Antibiotics for Sinusitis

Recommendation

Don't routinely prescribe antibiotics for acute mild-to-moderate sinusitis unless symptoms last for ten 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: AAO-HNSF Updated Clinical Practice Guideline: Adult Sinusitis (Affirmation of Value by the AAFP)}

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.

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.

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.
   
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. Accessed November 21, 2012.