Although there has been a lot of excitement about the role fungi may play in chronic sinusitis, there is still far more evidence to support a larger role for bacteria. When dealing with the “problem” or chronic sinus patient the bacteriology is different and anaerobes are more common. I typically treat a minimum of 3 weeks, and 4-6 weeks of antibiotics along with systemic steroids is not unusual.
If cultures can be obtained, they are. Studies have shown good correlation between endoscopically obtained cultures with those obtained in surgery. Augmentin, Cleocin, Cefuroxime, Clarithromycin, or a Quinolone are all good choices for empiric treatment. When using a quinolone I will generally use the higher dose, such as Ciprofloxacin 750 mg 2 times per day.
I tend to like the macrolides, especially Clarithromycin (Biaxin), as it is well tolerated and seems to have some other immunomodulatory (anti-inflammatory) activities. Often I will start with 500 mg 2 times a day for 2-3 weeks and then go to 250 mg once or twice a day for another 2-3 weeks. Patients often notice a metallic taste while on it. No matter what I always treat 7 – 10 days past the complete resolution of symptoms. I counsel my patients on the importance of this and try to get absolute compliance. Another Macrolide is Azithromycin and can be given at 250 mg ever other day or 2-3 times per week.
A former medical student of mine, and now a fellowship trained rhinologist at the Cleveland clinic, likes Doxycycline 100 mg 2 times a day. I would continue this out past 1 month. Bactrim DS 1 tab po bid for a month is another option.
Intravenous antibiotics rarely have a role. They are typically administered via central line access for 4-6 weeks. Having a central access line certainly brings with it risks.
Of note, patients with MRSA sinusitis are not contagious.