A 32-year-old man presents with a 10-day history of nasal congestion, purulent nasal discharge, facial pain over the maxillary region, and fever. CT paranasal sinuses shows acute maxillary sinusitis with air-fluid level. What is the drug of choice for empirical treatment?

Explanation

## First-Line Empirical Therapy for Acute Bacterial Sinusitis **Key Point:** Amoxicillin-clavulanate is the gold-standard first-line agent for acute bacterial sinusitis in both adults and children. ### Rationale for Amoxicillin-Clavulanate 1. **Spectrum Coverage** - Covers *Streptococcus pneumoniae* (most common pathogen) - Covers *Haemophilus influenzae* (including β-lactamase producers) - Covers anaerobes (important in chronic/recurrent cases) - Clavulanate prevents β-lactamase–mediated resistance 2. **Dosing in Acute Sinusitis** - Adult: 500/125 mg TDS or 875/125 mg BD for 10–14 days - High-dose formulation (875/125 mg) preferred for sinusitis 3. **Clinical Efficacy** - Achieves excellent sinus penetration - Rapid symptom resolution in 70–80% of cases - Cost-effective and well-tolerated **High-Yield:** Amoxicillin-clavulanate is preferred over amoxicillin alone because up to 40% of *H. influenzae* strains produce β-lactamase. ### Adjunctive Measures - Nasal decongestants (xylometazoline, oxymetazoline) for symptom relief - Saline nasal irrigation to promote drainage - NSAIDs for pain and fever **Clinical Pearl:** If the patient has severe penicillin allergy, fluoroquinolones (levofloxacin, moxifloxacin) are acceptable alternatives, but they are NOT first-line due to emerging resistance and cost. [cite:Scott-Brown's Otolaryngology 8e Ch 12]