Antibiotics

In otherwise healthy patients, antibiotics are likely more harmful than beneficial, especially in patients with symptoms less than 14 days. Current studies examining the efficacy of antibiotics for acute sinusitis have included generally healthy adults and most have excluded those with either severe illness or coexisting condition (eg, diabetes, pulmonary disease, congestive heart failure, immunosuppression, or prior sinus surgery). Since the majority of acute sinusitis cases are self-limiting, it is highly debated whether antibiotics should be used at all in people who are otherwise healthy.

A 2018 study found that 81% of antibiotic prescriptions for treatment of acute sinusitis were deemed inappropriate.7 In healthy patients believed to have signs of bacterial infection, controversy exists over whether to start antibiotics at the time of diagnosis or to use a watch-and-wait approach. Exceptions include patients with significant co-morbid conditions or immunosuppression.

A 2008 meta-analysis examined whether common signs and symptoms can be used to identify a group of patients that would benefit from antibiotics.8 The study found that 15 patients with acute sinusitis complaints would have to be treated with antibiotics before a single additional patient was cured. Patients who were older, who reported symptoms for longer, or who reported more severe symptoms all took longer to cure, but were no more likely to benefit from antibiotics than were other patients. Investigators concluded that antibiotics are not indicated even if symptoms have been present for longer than 7 to 10 days.8


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More recent research has shown that antibiotics are slightly more efficacious than placebo, but the risk of potential side effects needs to be weighed against the potential benefits. A 2015 systematic review showed that the use of placebo was almost as efficacious as using antibiotic therapy, and was also much safer.9

A 2018 Cochrane Review found that only 5 to 11 more patients per 100 will be cured faster if they receive antibiotics instead of placebo or no treatment. However, 13 more patients per 100 experienced side effects with antibiotics compared with placebo or with no treatment. Without antibiotics, almost half of patients were cured after 1 week, and 2 out of 3 were cured after 14 days. The authors concluded that given the low incidence of serious complications and considering antibiotic resistance and side effects to antibiotic therapy, there is no place for antibiotic therapy in people with uncomplicated acute sinusitis.10

A 2019 review reported that most cases of sinusitis are caused by viral or self-limiting bacterial infection, neither of which requires antibiotic treatment. This recommendation was based on the finding that only 1 in 17 patients achieved clinical cure at 7 to 14 days with antibiotics, while 1 in 8 had adverse side effects to the antibiotic.11

Antibiotics typically should be reserved for patients who are not responding to supportive care, whose condition is acutely worsening, or who have underlying medical conditions or immunosuppression. The AAO-HNS guidelines emphasize watchful waiting, without antibiotic therapy, as initial management for all patients with uncomplicated ABRS.12

If antibiotics are needed, coverage against Streptococcus pneumoniae, Haemophilus influenza, and Moraxella catarrhalis should be considered.Amoxicillin and amoxicillin/clavulanate are currently first-line, and doxycycline is second-line. Bacterial resistance is increasing, especially to S pneumoniae. Macrolides, such as azithromycin, are commonly prescribed, but not recommended due to high resistance (>40%).3  

Adverse Effects

Regarding antibiotic use, adverse effects are as likely (or even more likely) to occur as are benefits.1 Common adverse effects include nausea, vomiting, diarrhea, abdominal pain, and rash.1 More serious effects have been reported in those taking fluoroquinolone antibiotics, which are typically reserved for patients who have no other treatment options. These side effects have included tendon rupture, neuropathies, aortic aneurysm, and decrease in blood sugar which led the US Food and Drug Administration to release a number of warning labels from 2008 to 2018.13

Severe reactions may include Stevens-Johnson syndrome, and other life-threatening reactions — including anaphylactic shock and sudden cardiac death — have occurred. Development of Clostridioides difficile infection is another serious side effect, accounting for 500,000 infections and 29,300 deaths in 2011 alone.12

Treatment guidelines for uncomplicated ABRS have generally supported a 10 to 14 day antibiotic regimen; however, the evidence for this recommendation is weak. In fact, treatment of longer duration leads to the promotion of bacterial drug resistance, poorer patient compliance, higher toxicity, and a greater overall economic burden.3 Long-term antibiotic regimens are no more effective than short-term regimens; 3 to 7 days regimens have been shown to be just as effective as 7 to 10 days courses of the same therapy.14 

Intranasal Corticosteroids

The rationale for intranasal corticosteroids (INCS) in the management of acute sinusitis is due to their anti-inflammatory properties. Acute sinusitis is primarily an inflammatory condition; inflammation and edema of the nasal turbinates block the drainage routes and impair mucociliary clearance. By reducing inflammation, INCS foster drainage and increase aeration.5 As a first-line therapy for allergic rhinitis, which can be a predisposing factor for acute sinusitis, it stands to reason that INCS use may improve symptoms in acute sinusitis. The most common adverse effects are headache and epistaxis.5

A number of studies appear to support this hypothesis. A systematic review and meta-analysis of the effects of INCS on the symptoms of acute sinusitis found that they offer a small but significant symptomatic benefit at days 14 to 21.3,15 The researchers found that facial pain and nasal congestion were the symptoms most responsive to INCS and higher doses were associated with greater benefit.3,15

In a double-blind, placebo-controlled, randomized study, patients were assigned to 1 of 4 groups: mometasone nasal spray (MFNS) 200 ug twice daily, MFNS 200 ug once daily, amoxicillin 500 mg 3 times a day, or placebo. The group that received the MFNS 200 ug twice daily had significantly increased minimal-symptom days vs amoxicillin or placebo alone.16 A randomized, placebo-controlled study from Canada found that fluticasone nasal spray reduced symptoms of uncomplicated acute sinusitis compared with placebo and provided support for withholding antibiotics. The safety profile was similar to placebo.17 A systematic review of the literature involving 1943 participants treated with INCS for 15 or 21 days found modest effect with INCS in the resolution or improvement of symptoms; only minor adverse effects (epistaxis, headache, and nasal itching) were reported.6

INCS can be used as monotherapy in cases of mild or moderate severity or as an adjuvant therapy to antibiotics in severe cases.18 Combining an INCS with an antibiotic reduces symptoms more effectively than an antibiotic alone.19 Furthermore, INCS use may reduce the incidence of antibiotic resistance when fewer antibiotics are used.5 The latest update for clinical guidelines from the AAO-HNS state that clinicians may recommend topical intranasal steroids for symptomatic relief of ABRS.3

To obtain the best results, patients should clear their nasal passageway before application by blowing the nose or performing a nasal saline irrigation. It is also recommended to avoid sneezing or blowing the nose immediately after using the spray to retain the medicine.20 INCS are thought to be safe in pregnant women, given that the medicine is absorbed locally. There are several intranasal corticosteroids on the market, but no clear evidence that 1 spray works better than another. All of them have a similar side effect profile.20

Oral Corticosteroids

In a 2014 Cochrane Review, a total of 5 randomized controlled studies were found examining the use of oral corticosteroids in ABRS. Of these, only 1 study examined oral corticosteroids as monotherapy; the others studied oral corticosteroids in conjunction with antibiotics. In those patients receiving oral corticosteroids, the combined data of all 5 studies showed either modest improvement of symptoms or short-term resolution when compared with those in the control groups.

The study of oral corticosteroid monotherapy was analyzed separately as a subgroup. Oral corticosteroid therapy was found to have no benefits. The authors concluded that oral corticosteroids are ineffective as monotherapy for clinically diagnosed ABRS. There is limited evidence that the addition of oral corticosteroids to antibiotic therapy could be of benefit for modest symptom control.21