Antibiotics for Sinusitis

Recommendation

Don't routinely prescribe antibiotics for acute mild-to-moderate sinusitis unless symptoms last for seven or more days OR symptoms worsen after initial clinical improvement. (Symptoms must include discolored nasal secretions AND facial or dental tenderness to percussion.)

Most sinusitis in the ambulatory setting is due to a viral infection that will resolve on its own. Despite consistent recommendations to the contrary, antibiotics are prescribed in over 80% of outpatient visits for acute sinusitis.

Sinusitis accounts for 16 million office visits and $5.8 billion in annual health care.

Sources: Center for Disease Control and Prevention (CDC), Cochrane, and Annals of Internal Medicine


Supporting Information

Sinusitis is one of the most common diagnoses in primary care. Annually, it accounts for 15% to 20% of adult antibiotic prescriptions and costs more than $20 million in  patient visits. Current recommendations strongly support not prescribing antibiotics within the first week of illness for mild to moderate sinusitis.(1) A meta-analysis published in 2012 in the Archives of Internal Medicine states that some randomized controlled trials showed that patients assigned to antibiotics had a 7% to 14% higher rate of improvement in symptoms.(2) However, these researchers concluded that the potential harms from use of antibiotics to manage sinusitis, including adverse effects (e.g., diarrhea), increased risk of antibiotic resistance, and cost, clearly outweigh the potential minor benefits.

A Cochrane review compiled data from 59 studies that involved the use of a variety of antibiotics to manage simple maxillary sinus infection in primary care settings.(3) Studies that compared antibiotics with placebo showed that, in most cases, symptoms improved within two weeks, regardless of whether the participant received an antibiotic or not. The review found that, in addition to patient-related adverse effects (e.g., skin rash, abdominal pain, vomiting), antibiotic use poses the risk of increased resistance to antibiotics among community-acquired pathogens.


Related Links

Download a patient education handout on this topic:

Key Communication Concepts

Watch the video as Dr. LeFevre talks with a patient who asks for antibiotics to treat her sinusitis.

  • Provide Clear Recommendations
    The majority of patients want information about their health, illness and decision options.

    “The good news is that you will get better and we can treat the symptoms while your body fights the infection.”

     “I would not use antibiotics as this is most likely a viral infection and antibiotics don’t help”

     “I want to be sure that  later, when we use antibiotics and they are needed, we don’t have any resistance issue.”

  • Elicit Patient Beliefs/Questions
    Understanding patients’ treatment goals and perspectives about their health during the visit will help improve patient satisfaction and can shorten visits.

     Find out where the patient is coming from

    “You look uncomfortable today?”

     “I am sure you think this is like the other severe infection you had last time but most sinus infection do not require antibiotics and clear on their own.”

  • Provide Empathy, Partnership Legitimation
    Patients are more satisfied and are more likely to adhere to recommendations if they feel understood, supported, and a sense of partnership with their physicians.

     Make it clear that you are on the patient’s side (provide empathy and partnership)

    “I certainly understand that you want to get better and I want you to feel better.”

     “I want to reassure you that your symptoms are very different from those of last time. If you don’t feel better with this treatment I want you to call me back.”

  • Confirm Agreement/Overcome Barriers
    Finding common ground and understanding patient perspective and barriers will help reach agreement and provide patient satisfaction and hopefully improve patient health outcomes.

    “There are things we can do to help your symptoms to help you feel better. Let’s try this treatment and I expect that in the next several days you will feel better. If you develop any new symptoms like fever, rash or worsening pain you should call me. However, I expect like most people with this you will start to feel better with the treatment. If you don’t  again you can call me and we can reconsider if you need the antibiotics.”

References

  1. Chow AW, Benninger MS, Brook I, et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clinical Infectious Diseases; 2012:e1-e41.
    http://www.idsociety.org/Organ_System/#Rhinosinusitis(www.idsociety.org)
  2. Smith SR, Montgomery LG, Williams JW Jr. Treatment of mild to moderate sinusitis. Arch Intern Med. 2012;172:510-513.
  3. Ahovuo-Saloranta A, Rautakorpi U-M, Borisenko OV, et al. Antibiotics for acute maxillary sinusitis. Cochrane Database Syst Rev. 2008;(2):CD000243. Available at http://summaries.cochrane.org/CD000243/antibiotics-for-acute-maxillary-sinusitis(summaries.cochrane.org). Accessed November 21, 2012.