Acute sinusitis, often called a sinus infection, is characterized by inflammation of the mucous membranes lining the nasal passages and surrounding air-filled cavities. This inflammation leads to symptoms like nasal congestion, facial pain or pressure, and thick nasal discharge. The medical approach focuses on identifying the cause, as most cases are viral and do not require antibiotics. Prescribing specific medications, especially antimicrobials, depends entirely on whether the infection is determined to be bacterial or a self-limiting viral illness.
Determining the Need for Antibiotics
The primary challenge for doctors treating a sinus infection is distinguishing between a common viral infection and a bacterial one. The vast majority of acute rhinosinusitis cases are caused by viruses, meaning antibiotics offer no benefit and may contribute to drug resistance. Consequently, antibiotics are reserved for confirmed or highly suspected cases of acute bacterial rhinosinusitis (ABRS).
Doctors rely on specific clinical criteria to determine if a bacterial infection is likely. Antibiotics are indicated if symptoms persist for 10 days or longer without improvement. Another key indicator is a severe presentation, involving a high fever of 102°F or greater, coupled with purulent nasal discharge or facial pain that lasts for three to four consecutive days.
A worsening of symptoms after an initial period of improvement is also a strong sign of a secondary bacterial infection. For patients who do not meet these criteria, a “watchful waiting” approach is recommended, where symptomatic treatment is provided while monitoring for signs of bacterial development. This strategy limits unnecessary antibiotic exposure while ensuring bacterial infections are treated promptly.
Medications for Symptom Management
Since most sinus infections are viral, supportive care is a major component of treatment, even when antibiotics are prescribed. Over-the-counter pain and fever relievers are frequently recommended to reduce discomfort. Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen or naproxen, or acetaminophen, can effectively manage pain and systemic symptoms.
Intranasal corticosteroids, such as fluticasone (Flonase) or mometasone, are prescription or over-the-counter nasal sprays that reduce inflammation directly within the nasal passages and sinuses. These sprays decrease the swelling of the mucous membranes, which improves sinus drainage and ventilation. They do not provide immediate relief and may require several days of consistent use to show full effect.
Decongestants temporarily relieve nasal stuffiness by narrowing blood vessels. Oral decongestants like pseudoephedrine are taken systemically, while topical sprays like oxymetazoline provide local relief. Topical decongestants should be used for only three to five days to prevent rebound congestion, where nasal stuffiness returns worse than before upon stopping the spray. Saline nasal irrigation, using a salt-water solution, is a simple, effective method to wash away thick mucus and debris.
Specific Antibiotic Treatments
When a bacterial cause is confirmed or strongly suspected, the first-line medication is amoxicillin or amoxicillin-clavulanate. Amoxicillin-clavulanate (Augmentin) is preferred when there is a higher risk of antibiotic resistance, such as in patients who have recently taken other antibiotics. This combination medication includes clavulanate, which protects the amoxicillin from being broken down by certain bacterial enzymes.
The standard duration for antibiotic therapy in adults is seven to ten days, though some uncomplicated cases may be treated with a shorter five-day course. For patients with a penicillin allergy, alternative classes of antibiotics are prescribed. Doxycycline is a common alternative choice for adults.
Respiratory fluoroquinolones, which include medications like levofloxacin, are another class of alternatives. These drugs are highly effective but are reserved for patients with severe allergies, those who have failed first-line treatment, or those with significant risk factors. Using these broader-spectrum antibiotics sparingly helps mitigate the development of widespread antibiotic resistance. Patients must complete the entire course of the prescribed antibiotic, even if symptoms improve sooner, to ensure the infection is fully eradicated and prevent resistance.