Most of us are personally familiar with the symptoms of a sinus infection – congested nose, cough, fever, pain in the forehead or cheeks, and general misery. It’s impossible not to feel sympathetic for patients with sinus infections, and it’s understandable that they want to do whatever it takes to feel better as soon as possible. And for many doctors and patients “as soon as possible” means “antibiotics”. In fact, almost one fifth of antibiotic prescriptions are given for patients with sinus infections (sinusitis).

Here’s where the story gets complicated. Doctors have known for a long time that sinus infections almost always improve even without antibiotics. Originally we thought that the reason for this was because most cases of sinusitis were caused by viruses, which are unaffected by antibiotics. It was thought that only the minority of cases of sinusitis that were caused by bacteria required antibiotics. But it turned out that even most cases of bacterial sinusitis improved on their own, with most people feeling better in ten days regardless of antibiotics.

So the prevailing teaching has long been that for acute sinusitis the best treatment is nasal decongestants and medications for the cough, pain, and fever. Only the tiny number of people who don’t improve in ten days should be prescribed antibiotics. Still, many doctors either don’t know this recommendation or acquiesce to patients’ expectations for antibiotics. I have certainly been guilty of this misuse of antibiotics many times. A sick patient pleading for antibiotics may be misguided, but he’s rarely in the mood for a lesson about the medical literature and the potential harms to society of antibiotic overuse.

Now, when you’re healthy, is a good time for that lesson, and a study in this week’s Journal of the American Medical Association is the perfect reminder. The study enrolled 166 patients with an acute sinus infection. Half were randomly assigned to receive a ten day course of amoxicillin. The other half received placebo. Both groups were also offered nasal decongestants, cough suppressants, and medicines to reduce pain and fever. Every several days, the patients were interviewed about their symptoms, their satisfaction, and any adverse effects of treatment.

You can already guess the outcome. Both groups did equally well, without any earlier resolution of symptoms for the amoxicillin group. Some doctors concede that sinusitis resolves without antibiotics, but argue that patients feel better sooner if they receive antibiotics. This study debunked that argument. Even at day three there was no difference between the two groups.

The risk of all this antibiotic use is an acceleration of the increasing prevalence of multi-antibiotic-resistant bacteria that threaten to make all our antibiotics ineffective. So the next time you see me with a terrible sinus infection, let me recommend a good nasal decongestant, and let me reassure you that there’s nothing else I can do to get you well quicker. Time is your best friend. That’s why we call you patients.

Learn more:

Got A Sinus Infection? Antibiotics Probably Won’t Help (Shots, NPR’s Health Blog)
Sinus infection? Antibiotics won’t help (CNN Health)
Antibiotics Do Nothing to Cure Sinus Infections, Study Says: Most cases resolve on their own, and use of drugs can encourage resistance, researchers say (Chicago Tribune)
Amoxicillin for Acute Rhinosinusitis (Journal of the American Medical Association)
NDM-1: No Drug Matters (my most recent post about antibiotic resistance)