How long do antibiotics take to work for sinus infection

It was February, and clinic was teeming with respiratory infections of all kinds: mostly the common cold, but also bronchitis, pneumonia, and sinus infections. The patients were coming in usually thinking that they needed antibiotics for their sinus infection, or another respiratory infection.
The first patient on my schedule was a healthcare provider with “sinus infection” written down as her main issue.* She’d had about two weeks of nasal and sinus congestion which she blamed on a viral upper respiratory infection (URI, also known as the common cold). Her two young kids had been sick with colds all winter, so she wasn’t surprised to have these symptoms, along with endless postnasal drip and a cough.

Her congestion had improved a bit at one point, and she thought that she was finally getting better. But then, the day before her appointment, she awoke with throbbing pain between her eyes, completely blocked nasal passages, and, more concerning to her, green pus oozing from her left tear duct. She had body aches, chills, and extreme fatigue. “Do I maybe need antibiotics?” she asked.

Most sinus infections don’t require antibiotics

Ah, sinus infections. The New England Journal of Medicine published a clinical practice review of acute sinus infections in adults, that is, sinus infections of up to four weeks. The need for an updated review was likely spurred by the disconcerting fact that while the vast majority of acute sinus infections will improve or even clear on their own without antibiotics within one to two weeks, most end up being treated with antibiotics.

It is this discrepancy that has clinical researchers and public health folks jumping up and down in alarm, because more unnecessary prescriptions for antibiotics mean more side effects and higher bacterial resistance rates. But on the other hand, while 85% of sinus infections improve or clear on their own, there’s the 15% that do not. Potential complications are rare, but serious, and include brain infections, even abscesses.

But sometimes, antibiotics for sinus infections are needed

So how does one judge when it is appropriate to prescribe antibiotics for a sinus infection? There are several sets of official guidelines, which are all similar. When a patient has thick, colorful nasal discharge and/or facial pressure or pain for at least 10 days, they meet criteria for antibiotic treatment. If a patient has had those symptoms, but the symptoms seemed to start improving and then got worse again, then even if it’s been less than 10 days, they meet criteria for antibiotic treatment. (That’s referred to as a “double-worsening” and is a common scenario in bacterial sinus infections.)

The authors, however, also suggest that doctors discuss “watchful waiting” with patients and explain that most sinus infections clear up on their own in one to two weeks, and it’s a safe option to hold off on antibiotics. The symptoms can then be treated with a cocktail of over-the-counter medications and supportive care, like nasal saline irrigation, nasal steroid sprays, decongestants, and pain medications.

Of course, many patients expect and demand antibiotics for sinus infections, and even those who are open to watchful waiting may hear about the rare but possible complications of things like, oh, brain abscess, and opt to treat.

In the case of my patient above, she met criteria for treatment. She weighed the watchful waiting option against the potential risks of antibiotics for her sinus infection, and chose the prescription. I can tell you from very close follow-up that she improved quickly, though in truth, we will never really know if she would have gotten better anyway.

*This is a real case, details recalled as accurately as possible, based on my own experience as a patient with a sinus infection, originally posted here.

How is sinus infection diagnosed?

Diagnosis depends on symptoms and requires an examination of the throat, nose and sinuses. Your allergist will look for:

• Redness
• Swelling of the nasal tissues
• Tenderness of the face
• Discolored (greenish) nasal discharge
• Bad Breath

If your sinus infection lasts longer than eight weeks, or if standard antibiotic treatment is not working, a sinus CT scan may help your allergist diagnose the problem. Your allergist may examine your nose or sinus openings. The exam uses a long, thin, flexible tube with a tiny camera and a light at one end that is inserted through the nose. It is not painful. Your allergist may give you a light anesthetic nasal spray to make you more comfortable.

Mucus cultures: If your sinus infection is chronic or has not improved after several rounds of antibiotics, a mucus culture may help to determine what is causing the infection. Most mucus samples are taken from the nose. However, it is sometimes necessary to get mucus (or pus) directly from the sinuses.

Knowing what kind of bacteria is causing the infection can lead to more effective antibiotic therapy. A fungus could also cause your sinus infection. Confirming the presence of fungus is important. Fungal sinus infection needs to be treated with antifungal agents, rather than antibiotics. In addition, some forms of fungal sinus infection – allergic fungal sinus infection, for example – do not respond to antifungal agents and often require the use of oral steroids.

Your allergist may consider ordering a sinus CT. This test can help to define the extent of the infection. Your allergist may also send you to a specialist in allergy and immunology. The specialist will check for underlying factors such as allergies, asthma, structural defects, or a weakness of the immune system.

Biopsies: A danger of more serious types of fungal sinus infection is that the fungus could penetrate into nearby bone. Only a bone biopsy can determine if this has happened. Biopsies involving sinus tissue are taken with flexible instruments inserted through the nose.

Biopsies of the sinus tissue are also used to test for immotile cilia syndrome, a rare disorder that can cause people to suffer from recurrent infections, including chronic sinus infection, bronchitis and pneumonia.

Treatment

Antibiotics

Antibiotics are standard treatments for bacterial sinus infections. Antibiotics are usually taken from 3 to 28 days, depending on the type of antibiotic. Because the sinuses are deep-seated in the bones, and blood supply is limited, longer treatments may be prescribed for people with longer lasting or severe cases.

Overuse and abuse of antibiotics have been causing a major increase in antibiotic resistance. Therefore, patients with sinus symptoms should consider taking an antibiotic only if symptoms (including discolored nasal discharge) persist beyond 7-10 days.

Antibiotics help eliminate a sinus infection by attacking the bacteria that cause it, but until the drugs take effect, they do not do much to alleviate symptoms. Some over-the-counter medications can help provide relief.

Nasal decongestant sprays

Topical nasal decongestants can be helpful if used for no more than three to four days. These medications shrink swollen nasal passages, facilitating the flow of drainage from the sinuses. Overuse of topical nasal decongestants can result in a dependent condition in which the nasal passages swell shut, called rebound phenomenon.

Antihistamines

Antihistamines block inflammation caused by an allergic reaction so they can help to fight symptoms of allergies that can lead to swollen nasal and sinus passages.

Nasal decongestants and antihistamines

Over-the-counter combination drugs should be used with caution. Some of these drugs contain drying agents that can thicken mucus. Only use them when prescribed by your allergist.

Topical nasal corticosteroids

These prescription nasal sprays prevent and reverse inflammation and swelling in the nasal passages and sinus openings, addressing the biggest problem associated with sinus infection. Topical nasal corticosteroid sprays are also effective in shrinking and preventing the return of nasal polyps. These sprays at the normal dose are not absorbed into the blood stream and could be used over long periods of time without developing “addiction.”

Nasal saline washes

Nasal rinses can help clear thickened secretions from the nasal passages.

Surgery

If drug therapies have failed, surgery may be recommended as a last resort. It is usually performed by an otolaryngologist. Anatomical defects are the most common target of surgery.

Your surgeon can fix defects in the bone separating the nasal passages, remove nasal polyps, and open up closed passages. Sinus surgery is performed under either local or general anesthesia, and patients often can go home on the same day.

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