“I have sinusitis and I need an antibiotic.” As an ENT physician, this is a statement I hear all the time. And I am sorry to say, I cave in and write the prescription more than I genuinely believe is needed. Why? Its a long story…but one I believe that everyone needs to hear.
Since discovered and clinically utilized in the 1940s, countless lives have been saved due to the effectiveness of antibiotics curing many bacterial infections. However, their effectiveness has continually decreased over time due to bacterial resistance. How has this happenned so quickly? The main culprit…overutilization by physicians, ie. prescribing when not needed!
We have seen this resistance problem since the 1950s, and this has become even more of a problem in the past decade. The CDC estimates that 23,000 peope die a year in the U.S. due to resistant bacteria, otherwise know as “super bugs”.
Another piece of information regarding acute upper respiratory infections (URIs), sinusitis and bronchitis and pharyngitis, is that estimates show over 90% of these infections are due to viruses and not bacteria. Antibiotics can not kill viruses and do not improve infections caused by viruses, thus there is no need for antibiotics in over 90% of these infections. However, its estimated that a third of antibiotics prescribed by physicians in the U.S (costing us over a billion dollars a year!) are for URIs. Why?
The first reason is a social-cultural one: workers in the U.S have very little “paid sick days off” and want to minimize time missed from work and believe that an antibiotic will help. The second one is a dilemna in our ability to differentiate between a viral infection from a bacterial infection. Another reason is the competitive nature of practicing medicine today in the U.S., ie. doctors fear that many patients will just move on to another practioner to get what they want (the antibiotic). Another less common reason is the litigious nature of our society (I saw a patient who had a very bad acute sinus infection for only 3 days that was not treated with antibiotics initially as they were told it was a cold, and over 24 hours it progressed to involve the orbit-eye. This required surgery and intravenous antibiotics and the patient’s family wanted to file a lawsuit against the first practioner because they did not give an antibiotic. Ultimately, the patient did well and recovered from this aggressive infection. I believe this was a rare and aggressive infection, and no malpractice was done and explained that to the famliy.) Another reason is the widespread marketing of medicines by the pharmaceutical industry. All of these reasons, and some others, have led to overuse of antibiotics in the U.S.
So, when you have a sinus infection, how do you know to see a physician about potentially starting an antibiotic? The only way we have seen a clear difference between a viral and bacterial infection is the timing: if symptoms progress past 5 days or if symptoms last longer than 10 days, then it’s more likely to be a bacterial infection. Clinically, they look the same (green boogers and feeling bad). Radiographically, they look the same (no difference when looking at CT scans). So, in most cases, like Axl Rose said…”just a little patience” is what the patient needs.
When a patient tells me they have had a low grade fever and “feel sick”, with nasal congestion and facial pain-headache and “green snot” for 3 days, what do I tell them? I tell them that research shows that there is a 90% chance its a virus and here is an aggressive regimen I recommend to help:
1. Moisturization of nasal and sinus membranes: nasal saline sprays three times daily, steam in a hot shower twice daily, and increase non-caffeinated beverages.
2. Home remedies that have shown in some studies to help, what we in the field call “voodoo”: Honey and Lemon juice in warm water or tea. Getting plenty of rest as well.
3. OTC medicines: decongestant nasal spray (Afrin) in the AM and PM for 5 days, oral decongestants (Sudafed) as directed (if the patient does not have high blood pressure), mucous-thinning agents (Mucinex) twice daily, and tylenol +/- ibuprofen as needed for headache and pain.
4. Vitamins: both Zinc and Vitamin C have been shown in some studies to shorten the length of an acute infection, but need to be started at the onset of the infection. I typically say Vitamin C 500mg two times daily and Zinc lozenges 4 times a day for a week. Elderberry extract two times daily has also been shown to help hasten recovery from a URI, even helping influenza infections.
Now, if the infection symptoms get worse after 5 days or persist past 10 days then an antibiotic should be started. So, the next time you develop sinusitis, try to get plenty of rest and use the above regimen. Patience was noted to be a virtue many years ago…and most of the time, using it will prevent the overuse of antibiotics.
