When should I start an antibiotic?
Sinus infections are very common. With this time of year, as the colder weather sets in, I usually see an increase in appointments for sick visits like sinus infections. They are typically easy to diagnosis, and most patients know when they have one. The classic symptoms are headache, sinus congestion, increased mucus production, fever and so on.
The challenge is deciding when it’s time to start an antibiotic. Sinus infections can be caused by viruses, bacteria, or allergens, but only the bacterial sinus infections benefit from starting an antibiotic. It can be really tough clinically, meaning based on signs and symptoms, to differentiate between the different possible causes. The main factor used to determine if an antibiotic is prescribed is duration of symptoms. Viral sinus infections typically resolve on their own in less than a week, whereas bacterial infections persist for longer than 7-10 days. Another clue is “double worsening,” which refers to a resurgence in severity of symptoms after initial improvement.
Frequently I will have patients reach out because of a fever, thinking this is a sign for sure that antibiotics are needed. This is not the case though, as viral infections can cause fevers just like bacterial infections. Another reason I hear from a patient is because of a change in the color and consistency of their mucus from clear to thick/green/yellow, thinking this represents the presence of bacteria. Rather, the color change means that there are white cells present, which is what the body uses to fight off infection, so this happens with both viral AND bacterial infections. So again, this doesn’t really help to pin down the cause of the infection.
Sometimes I get a call from a patient on day one of symptoms, because they want to start an antibiotic and take care of it before it gets worse. While I love the preventative mindset, it is not generally the right approach to sinus infections. Commonly sinus infections will resolve on their own without any treatment. Taking an antibiotic comes with a lot of risks, so ideally you only want to take one if necessary. When starting any treatment, you always want to weigh the risks and the benefits. If you have a viral infection, the benefit of the antibiotic is nothing, whereas the risks are many, ranging from uncomfortable side effects like stomach upset to more serious effects like allergic reactions, dangerously irregular heart rhythms, or even a terrible diarrheal infection called c diff.
So next time you feel a sinus infection coming on, stick to supportive care for the first few days - over the counter medications like Tylenol or Motrin, soothing fluids like honey in tea, rest and self care. The benefit of direct access primary care is that you can keep in touch with me throughout your illness, so we can decide together when it’s the right time to start an antibiotic. And in the meantime, keep focused on preventative measures to stay healthy, like hand washing!
