When do you really need antibiotics for that sinus infection?

It was February, and clinic was teeming with respiratory infections of all kinds: mostly the common cold, but also bronchitis, pneumonia, and sinus infections. The patients were coming in usually thinking that they needed antibiotics for their sinus infection, or another respiratory infection.
The first patient on my schedule was a healthcare provider with “sinus infection” written down as her main issue.* She’d had about two weeks of nasal and sinus congestion which she blamed on a viral upper respiratory infection (URI, also known as the common cold). Her two young kids had been sick with colds all winter, so she wasn’t surprised to have these symptoms, along with endless postnasal drip and a cough.

Her congestion had improved a bit at one point, and she thought that she was finally getting better. But then, the day before her appointment, she awoke with throbbing pain between her eyes, completely blocked nasal passages, and, more concerning to her, green pus oozing from her left tear duct. She had body aches, chills, and extreme fatigue. “Do I maybe need antibiotics?” she asked.

Most sinus infections don’t require antibiotics

Ah, sinus infections. The New England Journal of Medicine published a clinical practice review of acute sinus infections in adults, that is, sinus infections of up to four weeks. The need for an updated review was likely spurred by the disconcerting fact that while the vast majority of acute sinus infections will improve or even clear on their own without antibiotics within one to two weeks, most end up being treated with antibiotics.

It is this discrepancy that has clinical researchers and public health folks jumping up and down in alarm, because more unnecessary prescriptions for antibiotics mean more side effects and higher bacterial resistance rates. But on the other hand, while 85% of sinus infections improve or clear on their own, there’s the 15% that do not. Potential complications are rare, but serious, and include brain infections, even abscesses.

But sometimes, antibiotics for sinus infections are needed

So how does one judge when it is appropriate to prescribe antibiotics for a sinus infection? There are several sets of official guidelines, which are all similar. When a patient has thick, colorful nasal discharge and/or facial pressure or pain for at least 10 days, they meet criteria for antibiotic treatment. If a patient has had those symptoms, but the symptoms seemed to start improving and then got worse again, then even if it’s been less than 10 days, they meet criteria for antibiotic treatment. (That’s referred to as a “double-worsening” and is a common scenario in bacterial sinus infections.)

The authors, however, also suggest that doctors discuss “watchful waiting” with patients and explain that most sinus infections clear up on their own in one to two weeks, and it’s a safe option to hold off on antibiotics. The symptoms can then be treated with a cocktail of over-the-counter medications and supportive care, like nasal saline irrigation, nasal steroid sprays, decongestants, and pain medications.

Of course, many patients expect and demand antibiotics for sinus infections, and even those who are open to watchful waiting may hear about the rare but possible complications of things like, oh, brain abscess, and opt to treat.

In the case of my patient above, she met criteria for treatment. She weighed the watchful waiting option against the potential risks of antibiotics for her sinus infection, and chose the prescription. I can tell you from very close follow-up that she improved quickly, though in truth, we will never really know if she would have gotten better anyway.

*This is a real case, details recalled as accurately as possible, based on my own experience as a patient with a sinus infection, originally posted here.


  1. package forwarding

    Very Helpful information for my family because most of them are infected. After doing much research Finally, have found a useful article. Thanks

  2. Donna OBRyan

    Rarely have I taken antibiotics, .but took three rounds last winter. Regular nasal wash and allergy shots have helped. Do you recommend allergy shots and probiotics after antibiotics.?

  3. Chicago Catt

    I’m a lifelong chronic and acute sinus infection patient. I have carefully observed my symptoms and patterns over 30+ years and can tell the difference between actually getting better and double worsening, between a fleeting viral sinus infection and a bacterial sinus infection settling in for a long spell. I am fortunate enough to have a strong relationship with my primary care physician and she recognizes my self-knowledge. If I get to 10 days without relief, she will provide me with an antibiotic prescription, but I typically wait another couple days to start it to be 100% sure it’s necessary. I don’t want to jinx myself, but we’re doing something right. For the first time in my 46 years, I have gone more than 4 months without a sinus infection or even a URI. As of today, it’s 15 months! 🙂 Lots of hand washing and a daily multivitamin are also big contributors.

  4. bettyd

    I have chronic post nasal drip. Now have left forehead ache, not
    severe but troublesome. Could this be sinus infection?
    Should I see a MD? Many thanks for advice.

  5. billc

    Of course there are some segments of the population that should not decided to wait 10 days to see what will happen. Specifically the elderly and/or immune compromised. Children who have serial ear infections, etc. Sometimes these individuals, for a variety of reasons, wait longer than they should. It would be nice to mention this in articles such as this one which give the impression that everyone should follow these suggestions.

    • Monique Tello, MD, MPH
      Monique Tello, MD, MPH

      I completely agree. The guidelines apply only to healthy adults. There are many patients with complicating factors who would end up with an entirely different plan, and they should discuss with their own doctor.

  6. 561pharmacologicalproperties

    Thanks for the write this helpful content..very nice information for me..Thanks again..

  7. Olabode

    Good post. Being infected is a sign that the body immunity system is weak. I will suggest that antibiotics should be taken after the physician have given his/her verdict on the infection. I am not supporting self medication because some drugs does have side effects.

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