Global overuse of antibiotics increases antibiotic resistance and unnecessary medication-related adverse events.1 The COVID-19 pandemic underscored the necessity of proper diagnosis and treatment of respiratory infections in primary care. Reducing inappropriate prescribing for acute rhinosinusitis is crucial to limiting the development and spread of antibiotic resistance.2,3 The World Health Organization has identified the overuse of antibiotics and subsequent resistance as a primary public health concern, and the United Nations convened a high-level meeting to coordinate approaches to address the root causes of antimicrobial resistance, only the fourth health issue to ever be addressed by the General Assembly.4
Inappropriate use of antibiotics is not just a societal issue but an individual concern as well. Significant microbiome and metabolic changes have been associated with antibiotic use that may have long-term health effects, potentially increasing the risk of obesity and cancer.5–9 Per the Centers for Disease Control and Prevention, antibiotics are responsible for 16% of adverse drug reactions treated in emergency departments.10
Acute rhinosinusitis is one of the most inappropriately treated outpatient respiratory infections. Most patients with rhinosinusitis are prescribed antibiotics, even though the condition is usually caused by viruses.11 The lack of point-of-care tests, clinical markers, or evidence-based clinical prediction rules leaves the physician with few tools to distinguish viral vs bacterial acute rhinosinusitis, unlike almost all other infections commonly seen in primary care (eg, pharyngitis, COVID-19, influenza, urinary tract infections, pneumonia).12–16
In a 2025 article published in American Family Physician, Drs. Butler and Hernandez explained well the Infectious Diseases Society of America (IDSA) sinusitis guidelines.17 However, due to limited primary care data, the guidelines (from 2012) are based on expert consensus rather than evidence, and they serve as a prime example of why family medicine should not rely on subspecialty groups to dictate the care we provide.18
The IDSA guideline strongly recommends waiting 10 days to start antibiotics for a respiratory infection, but the recommendation is based on low- to moderate-quality evidence.18 The IDSA also strongly recommends that if a patient with acute rhinosinusitis does not respond to antibiotic treatment after 3 days, the clinician should broaden coverage or switch to a different antimicrobial class; if the patient does not improve in 3 more days, referral to a subspecialist and computed tomography or magnetic resonance imaging is recommended.18
Imagine how difficult it would be to make an appointment with an otolaryngologist if we were referring all patients who had persistent acute rhinosinusitis symptoms and how often radiology departments would be delayed if imaging was performed for all these patients. Ask any family physician what they think when their patient does not respond to an antibiotic in 3 days. They most likely think, “maybe this is a virus or the patient has allergies,” not “I'd better add another antibiotic and think about scheduling imaging.”
Of course, we need to be vigilant for the minority of patients who have poor outcomes. However, a cohort study from Norway that examined 711,069 episodes of acute rhinosinusitis found that antibiotic prescribing was associated with increased risk of hospitalization, while not having a protective effect against complications.19 Furthermore, severe complications (eg, intracranial infection, orbital infection, osteomyelitis, sepsis) occurred in only 3 in 10,000 patients.19
In the United States, 1 in 7 adults (approximately 30 million office visits) is diagnosed with acute rhinosinusitis every year, resulting in antibiotic prescriptions for 1 in 5 of these patients and accounting for more than $11 billion in direct annual costs.12,20–25 Yet the National Institute of Allergy and Infectious Diseases, the US agency primarily charged with funding studies of acute rhinosinusitis, has funded only one very small randomized trial in primary care. Of the nearly $2 billion in funding that the National Institute of Allergy and Infectious Diseases disperses every year, they have almost completely ignored one of the most common reasons patients visit our clinics. The most recently published Cochrane review on acute rhinosinusitis from 2018 found only 15 studies for this condition, whereas the most current Cochrane review about vitamin D and mortality identified 159 articles.12,26 Even three to five more acute rhinosinusitis studies would help us better understand how best to treat patients.
Unfortunately, until more studies are performed, we must rely on the limited data we have, which means diagnosing likely bacterial acute rhinosinusitis if a patient has purulent nasal discharge, cacosmia (inability to recognize smells), double-sickening, teeth pain, or the physician's gestalt. We also should consider that for most patients, the harms of antibiotics are as high or higher than the benefit of slightly quicker symptom resolution. Most relevantly, we must cautiously use subspecialty guidelines for a disease that is rarely seen in a subspecialists office.
