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 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 recently 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, they do…
So how does one judge when it is appropriate to prescribe the antibiotic? 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, 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, 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.