By Kathryn Galbraith, MD
With the growing costs of healthcare and the huge amount of information and testing available to us, it can be quite difficult to know what tests and treatments are most likely to be beneficial, are least likely to harm, and are most cost-effective. For this reason, the “Choosing Wisely” initiative began and was a very successful, multi-year effort of the ABIM (American Board of Internal Medicine) Foundation to help physicians be better stewards of our finite health care resources. The aim was to promote conversations between doctors and patients and to help patients choose care that is supported by evidence, does not duplicate other tests or procedures already received, is free from harm, and is truly necessary. Though the initiative is complete, many topics were studied and resulted in succinct recommendations for and against certain treatments and tests that are still referenced today; one of these was the use of antibiotics for sinusitis.
Now that winter is here with an increase in the number of viruses and colds and generally drier air often made worse by wood stove use, sinus symptoms are on the rise. While it is very tempting to go to the doctor to request antibiotics for sinus congestion and inflammation, termed “sinusitis,” this is often not necessary. According to the American Academy of Family Physicians (AAFP) and the Choosing Wisely campaign, antibiotics should not be routinely prescribed for acute mild to moderate sinusitis, unless the symptoms last 10 or more days or the symptoms worsen after initial improvement.
The sinuses are air-filled spaces in the skull that are lined by the same tissue that lines the nasal passages. These tissues can become swollen and inflamed, blocking the drainage of the sinuses, and causing nasal congestion, headache, facial pressure, and tooth pain. The cause of this inflammation is most commonly viral, but can also be allergic, irritant or, least commonly, bacterial. Because antibiotics only kill bacteria, they are not recommended in most cases of sinusitis. The fact is that most cases of sinusitis—even many of those caused by bacteria—resolve on their own within 2 weeks.
Apart from being largely unhelpful, antibiotics can be harmful. According to the Cleveland Clinic website, antibiotics have many potential downsides. Some will have side effects such as dizziness, stomach or digestive problems, or rashes. Yeast infections of the mouth or vagina can also be caused by antibiotics. In rare cases, a severe reaction can occur that can be life-threatening. Antibiotics can also adversely interact with other medicines such as coumadin, antacids, anti-inflammatories like ibuprofen, and beta blockers used for hypertension and heart disease. In addition, the overuse of antibiotics sets up the potential for the bacteria to become resistant to them, meaning that when the antibiotics are needed in the future they will not work.
Treating sinusitis with antibiotics can also be expensive. Sinusitis accounts for 30 million office visits and 75% of outpatient antibiotic prescriptions in primary care, according to the AAFP website.
Antibiotics do have their place, however. According to the AAFP, antibiotics may be considered if symptoms have lasted 7 or more days, if symptoms significantly worsen after 3 to 5 days, or if symptoms are severe for 3 or more days. Severe symptoms may include exquisite pain and tenderness around the nose and eyes, signs of a skin infection including a red and hot rash that spreads rapidly, or a fever over 102 degrees F. If antibiotics are needed, Augmentin, a penicillin derivative, is the most effective, as long as there is no known allergy to the medicine.
So what should you do in the initial days of sinus pain and pressure?
- First, rest. Your body needs time to recover and fight the infection.
- Drinking warm liquids like tea keeps you hydrated and helps to loosen mucus, allowing it to drain faster. Breathing warm, moist air such as in a steamy shower also loosens mucus.
- Rinsing your nose with saline nasal sprays or washes can soothe irritated tissue and remove any irritants or allergens trapped on the nasal or sinus tissues. Follow the directions on the label of these products.
Over-the-counter medications can help to relieve sinusitis symptoms as well, but use them with caution. Tylenol or Non-steroidal Anti-inflammatory Drugs (NSAIDs) like ibuprofen and naproxen help relieve the pain and pressure in the head and sinuses. Generic pseudoephedrine (brand name Sudafed) can relieve congestion; sign for this at your pharmacy window. Steroid nasal sprays like Flonase or Nasonex can also be beneficial and can be used long-term, unlike Afrin or similar “decongestant” nasal sprays that must be stopped after 3 days.
Talk to your doctor about which options might be best for you.
For more information, talk to your doctor or visit www.aafp.org.
