- Pregnant women.
- Children. The American College of Chest Physicians advises against the use of over-the-counter decongestants and other cold medications in children ages 14 years or younger. Children are at particular risk for side effects that depress the central nervous system. Such symptoms cause changes in blood pressure, drowsiness, deep sleep, and, rarely, coma.
Antihistamines
Older antihistamines such as diphenhydramine (Benadryl) are helpful in relieving cough when used alone or in combination with a decongestant.
Expectorants
Expectorants are drugs that cause mucus to be coughed up from the lungs. The most common type used is guaifenesin, which is found in many over-the-counter (OTC) cough syrups as well as prescription products. Expectorants used to be recommended for treatment of sinusitis-associated cough, but some recent guidelines advise against their use. According to the American College of Chest Physicians (ACCP), expectorants and cough suppressants do not help treat cough. The ACCP recommends that adults instead take a decongestant or antihistamine to relieve cough. The ACCP also recommends against OTC cold and cough medicine for children ages 14 years and younger. Parents should talk with their child’s pediatrician for advice on treating cough.
Antibiotics for Acute Sinusitis
Overview on Antibiotics and Their Overuse. Sinusitis is the fifth most common diagnosis for antibiotic prescriptions. And, there is much evidence that antibiotics are inappropriately prescribed for many patients.
- A major analysis reported that antibiotics helped only 1 child out of 8 who had persistent nasal discharge for at least 20 days. Even when they were helpful, benefits were modest in reducing duration of the infection. No long-term benefits have been reported. This study backed up a number of small studies that have found no significant benefit from antibiotics for most children. In a 2001 study, for example, 87% of children improved regardless of their treatment.
- Although antibiotics may prevent complications and reduce the risk of recurrent or chronic sinusitis, few well-conducted studies have been performed to confirm or refute their benefits in most cases for which they are prescribed.
The intense and widespread use of antibiotics--not only for sinusitis but also for other upper respiratory tract infections--is leading to a serious global problem, which is bacterial resistance to common antibiotics. For example, according to reports in 2002 and 2001, in Canada 15% of S. pneumoniae strains are resistant to penicillin; in the U.S. 30 - 40% are resistant; in Hong Kong 70 - 80% of strains no longer respond to penicillin. Furthermore, in the U.S. about 23% of S. pneumoniae are currently resistant to at least three antibiotics. High rates of resistance strains are even being observed in infants. In general, regions with the highest rate of resistance are those in which antibiotics are the most heavily prescribed. Encouraging studies are now reporting that inappropriate antibiotic prescriptions are on the decline.
When to Use Antibiotics. Because the majority of sinusitis cases resolve on their own, doctors generally wait 10-14 days before prescribing antibiotics. However, antibiotics may be prescribed sooner if severe symptoms develop. These symptoms include:
- Fever
- Facial pain or tenderness
- Swelling around the eyes
Antibiotic Regimens
- The standard first-line antibiotic treatment for acute bacterial sinusitis is a 10-14 day course of amoxicillin. Trimethoprim-sulfamethoxazole is an alternative choice.
- If no change occurs within 3-5 days, the doctor may prescribe a different type of antibiotic such as amoxicillin-clavulanate, cephalosporin, or a macrolide.
- If the patient does not respond after 21-28 days, broad-spectrum antibiotics such as amoxicillin-clavulanate, cefuroxime, or cefpodoxime may be used. Other choices include clarithromycin or azithromycin (macrolides) or levofloxacin (a fluoroquinolone).
Side Effects of Antibiotics. Most antibiotics have the following side effects (although specific antibiotics may have other side effects or fewer of the standard ones):
- The most common side effect for nearly all antibiotics is gastrointestinal distress.
- Antibiotics double the risk for vaginal infections in women. Taking supplements of acidophilus or eating yogurt with active cultures may help restore healthy bacteria that offset the risk for such infections.
- Allergic reactions can also occur with all antibiotics but are most common with medications derived from penicillin or sulfa. These reactions can range from mild skin rashes to rare but severe, even life-threatening anaphylactic shock.
- Certain drugs, including some over-the-counter medications, interact with antibiotics; patients should inform the doctor of all medications they are taking and of any drug allergies.
Specific Antibiotics Used for SinusitisBeta-Lactams The beta-lactam antibiotics share common chemical features and include penicillins and cephalosporins. Their primary action is to interfere with bacterial cell walls. Penicillins. Amoxicillin (Amoxil, Polymox, Trimox, Wymox, or any generic formulation) has been the most widely prescribed antibiotic for acute sinusitis. This penicillin is both inexpensive and at one time was highly effective against the S. pneumoniae bacteria. Unfortunately, bacterial resistance to amoxicillin has increased significantly, both among S. pneumoniae and H. influenzae, and penicillins are no longer as reliable as it was. Amoxicillin-clavulanate (Augmentin) is a type of penicillin that works against a wide spectrum of bacteria. An extended release form has been approved for treating adults with sinusitis infections that have become resistant to penicillin. Many people have a history of an allergic reaction to penicillin, but some evidence is suggesting that the allergy may not recur in a significant number of adults. Skin tests are available that could determine if some people previously allergic could use these important antibiotics. Cephalosporins. These drugs are also effective against S. pneumoniae. They are often classed by generation:
The later-generation antibiotics cefpodoxime, cefdinir, and cefuroxime are good choices for penicillin-allergic patients with mild to moderate sinusitis who have been treated in the previous 4 to 6 weeks. Penems, a type of beta-lactam antibiotic, are also being investigated for sinusitis treatment. Macrolides and Azalides Macrolides are a class of antibiotics that are divided into different sub-groups. Azalides are one of those sub-groups. This type of antibiotic is often used to treat mild-to-moderate bacterial sinusitis in patients who are allergic to penicillin. Some of the most common macrolids/azalides are azithromycin (Zithromax), clarithromycin (Biaxin), and roxithromycin (Rulid). An extended-release form of azithromycin (Zmax) was approved in 2005 as a single dose treatment for mild-to-moderate acute bacterial sinusitis. These antibiotics are also effective against many strains of S. pneumoniae and M. catarrhalis, but macrolide-resistance rates doubled between 1995 and 1999 as the number of children treated with the antibiotics increased. Erythromycin is not effective against H. influenzae. Macrolides have anti-inflammatory actions, which may have benefits for some patients with chronic sinusitis. Investigators are studying long-term low-dose macrolide treatments, which are not intended to eliminate bacteria, but to reduce inflammation. Studies suggest that this approach may be effective without increasing the risk for bacterial resistance. Trimethoprim-Sulfamethoxazole Trimethoprim-sulfamethoxazole (Bactrim, Cotrim, Septra) is another first-line antibiotic for sinusitis. It is less expensive than amoxicillin and particularly useful for patients with mild sinusitis who are allergic to penicillin. It is no longer effective, however against certain streptococcal strains. It should not be used in patients whose infections occurred after dental work or in patients allergic to sulfa drugs. Allergic reactions can be very serious. Fluoroquinolones (Quinolones) Fluoroquinolones (also simply called quinolones) interfere with the bacteria's genetic material so they cannot reproduce. Newer generation fluoroquinolones, which include levofloxacin (Levaquin), sparfloxacin (Zagam), gatifloxacin (Tequin), and moxifloxacin (Avelox), are currently the most effective agents against the common bacteria that cause sinusitis. They are recommended for adults with moderate sinusitis who have already been treated with antibiotics within 6 weeks or who are allergic to beta-lactam antibiotics. Some of the newer fluoroquinolones only need to be taken once a day, which make compliance easier. Some, but not all, quinolones cause photosensitivity. S. pneumoniae strains resistant to the quinolones have been uncommon in the U.S. but their numbers are increasing. In fact, levofloxacin was the first drug approved specifically for penicillin-resistant S. pneumoniae. Unfortunately, studies are now finding resistance to this drug as well. Lincosamide Lincosamides prevent bacteria from reproducing. The most common lincosamide is clindamycin (Cleocin). This antibiotic is useful against many S. pneumoniae bacteria but not against H. influenzae. Tetracyclines Tetracyclines inhibit bacterial growth. They include doxycycline, tetracycline, and minocycline. They can be effective against S. pneumoniae and M. catarrhalis, but bacteria that are resistant to penicillin are also often resistant to doxycycline. Tetracyclines have unique side effects among antibiotics, including skin reactions to sunlight, possible burning in the throat, and tooth discoloration. Ketolides In January 2006, the FDA issued a Public Health Advisory for health care providers and patients using telithromycin (Ketek), the first antibiotic in the ketolide class. The drugs had shown promise in treating many of the otherwise antibiotic-resistant bacterial strains and is approved for treating community acquired pneumonia (CAP), chronic obstructive lung disease, and acute sinusitis. Patients treated with this antibiotic should stop using it if jaundice (yellowing of the skin or whites of the eyes) develops. The FDA issued this advisory after three cases of severe liver injury in patients treated with Ketek. In June 2006, the FDA reported that four people had died after taking the drug. The FDA also ordered the manufacturer to add a warning to the drug's label about potential liver problems. Early studies of Ketek did not reveal any significant risks of liver injury, compared with other antibiotics. In December 2006, however, the FDA recommended that Ketek should not be used in patients with sinusitis or bronchitis. The FDA panel also recommended that the drug should carry a black box warning noting the potentially serious side effects, including liver failure, vision problems, loss of consciousness, and neuromuscular problems. |
Intranasal Nebulized Antibiotics
In 2003, research by scientists at Stanford University suggested that delivering medications directly to the sinus passages (instead of the bloodstream, like a pill might) significantly increases the amount of time chronic sinusitis patients remain infection free. The treatment, called nebulized antibiotic therapy, requires that patients inhale antibiotics in mist form to topically treat their sinusitis. The study, published in the journal of Otolaryngology - Head and Neck Surgery showed that nebulization therapy increased the infection free period for some patients by almost 300% when compared to other treatments.
Emergency Treatment
Patients who show signs that infection has spread beyond the nasal sinuses into the bone, brain, or other parts of the skull require emergency care. High dose antibiotics are administered intravenously, and emergency surgery is almost always necessary in such cases.
Severe Fungal Sinusitis. Sinusitis caused by severe fungal infections is a medical emergency. Treatment is aggressive surgery, and high-dose antifungal chemotherapy with a drug such as amphotericin B can be life saving. The use of oxygen administered at high pressure (hyperbaric oxygen) is showing promise as additional therapy for potentially deadly fungal infections.
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