Antibiotics for Sinusitis: To Use or Not to Use?

It is a common scenario in an otolaryngology office: A patient with nasal congestion and a sinus headache wants an antibiotic to eradicate the problem-and quickly. The clinician must often make a judgment call. Should the physician treat empirically with an antibiotic, possibly due to pressure from the patient, or should the physician encourage the patient to explore other options first?

The correct answer has several components: Identifying the appropriate treatment involves a series of further questions, and even then, there is more than one good approach. Further, the decision to treat bacterial sinusitis with antibiotics or not is a balancing act between more rapid healing and the risk of promoting antibiotic-resistant organisms, particularly methycillin-resistant Staphylococcus aureus (MRSA).

In separate phone interviews, two experts discussed the latest thinking about treating bacterial sinusitis with antibiotics.

Diagnosis Is Key

There are three questions the otolaryngologist needs to ask before prescribing an antibiotic for sinusitis, said Richard M. Rosenfeld, MD, MPH, Professor of Otolaryngology at State University of New York-Downstate Medical Center in Brooklyn. The first question to ask is, does the patient have sinusitis? he said. Is the patient’s clinical presentation consistent with a diagnosis of sinusitis?

The second question asks whether the infection is viral or bacterial. The third and final question addresses the appropriateness of antibiotics.

Dr. Rosenfeld noted the definition of acute sinusitis in the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) clinical practice guidelines: A patient who has purulent anterior or posterior nasal drainage for up to four weeks, as well as nasal obstruction or facial pain or pressure, is considered to have acute sinusitis.1

Otolaryngologists are in an excellent position to be thorough in the diagnostic workup, said Jack B. Anon, MD, Clinical Professor of Medicine in the Department of Otolaryngology at the University of Pittsburgh College of Medicine. The trained otolaryngologist is the best physician to make this diagnosis, he said.

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Figure. The issues to consider in deciding whether to prescribe antibiotics are the severity of the infection and the patient’s thoughts regarding the benefits of antibiotic treatment compared with the risk of adverse events.

Viral or Bacterial?

The first, obvious step is to get the history of the condition and the patient’s overall medical history. If the patient’s symptoms meet the AAO-HNS standards, the physician next asks the second question: Is the infection viral or bacterial? According to the AAO-HNS guidelines, a sinus infection is likely to be bacterial in two circumstances: if it persists for 10 days or more without improvement, or if a double worsening pattern is present, according to Dr. Rosenfeld.1