Sinus Infections - Antibiotics or not?

"Doc, I think I have a sinus infection and need an antibiotic."

This is an example of one of the most common comments that I encounter when I go into a patient room. The truth is that this patient scenario is also one of the most frustrating types of visits that I have as a physician. I want to do the right thing for the patient but often their mind is already made up about what they have and what treatment they need before I enter the room. 

What does the current evidence tell us about sinus infections? First of all I find that there tends to be a lot of confusion about what a sinus infection is. Many patients equate sinus pressure with being synonymous with a sinus infection. Sinus pressure or inflammation of the sinuses (Sinusitis) can actually be caused by many things. These include viruses, allergies, and bacteria. The most common cause is a viral infection associated with the common cold. Bacterial sinusitis, which is treated with antibiotics, complicates viral sinusitis in only about 0.5 to 2 percent of cases. (1) This means that the vast majority of patients that present with a "sinus infection" should not be treated with antibiotics. 

So how do we determine if someone has bacterial sinusitis which can be treated with antibiotics. The Infectious Disease Society of America suggests the following three criteria (2):

• Persistent signs or symptoms that don't show clinical improvement in 10 days
• Onset of severe symptoms or signs of high fever (>39°C or 102°F) and purulent nasal discharge or facial pain for 3-4 consecutive days
• Worsening symptoms after initial improvement after 5-6 days 

The bottom line is that a sinus infection doesn't necessarily mean antibiotics. Of course, each individual case is different and the advice in this post should not substitute for getting a consultation with your doctor. Let me know what you think in the comments below.

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References:

1. Fokkens W, Lund V, Mullol J, European Position Paper on Rhinosinusitis and Nasal Polyps Group. EP3OS 2007: European position paper on rhinosinusitis and nasal polyps 2007. A summary for otorhinolaryngologists. Rhinology 2007; 45:97.

​2. Chow AW, Benninger MS, Brook I, et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Dis 2012; 54:e72.