Hopkins C, Surda P, Walker A, Wolf A, Speth M, Jacques T, et al. EPOS 4 patients. Rhinology. 2021 Suppl. 30: 1-57.
Treatment of Rhinosinusitis
What are antibiotics used for in rhinosinusitis?
Antibiotics are medications to fight infections caused by bacteria. To cope with different kinds of bacteria, doctors have developed antibiotics that act in different ways – for example, some of them may fight bacteria through may damaging the wall or coating of the microbe, interfere with their ability to reproduce, or by blocking their growth mechanisms.
The problem of too many antibiotics
However, bacteria can change and adapt to become “resistant” to antibiotics. This is because bacteria exist in populations of many millions, and amongst that enormous population, there will be some that have a natural capability to defeat certain antibiotics. These bacteria will not only survive, but then will become parent bacteria for a whole new generation of bacteria that have the same natural capabilities to defeat antibiotics. This ability to evade or defeat antibiotics is what is meant by the term “resistance”.
Clearly, the problem of resistant bacteria poses problems for both healthcare professionals and patients as infections become harder to treat. However, we have also started to recognise that resistance is not the only problem caused by antibiotic use. Although some bacteria may cause infections, there are many millions of bacteria that live alongside humans without causing any problems at all. In fact, some of these bacteria are probably vital to keeping us healthy. This is the principle of the “probiotic” drinks that you might have seen in a supermarket. However, when we use antibiotics for an infection then some of these helpful bacteria will also be killed.
Changing how we use antibiotics
For these reasons, there have been many changes to the way that doctors think about how to treat infections and the best way to use antibiotics to avoid harm through their overuse. For instance, the routine use of antibiotics in acute rhinosinusitis (‘common cold’) in adults and children is not recommended because these are most often due to viruses (viruses are very tiny organisms that are entirely different to bacteria) On the other hand, antibiotics are powerful tools for the treatment of infections caused by bacteria. Thus, careful assessment of what is thought to be the most likely cause of infection is necessary.
Acute bacterial rhinosinusitis
Although the most common cause of acute rhinosinusitis is a viral infection, in certain cases, it may be caused by bacterial infection. This can be recognised by severe symptoms – e.g. fever above 380C, feeling sick again after seeming to make an initial recovery, one-sided disease, severe pain, or on rare occasions, signs that infection has spread out of the sinuses into the eye or brain (Table 9.1). Where these symptoms of a bacterial sinus infection are present, the use of antibiotics has some benefit, although are still not needed in most cases. The course tends to be short (<4 weeks) and uses antibiotics that target the most likely bacterial cause (such as amoxicillin/penicillin). Antibiotics in the treatment of acute, bacterial rhinosinusitis are usually well-tolerated and improvement of symptoms can be expected within 10 days.
(For an example of the use of antibiotics for acute bacterial rhinosinusitis, see case report 1).
Antibiotics for chronic rhinosinusitis
Chronic rhinosinusitis is a quite different disease to the short, sudden episode of infection described by the term acute bacterial rhinosinusitis. Acute infections can usually be linked to a virus or bacteria as the cause of the symptoms. By contrast, it is not nearly so clear what causes chronic rhinosinusitis and the role of bacteria in this differs from patient to patient.
Long-term antibiotics can be helpful in a certain subgroup of patients suffering from exacerbations of chronic rhinosinusitis with pus contained in their nasal discharge (or seen in the nose by a doctor with a nasal endoscope). In these cases, long-term courses of antibiotics (>4 weeks) can be prescribed in addition to baseline therapy (i.e., nasal steroids and saline rinses). The antibiotics chosen are often of a type referred to as ‘macrolides’ and are used for their immunomodulatory effects. The aim of this treatment is to get through periods where symptoms may have ‘flared up’ and to be able to return to using the standard baseline therapy of saline rinse and nasal steroids (see second patient experience).
In some cases, patients with chronic rhinosinusitis may develop an acute exacerbation, and in these cases, short courses of anti- biotics may be used.
How, when and for how long you should take your antibiotics?
Antibiotics are usually prescribed as tablets, capsules or liquids. It is crucial to take the medication exactly as your healthcare professional tells you (Table 9.2). Macrolides when used for CRS are usually given for up to 12 weeks in a low dosage and it can take at least 6-8 weeks before any improvement is noticed.
Side effects (and what to do if they occur)
Like all medications, antibiotics have side effects (Table 9.3): Gastrointestinal-related side effects (diarrhoea and loss of appetite) are reported frequently. Other side effects include rash, dizziness, nausea and yeast infections. The most serious side effects include allergic reactions and Clostridium difficile infection causing diarrhoea, but these are rare. Macrolides also have a particular potential risk in patients with a background of heart disease (particularly used as long-term oral antibiotic treatment), and your doctor may ask you to undertake some simple tests to check your heart health prior to starting this type of antibiotics.
The use of antibiotics can be problematic in combination with other medications and in patients suffering from severe liver or kidney disease. Before taking any antibiotics, inform your
healthcare professional regarding your personal medical history including allergies and other medication you may be taking to make sure that there is no interaction between this and the anti- biotics. If side-effects do occur, there will be a leaflet contained within your medication that has information on whether these may be due to the medication. If you have any serious symptoms that you think are related to the antibiotics, please contact your healthcare team for further advice.
Patient’s experience with antibiotic treatment
Patient 1 reports:
A 19-year-old female patient was presented to the otorhinolaryngologist suffering from fever (400C), acute, severe, one-sided facial pain and raised inflammatory parameters in the blood. Clinical examination including nasal endoscopy revealed purulent nasal secretion. Due to the combination of symptoms, a short-term course of systemic antibiotics was prescribed as add-on therapy to NSAID, saline sprays and decongestants. An improvement of symptoms was achieved after 3 days with total resolution after 1 week.
Patient 2 reports:
A 48-year-old male patient was presented to the otorhinolaryngologist suffering from chronic, bilateral, diffuse rhinosinusitis for more than 15 years. Since symptoms (nasal discharge and facial pain) increased 6 weeks ago, nasal steroids, saline rinses as well as a course of systemic steroids were prescribed. Unfortunately, symptom control was still insufficient. After additional workup including nasal endoscopy (showing purulent secretion), a course of long-term antibiotics was prescribed. Ten weeks after, a symptom relief was achieved, diagnostic nasal endoscopy showed no further purulent secretion and the patient returned to his baseline therapy including nasal steroids and saline irrigations.
Frequently asked questions
Why won’t my GP give me antibiotics for my sinusitis as I need to get back to work quickly?
Antibiotics are powerful instruments to fight diseases caused by bacterial infections. Most cases of rhinosinusitis are caused by viral infections. Randomized, controlled trials did not show any benefits in the use of antibiotics in patients suffering from viral rhinosinusitis (‘common cold’). On the other hand, antibiotics can cause several side effects that have to be considered. Only in the few cases of diagnosed, severe, bacterial sinusitis or chronic rhinosinusitis, the use of antibiotics can be indicated.
Is there anything I can do to help my acute sinusitis except take antibiotics?
Yes, several medications apart from antibiotics are available for the (symptomatic) treatment of acute sinusitis. Treatment options comprise nasal saline irrigations, NSAIDS, paracetamol, decongestants, local steroids, etc.. Treatment strategies should be indicated according to the recommendation of your healthcare worker.
How can do long term courses work in chronic rhinosinusitis if it’s not caused by infection?
The mucus transport of the upper and lower respiratory tract (‘mucociliary clearance’) is the first line of defence in our respiratory system. Failure of mucociliary clearance can be caused by chronic or recurrent infections and can be improved by prolonged antibiotics in a certain group of patients.
Is there anything I can do to reduce the risk of side effects from antibiotics?
The best way to avoid the risks of antibiotics is to avoid unnecessary usage. For the treatment of acute and chronic rhinosinusitis, a broad range of medications apart from antibiotics are available. Treatment options comprise nasal saline irrigations, NSAIDS, paracetamol, decongestants, steroids, etc. If you have any concerns you should discuss your treatment options with your doctor or pharmacist.
Always follow the instructions on how to take your medicines – some antibiotics should be taken with water (as some, like doxycycline should not be taken with dairy products), while others should be taken with meals to reduce the risk of tummy upset. Take them at regular intervals if possible and complete the course prescribed. Some antibiotics react strongly with alcohol (especially metronidazole). There is some evidence that taking a probiotic can reduce the risk of antibiotic associated diarrhoea.
If you develop a rash, severe diarrhoea, vaginal itching or white spots on the tongue, please contact your doctor. If you develop any swelling of the lips or tongue, or difficulty breathing please seek emergency medical care.
When should I be worried about a sinus infection not settling down?
A viral sinus infection may be transitioning to a bacterial sinus infection when the sinusitis symptoms have lasted for longer than 10 days, there is severe local facial pain (usually one-sided), and/or a so called “double sickening” (when symptoms are improving and then suddenly worsen again) occurs.
Signs that a bacterial sinus infection may be becoming severe and require urgent medical attention include swelling/redness sur- rounding the eyes, change in vision (for example decreased, blurry or double vision), severe headache, sensitivity to light or sound, neck stiffness, confusion or change in consciousness. In these cases, one should consult a physician immediately.
I needed surgery for an abscess in my eye – could this have been prevented if I had antibiotics earlier?
No. Studies suggest early oral antibiotics do not prevent the development of complications. Although complications of sinusitis are rare, they often occur quickly, both in people who have and have not been given antibiotics.
Have I got CRS because my doctor didn't give me antibiotics at the beginning?
No, this is unlikely to be the case. CRS is an inflammatory disease, not an infectious (for example, bacterial) disease. The underlying causes of CRS are not yet totally clear but because it is not infectious in nature, it is not thought to arise from untreated infectious dis- ease, such as a bacterial rhinosinusitis.