New Advice on Treating Sinus Infections With Antibiotics

Guidelines released in December 2011 by the Infectious Diseases Society of America (IDSA, a professional association for health care providers who specialize in infectious diseases) offer physicians new advice about how to diagnose and treat sinus infections and how to avoid the widespread problem of overprescribing antibiotics, a practice that can cause unnecessary side effects and that hastens the development of superbugs resistant to treatments. The guidelines also give new information about which antibiotics to use (if an antibiotic is indicated) and which to avoid, because many strains of bacteria common in the U.S. are already becoming resistant to these drugs. (See the article "Increased Risk of Cardiovascular Death With Azithromycin and Levofloxacin" for more information on two specific antibiotics.)

What are sinuses and sinusitis?

Sinuses are a series of four pairs of air-filled spaces connected to and draining into the nose. Sinus infections (sinusitis, or inflammation of the sinuses, which often affects the nose) are experienced by nearly 1 in 7 adults each year and are more common in adults between 45 and 74 years. Symptoms of sinusitis can include a runny nose with discolored mucus, stuffy nose, nasal congestion, facial pressure or pain, headache, cough, fever and tiredness.

The vast majority of sinus infections — 90 to 98 percent — are caused by cold viruses and should therefore not be treated with antibiotics. For these viral infections, antibiotics will not help, and in otherwise healthy people, the symptoms will usually begin to resolve with no medication after three to six days. Most, if not all, symptoms will be gone by day 10. Any fever associated with sinusitis will actually peak and go down even faster, with temperatures decreasing within 24 to 48 hours.

In contrast, bacterial infections of the sinuses generally last longer, and treating these infections with antibiotics can shorten the course of the illness and provide earlier symptom relief.
 

When should sinusitis be treated with an antibiotic?

Distinguishing between a viral infection and a bacterial infection can be tricky; there is no easy test. Doctors usually diagnose the cause of an infection on the basis of symptoms alone, and symptoms of viral and bacterial infections can be similar.

In addition to incorrect diagnoses, patients can contribute to the overprescribing of antibiotics by asking their doctors for these drugs, following the mistaken theory that antibiotics cannot harm them and might help, according to Dr. Thomas M. File, co-author of the guidelines and chair of the Infectious Disease Section at Northeast Ohio Medical University. However, frequent antibiotic use for a viral infection can cause harm by contributing to antibiotic resistance and inducing unnecessary side effects such as diarrhea, rash and headache.

The new guidelines recommend treating a sinus infection with an antibiotic when symptoms persist for more than 10 days without any evidence of clinical improvement. This indicates that the sinus infection may be bacterial, not viral. The following severe symptoms could also indicate that the infection may be bacterial: fever higher than 102 degrees Fahrenheit and lasting for at least three to four consecutive days, or worsening of symptoms (for example, new onset of a fever, headache, or increased runny nose after symptoms have run their course and have begun to improve).

How long do I need to take an antibiotic?

The IDSA suggests a shorter course of treatment than seen in earlier guides: just five to seven days. However, the new guidelines still recommend longer treatment (10 to 14 days) for children. The association also acknowledges that longer treatment may be needed for elderly adults and people with other diseases because of a higher risk of re-occurring symptoms for these groups.

What antibiotic should I use for a bacterial sinus infection?

The IDSA guidelines recommend that bacterial infections be treated first with a combination drug, amoxicillin-clavulanate (AUGMENTIN). Bacteria’s increasing resistance to amoxicillin (AMOXIL) alone, which is often prescribed in standard practice, justifies the combination treatment. Higher doses of amoxicillin-clavulanate may benefit certain high-risk patients: people with severe infections (fever 102 degrees Fahrenheit or higher), seniors over the age of 65 and children under the age of 2.

Doxycycline (ORACEA, VIBRAMYCIN) is another alternative for the treatment of bacterial infections.

The guidelines warn against the use of clarithromycin (BIAXIN), azithromycin (ZITHROMAX) or trimethoprim-sulfamethoxazole (BACTRIM, COTRIM, SEPTRA) because of growing rates of bacterial resistance.

Also, the guidelines advise against the use of antihistamines (for example, loratadine [CLARITIN]) or decongestants (such as pseudoephedrine [SUDAFED], a “Do Not Use” drug) to help with bacterial sinus infections. Finally, topical decongestants (such as oxymetazoline, found in products like AFRIN, for example), while providing some symptom relief, could potentially lead to rebound congestion and inflammation, especially if taken for more than a few days.

What You Can Do

To help with sinusitis symptoms, you should be sure to drink plenty of fluids. You also can take acetaminophen (TYLENOL) for sinus pain and clear out a stuffy nose with sterile saline solution, which comes in drop and spray forms. This advice is applicable for all people with sinusitis, most of whom will not need an antibiotic because they have a viral, not a bacterial, infection.

If you are prescribed an antibiotic to treat a bacterial sinus infection, you should talk with your doctor about what length of treatment would be right for you.

Most symptoms will begin to improve within a few days of being prescribed an antibiotic. Contact your doctor if symptoms do not improve within three to five days.

Improvement can take slightly longer for elderly and other high-risk patients, but even in these groups, failure to improve within three to five days is a sign that the prescribed medication may not be working and a new treatment should be tried.