Sinusitis – antibiotics not always indicated


Category : General, Medical Rants

When Trouble Hits Those Holes in Your Head

Doctors are advised to use antibiotics to treat sinusitis when at least three of four signs are present: purulent (yellowish or greenish) nasal discharge predominantly on one side, local facial pain mainly on one side, purulent nasal discharge on both sides or pus in the nasal cavity.

Many physicians as well as patients take purulent nasal discharge lasting seven or more days as the primary indication of a bacterial sinus infection. Yet, study after careful study has shown no reliable benefit of antibiotics when doctors try to apply this or any of the other criteria in deciding on drug treatment.

In the latest study, published last month in The Journal of Family Practice, no significant benefit over a placebo was found from using the antibiotic amoxicillin among 135 patients with typical indications of a sinus infection. All the patients complained of sinusitis, with pus in the nasal cavity, facial pressure or nasal discharge lasting longer than seven days.

A small subgroup of patients receiving the antibiotic became better faster than the others. But the researchers were unable to discern anything about those patients in advance of treatment that indicated a bacterial infection, as opposed to a viral one.

That does not mean that antibiotics are useless in treating sinusitis. But it does mean more research is needed to help doctors determine who is most likely to benefit from the costly and potentially harmful drugs.

But all of my patients KNOW that antibiotics are necessary. And we (most primary care physicians) provide antibiotics to these patients, despite uncertain data on their efficacy.

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Comments (18)

very good post, and timely with all the “i have sinus” self-diagnosis terminology i’ve been seeing this month!

I do not think that many doctors will argue with you here about the overutilization of antibiotics. But I don’t want to act like a hypocrite either because I will be the first to tell you that I frequently give prescriptions to patients for antibiotics despite the fact that the probability is more likely viral. Very little in medicine is certain. There is no quick test that differentiates viral sinusitus from bacterial sinusitus. When my patients schedule an appointment to see me they are taking valuable time off of work and if they thought that I would tell them you just have to wait it out, they would never have made the appointment. Take decongestants, increase fluids and give it two weeks and you will be better only produces anger from the patients; I spend more time justifying myself to them and it never convinces them. I did this after first getting out of resiedency and lost a ton of patients and even had multiple complaints filed against me with the state attorney general. Fighting these frivoulous cases drained me mentally and has taken a great deal of the pleasure I used to have in being a doctor. Nowadays, like the vast majority of overburdened doctors, I just give them what they want and I no longer lose patients or get cases filed against me with the attorney general. Is this right? No it isn’t, but it sure beats the alternative. So please save the rightous pontification for your students.

I am just out of residency, where you are actually rewarded for doing the right thing, withholding antibiotics appropriately, which pisses some patients off and they don’t come back unless they are really sick (since most of them can’t go to private physicians due to cost and lack of insurance). I recently joined a group of several physicians (who I otherwise have a great deal of respect for) where, since I am the new guy, I do all the walk in stuff in the morning before regular clinic opens. All I see is the snots and the standard of care for this area apparently is antibiotics and likely a steroid injection (many times they think they are getting antibiotic shots rather than steroids). This is common even if they have only had a couple of days of symptoms. I hate it, so I tell them all about viruses and antibiotic resistance, and I tell them, and I tell them, and when I get done most of the times they say “so do you think its my sinuses causing this?” or “so will you give me a shot, so I can go back to work today.” Then I move on to the next room and do it again. Sometimes I am too tired or too far behind to fight the fight, so I turn off my brain and I do what they want, and I make more money and I get done faster and the patients are happier for the moment. But I know it is wrong so I start over the next day. I have posted material from the CDC-cough sniffle sneeze, no antibiotics please posters- in all my rooms. And I am seeing some rewards. Some patients prefer to wait to see their regular doc rather than see me quickly because they know I won’t give in, but that is okay because we are both happy. Some patients however approve and will come in and say “I don’t want antibiotics if I don’t need them but I just want you to check” that is a great feeling. I don’t care what any overburdened doctor says, wrong is wrong. If you think you won’t get in trouble using antibiotics, think again. I have a friend being sued right now by the family of a woman who was otherwise healthy, who had an anaphylactic reaction and died after receiveing a shot of Rocephin, this was not her first time to get rocephin either. Hopefully he can prove the injection was necessary.

I have been suffering for over 26 yrs. with chronic bi-lateral sinusutis, having nearly two dozen maxillary drainages and three ‘windows’ (Caldwell Luc) procedures and one frontal operation, finding that antibiotics for the most part are useless–unless there is a high white blood cell count to warrant using them. I have spent six months undergoing treatment with every antibiotic known to mankind, at that time, without any signs of improvement. Almost every time that I have been prescribed antibiotics I ended up in the emergency room with more serious conditions due to viral interdiction. I stringly suggest that prescribing antibiotics for sinusitis only be for acute cases, and then, only when the blood test warrants it.

I, too, have had some serious sinus problems, resulting in chronic bacterial sinusits that required surgery (BFESS, NAR).

repeated use of antibiotics was not useful, and actually was harmful. I had an adverse reaction to Avelox that resulted in peripheral neuropathy, vasculitis, and tendinopathy (3 months of physical therapy required). The ENT who prescribed the drug was horrified at the results and has vowed never to use it again.

Since then, I’ve found that nasal irrigation using a machine is much more helpful in correcting my subsiquent bouts with sinus infections and inflammation. About 8 months ago I was prescribed a Z-pack and prednisone to treat an obvious sinus infection, but instead I irrigated using a solution of 480ml of cool distilled water, 3ml of hydrogen peroxide, 5ml of Alkalol, and some Xyletol for 3 days. I also took decongestants and used hot packs on the face. The infection cleared within a few days. I’ve done this another time since then, with the same result.

Since research has shown that standard antibiotics are not effective in an anaerobic environement (bone), with little blood flow, I don’t see the point in using them to treat sinusitis, either acute or chronic. Patients have better luck from steroids and home remedies like the one listed above.

Nevertheless, more research is needed.

I’m suffering from a cold right now (started out with a fever a little over a week ago) and lots of yellow/green snot that no longer shows signs of dissipating and I think to myself, “sinus infection?” I don’t really want to take antibiotics, but I’d like to do something to help myself heal. And this is, I think, where western medicine falls short. Of course you don’t want to prescribe antibiotics, but you give people no alternative–“thanks for coming in, I’ll surely take your money for the visit, but there’s nothing you can do, but suffer.” I suggest you educate yourselves about alternative therapies and help people to heal themselves naturally.

I’ve had allergy and sinusitis problems for the past five years. Have received allergy shots twice. The severity of my symptoms depend upon my environment. I’ve moved several times in the last few years, and after moving to a less industrial area last fall I’ve had really no allergy symptoms at all. But stress levels also impact my allergy problems. A serious conflict at work developed several weeks ago. And last week I developed all the signs of sinusitus. At its worst, I once had an infection that lasted 4 months and resulted in my having to delay completion of my doctoral dissertation. I know also from experience that the quicker I can get rid of the symptoms, the less likelihood there will be of a month-long infection, or further relapses throughout the fall.

I’m new in town, so I went to a new general practioner. I explained my problem, told him that I usually take Allegra and Flonaise when my allergy symptoms were up, and that sometimes my sinus infections last for weeks or even months and on those occasions I’ve only gotten rid of them with antibiotics. He wrote out a prescription and said that the nurse would give me ‘a shot,’ and was out the door. It was a steroid shot, an anti-inflamatory. I’ve never been given a shot in the doctor’s office, for sinusitus or any other flu or virus before, and was really caught off guard. I felt like a guinea pig. I like to read the package and find out what I’m taking before I take it. I am allergic to sulfide drugs and penicillin, and like to look medicines up on Nader’s public health website, and other sites … rather than becoming a victim of drug companies, trying to sell their latest antibiotic. I don’t think that the shot I did anything. And he’d given me a Clarynex prescription although Allegra is what I always take — because it works much better! A week later, the sinus pressure in my head was only worse. I went back and asked the doctor for antibiotics. He prescribed Ketek, which I’d never heard of, and said he was also going to give me a shot. I told him that I’d always used the Z-pack of azithromycin, and this had worked well. He said Ketek was better for sinus infections. I’ve got the pills but haven’t taken them yet… because I’ve been having a terrible reaction to whatever he shot me with this time. As he explained it to me, I believed that I was receiving an injection of Ketek… but my pharmacist said that this drug isn’t injectable. I’ve had a high fever and weakness all day–a dramatic decrease in energy, dizziness and sore ear channels and throat. After having read this page, I suspect that I may have received a shot of Rocephin … which shouldn’t be given to people who are allergic to penicillin.

Did I mention that the doctor’s second visit with me was rushed because he was entertaining represenatatives from several drug companies that day–suited business guys who I could hear in the hall, inviting him to such and such free weekend seminar. When you have five minutes in a room with a doctor, and he’s overworked … and you’re tired and sick … and a younger female (i.e. I find that sexism continues to be a problem in the power dynamics/communication patterns of a patient-male physician relationship), it’s extremely difficult to have any kind of relationship of trust. A mild antibiotic does the trick for me. Why am I being subjected to expensive, drugs with new FDA approval and a slew of potentially dangerous side-effects? I’ve been lying in bed today, wondering whether I should try to sleep off the effects of whatever I’ve been shot up with, or whether I should go to the ER. Had to go to the ER after taking Bactrim once. I lived for five years in Germany. Never have I walked into a doctor’s office there with the fear that I’d be too sick/weak to talk the out of giving me something that was so potent that it would knock everything out of me, or turn my tounge black. I’m going to scream at the next doctor who tries to shoot me with a drug, whose side effects I don’t understand. The Ketek, also, is something I’d also never take. Among the serious side effects are blindness and heart problems …!!

You are a real piece of work. I am on Ketek now with no problems. What kind of person lets a doctor shoot them with something that they don’t know about BEFOREHAND. IT is your fault for not speaking up before hand.

Ketek really helped me. (But then, I don’t bother doctors or take medicine when I don’t need it.) I suggest that you won’t get anywhere by “screaming at your doctor.” Just become informed and take only what you really need.

I have been having sinusitis chronically for ten years now. I’ve had lots of antibiotics and have been using a medicine called nasonex for years. I think I am just as frequently ill than before, and I would still be using the same stuff today if I listened to my doctor.

But I decided otherwise because I didn’t like the idea that I would never be cured. I taught myself to rinse my nose properly with salt water. It took a lot of time, several years until I dared going out without my little nasal spray. I was real scared of the tremendous pain. But now I feel secure.

I had a crisis three days ago, this morning I had to go to bed one our to ease the pain. But now I know the pain. In fact the pain comes at the end of a flu when all the pus is being eliminated of the upper sinus. This morning was the first time I couldn’t get rid of the pain in one salt water rinsing. As I said I had to go back to bed. But then the “plug” came out. I could blow my nose at last.

In fact I wish my doctor could have tought me how to rinse properly because now I think it is essential in my every day fight against the pain of sinusitis.

I think it has been two years now that I don’t take any antibiotics any more. And no cortico-steroids either!

The medicine may have helped me. I am not saying no one should use any, but please explain your patients the mechanics of the pain. The stuff has to come out some how!

To be honnest I have to say I had two operations to open up frontal and Ethmoidian sinuses. But my life got easier several years after the last operation.

I just hope I don’t sound like some illuminated freak. I believe in our medicine, I just think it lacks prevention and education.

This is all very interesting reading. I’ve gone through sinusitis for a few years now, at very random times, and I’ve always been prescribed Amoxocillin/Amoxocil. It became a joke for me when if I just took OTC decongestants, I would rid myself of the sinus infection much sooner than I would by taking Amox. Now, however, I’ve discovered I inherited my parents’ high blood pressure, so the typical OTC decongestants are verboten to me. I’ve recently discovered a lovely doctor, and she’s working with me to determine what’s in my best interests. She’s the one who suggested I try saline nasal sprays, which I’ve had success with so far. And she’s the one who’s gotten me off Amoxocillin and onto the Z-pack. Since today was my first dosage of the Z-pack, I really can’t speak to its efficacy. And today I received my first ever steroid shot, which was fantastic. I admit, I was worried and, thus, when she suggested the shot I must’ve thrown a barrage of questions (as much as I could think of whilst having both sinus cavities painfully swollen) at her. Now, unfortunately, the clear passages created by the shot have worn off and I’m back to being stuffy, but I’m no longer inflamed and my mucus output appears to be getting much better. I’m using cortico-steroids and they seem to be working for the most part. My main problem though and which is new this bout of sinusitis is intense sleeplessness and restlessness. Whilst I should be abed and asleep, I’m sitting here at my laptop reading up and researching various information regarding sinusitis. And, again, since I’ve just discovered I have hereditary hypertension, my usual outlets are closed off to me. Time for more research and good discussions with my doctor–something I suggest and encourage *all* patients to do. After all, whilst doctors do indeed know a terrible amount of information about the human body, they are, simply, human with their foibles. Just like the rest of us. Thus, it’s in our best interests to be as well-informed as we possibly can. Keep a journal with questions, comments, observations and share these with our doctor. Be actively engaged in our own health. In our own lives. Oh, and researching and being informed is not necessarily limitied to traditional western medicines either. Look into homeopathy, natural methods, etc.

What are the ingredients of this injection given for sinusitis. My daughter has recently been diagnosed as Bipolar. She rec’d this injection Wednesday for a sinus infection and had a serious “psychotic’episode today?

It must be hard for doctors. If my doctor were to say “wait two weeks and it’ll go away,” I’d feel frustrated, because I wouldn’t go and see a doctor for a sinus infection that had been bothering me for less than a month. I’ve already waited somewhere between 4 and 12 weeks and they say it will go away if I keep waiting.

In my experience, most doctors prescribe antibiotics straight away. I tell them, “I don’t like to take antibiotics too often,” but they tell me, “this will help,” so what can I do? I know from my reading that it probably won’t help, and yet it often does seem to help… placebo?

I also suffer from frequent sinus “migraines”, I use a nasal saline irrigator daily, and also occassional sudaphed tabs or decongestant spray. My headaches have become very frequent, and lately, daily. I had to miss work today due to one of these headaches. I am about at my wits end. I am often stuffed up, usually worst when I awaken. But, I do not suffer from any running nose, or yellow/green nasal drainage. I feel the pressure in my sinus’s, and the worst pain/pressure is behind my eyes and in my forehead. Should I try antibiotics?
I’m thinking that a one-time Rocephin 1 gm IM dose might not be enough, but not sure.. Just to add, I have always had extremely dry eyes and sinus’s also. Maybe this is why I dont have a lot of nasal discharge..

And lastly, for you physicians that “give in” and hand out scripts of antibiotics “because they demand them”, I say this.. I work in the ER, and we are flooded with 90% clinic cases due to MD’s like you. People anymore think if they are sick for a day, or even often hours, and if their kids run one fever of 99 deg, then they need to go to the ER and get an antibiotic.. And get it.. You have and continue to cause the problem that you complain about. Paint it how you will, you are not practicing medicine, you are simply practicing “liability”…

I have got chronic sinusitus, is it ok to go to work with this.

Alot of what ive read here is very interesting. ive been suffering from a sinus infection for about 12 days now. problem is i am a self employed daycare provider and do not have medical coverage. i do not get days off nor do a get much chance of rest so after suffering for about 7 days my grandmother demanded i go to an urgent care and she would pay for it (i also do not have medical coverage). i went and was diagnosed with bronchitis and a sinus infection. he prescribed me the z pac which i had never taken before. i was to take 2 pills the first day and 1 pill for the next 4. well it is in the fourth day and i still have serious sinus pressure so bad my teeth ache and i cant chew anything. my right eye feels like it is going to pop right out of my head and now my right ear is starting to throb. since 5am this morning i have taken a OTC sinus med., my antibiotic, Dayquil, and 3 advil with no relief. i have even tried excedrin migraine. i finally called my neighbor and got some leftover amox from her and took that. my teeth and face and ear no longer ache after about 2hrs of taking that and my nose is running which makes me think my sinuses must be FINALLY draining. ive never loved having my nose run so much in my life. thank god my neighbor is smarter than the dr at the urgent care. cheaper too. i dont need medical coverage since apparantly im better off NOT going to drs.

My Grandma told me to just snort warm water with as much salt as possible the expose of it daily or even twice a day. Salt water is healing and it is natural. If you suffer from allergies then, hello.. get rid of what irritates your sinuses. Remove Rug and replace with Tile. Dust weekly. Bleach all windows and keep bathrooms bleached. Reomve unnecessary animals that have annoying pet dander! Basically good housekeeping and common sense fixes most allergies. But honestly I am a natural blond at age 28 I seem to think that what my problem is the lack of nose hair! I mean when I look in the mirror (3x) there are no hairs in my nose. Maybe if there were to be some then it would catch the debris that make me develop and runny nose or stuffy nose. 🙂
My Grandma says that is silly of me to think that but hey it sounds logical to me. Or maybe I need to have my deviated septom corrected and then take out the adenoids. That helps a great deal. It may be really painful if this is done at an adults age but hey, I figure one thing, I hate being sick! I hate runny noses and stuffy ones ( I cant sing with a stuffy nose) lol, with a runny nose I have to constantly be rubbing it and then it gets raw, then schaffy looking like Im a reptile shedding its old skin. Embarrassing to go through. But I guess its nature taking its course. There has got to be something that can be done surgically to prevent and correct the problem! Remove whatever it is that continues to swell up and close my passage in there!
Thanks for reading.

I had surgery for chronic sinusitis and polyps several years ago and have had great improvement. I still get occassional sinus infections, and I do know confidently when I have one that needs antibiotics.  I usually suffer through about  2 weeks of pain, pressure and general discomfort. After 2 or 3 doses of amox, my passages open and the head fog lifts very quickly. I use various other natural treatments, but by the time I decide a doctor visit is needed, I better get anitibiotics or I'll go to someone who will give them since I know my own sinuses very well.

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