Case 10

A 23-year-old woman comes to the physician

because of an 8-day history of nasal discharge
and congestion accompanied with sinus pain. A
diagnosis of bacterial sinusitis is made.
 Which of the following is the most likely
causative pathogen in this condition?

a. H.influenzae
b. Staphylococcus aureus
c. Clostridium difficile
d. E.coli
e. Enterococcus
YES!
Acute bacterial sinusitis is most often caused by
the same bacteria implicated in acute otitis
media: S.pneumoniae and H.influenzae.

NEXT QUESTION
NO!
Staphylococcus aureus rarely are a cause of
bacterial sinusitis.

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NO!
Clostridium difficile are not a cause of bacterial
sinusitis.

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NO!
E.coli are mainly found in the gut. They are not a
cause of bacterial sinusitis.

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NO!
Enterococci are found in human intestines, they
are not a common cause of sinusitis.

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a. Ciprofloxacin
Which of the following is the most appropriate choice of initial therapy for this patient?

b. Amoxicillin
c. Vancomycin
d. Sulfamethoxazole
e. Penicillin G
NO!
Only the respiratory fluoroquinolones
(levofloxacin, gemifloxacin and moxifloxacin) are
indicated in the treatment of sinusitis. Due to
resistance, ciprofloxacin is not effective.

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YES!
For the treatment of uncomplicated bacterial
sinusitis, amoxicillin is the drug of choice.

NEXT QUESTION
NO!
The use of vancomycin is restricted to the
treatment of multi-drug resistant Gram-positive
organisms or in patients who are severely
allergic to penicillin. It is not indicated in the
treatment of sinusitis.

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NO!
The sulfonamides are rarely used alone due to
problems with resistance. Co-trimoxazole is
recommended for use in penicillin-allergic
patients.

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NO!
Penicillin G is not effective against Gram-
negative organisms such as H.influenzae. In
addition it can only be administered IV and this
route is not normally used for such a minor
infection.

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 The patient mentions that she has had this
condition on multiple occasions in the past and
that amoxicillin has never been successful for
her. Which of the following drugs is most likely to
be a successful alternative?
a. Ceftriaxone
b. Ciprofloxacin
c. Ampicillin
d. Vancomycin
e. Cefazolin
YES!
Ceftriaxone is indicated for the treatment of
sinusitis in patients with previous treatment
failure.

WELL DONE
NO!
Only the respiratory fluoroquinolones
(levofloxacin, gemifloxacin and moxifloxacin) are
indicated in the treatment of sinusitis. Due to
resistance, ciprofloxacin is not effective.

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NO!
Ampicillin is not indicated in the treatment of
sinusitis in patients that have already failed
treatment with amoxicillin.

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NO!
The use of vancomycin is restricted to the
treatment of multi-drug resistant Gram-positive
organisms or in patients who are severely allergic
to penicillin. It is not indicated in the treatment
of sinusitis, even if first-line therapies have failed.

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NO!
Cefazolin is a first generation cephalosporin with
activity against mainly Gram-positive organisms.
It would not be effective against H.influenzae.

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