Adult Chronic Sinusitis and Its Complications

By G. Douglas Campbell Jr., MD, FCCP

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Medical Management of Chronic Rhinosinusitis

Antimicrobial Therapy

Antimicrobial therapy is indicated in acute exacerbations of chronic rhinosinusitis, and the antimicrobial agents generally recommended are the same agents approved for acute rhinosinusitis (Table 4). There is controversy as to whether antimicrobial agents are effective in all cases of chronic rhinosinusitis, in part because few studies have been performed in this setting.³¹ Chronic rhinosinusitis is a multifactorial process that in some cases is not caused by bacterial infection. Ideally, therapy should be directed by results of sinus cultures, but this requires a sinus tap, which can be painful and costly; therefore, most initial therapy is empiric. The presence of purulent secretions, facial pain, and radiographic evidence of an air-fluid level are all considered indications for antimicrobial therapy.²⁵ Most of the published literature suggests using the same agents that are effective in acute rhinosinusitis, and the choice is quite large. Selection is based on local resistance patterns, severity of disease, and prior recent antimicrobial use.^29,31-34 In choosing antimicrobial therapy in chronic rhinosinusitis, the oral agents listed in Table 4 have been recommended by several authors. Additionally, they have recommended that treatment be of prolonged duration, at least 3 weeks; some recommend therapy for 4 to 6 weeks. With at least one fluoroquinolone, ciprofloxacin, a success rate of 85% was achieved in patients with chronic sinusitis after only 10 days of therapy.^29,35,36 Therefore, it is not unreasonable to suggest that therapy with the newer fluoroquinolones for the respiratory tract would be equally effective. If there is inadequate response at 10 days, then a longer duration of therapy should be considered. When using any antimicrobial agent, if response is slow, consideration should be given to adding an agent with anaerobe coverage (eg, clindamycin). Because of the increased incidence of beta-lactam resistance, ampicillin alone is probably of limited usefulness in this disease.

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