnitus, or vertigo; and (4) suppurative complications of otitis media (eg, meningitis, facial nerve paralysis). The benefits of tympanostomy tubes include reduced rates of recurrence and earlier restoration of hearing.

Acute sinusitis
In all types of sinusitis, antibiotics are only one part of pharmacologic therapy; use of nasal sprays, humidifiers, decongestants, antihistamines, and even mucolytics may help control symptoms and speed recovery.

The Task Force on Rhinosinusitis of the American Academy of Otolaryngology-Head and Neck Surgery recommends the same antibiotics for acute sinusitis and acute otitis media (23). The choice of a specific agent for both illnesses should be based on the same factors.

Antibiotics that do not cover the major causative organisms of sinusitis and are not recommended include penicillin, erythromycin, cephalexin (Biocef, Keflex), and tetracycline. Cefixime (Suprax) and ceftibuten (Cedax) have inadequate activity against S pneumoniae and are also not good choices for acute sinusitis.

Mild cases of acute sinusitis lasting 7 days or less usually are viral infections and should not be treated with antibiotics. In patients who meet the diagnostic criteria for acute sinusitis (table 1) and have progressive or nonresolving symptoms, a 10- to 14-day course of amoxicillin is appropriate initial therapy (24).

Chronic sinusitis
Amoxicillin and clavulanate, cefpodoxime, and cefuroxime have been used successfully to treat chronic sinusitis. Clindamycin (Cleocin) also is helpful in such infections, in which staphylococci and anaerobes are common, but it is generally not used alone because it lacks gram-negative coverage. In severe cases, ciprofloxacin or ofloxacin (Floxin) may be given in combination with metronidazole (Flagyl, Protostat) or clindamycin. Chronic sinusitis is usually treated for 3 to 6 weeks.

If symptoms progress after 72 hours of initial empirical therapy for either acute or chronic sinusitis, a broader-spectrum antibiotic (eg, a beta-lactamase-stable agent) may be indicated. Initiation of such treatment is recommended for severe acute sinusitis or prolonged, symptomatic chronic sinusitis. In difficult cases, a culture from the middle meatus or the sinus itself may be helpful.

Correspondence: Gurpreet S. Ahuja, MD, Department of Otolaryngology-Head and Neck Surgery, UCI Medical Center, 101 The City Dr S, Bldg 25, Orange, CA 92868. E-mail: gsahuja@uci.edu.

Otitis Media                        ACP Med 2006

The most common causes of purulent otitis media are the pneumococcus, nontypable strains of Haemophilus influenzae, and Moraxella catarrhalis; the previously important group A streptococci are now uncommon but may be more aggressive than other pathogens.1,2 Other organisms that can cause acute otitis media are coagulase-negative staphylococci and anaerobic bacteria. Gram-negative bacilli and Staphylococcus aureus can cause acute otitis media in neonates. Viruses and mycoplasmas are uncommon as the primary pathogens in acute otitis media, but in 41% of children with acute bacterial otitis, respiratory tract viruses are also present; respiratory syncytial virus is the most common causal organism, followed by parainfluenza and influenza viruses. Purulent nosocomial otitis is uncommon and occurs in only 4% of patients who have undergone endotracheal intubation; gram-negative bacilli are the responsible agents in this setting.

1. Palmu AAI, Herva E, Savolainen H, et al: Association of clinical signs and symptoms with bacterial findings in acute otitis media. Clin Infect Dis 38:234, 2004 [PMID 14699456]

2. Segal N, Givon-Lavi N, Leibovitz E, et al: Acute otitis media caused by Streptococcus pyogenes in children. Clin Infect Dis 41:35, 2005 [PMID 15937760]

        2007