Rewriting the Rules of Rhinosinusitis

“Previously, the guidelines stated that after you’ve made a diagnosis of sinusitis, your options are to either start antibiotics or wait,” Dr. Payne said. “The updated guidelines basically remove the antibiotic option when a patient has had symptoms for less than 14 days.”

The step away from antibiotic therapy is supported by studies showing that many cases of bacterial ARS resolve without treatment.

“Studies going back a couple of decades have found that even when patients meet all the criteria for acute bacterial sinusitis with symptoms beyond 10 days, you only see positive cultures in about 60% of those patients. So, it’s really important to recognize that even when you think it’s bacterial sinusitis, many patients are still likely to get better on their own,” Dr. Bleier said.

Healthcare providers can and should offer patients symptomatic relief with analgesics, topical steroids, and nasal irrigation during the watchful waiting period. If symptoms do not improve within three to five days of watchful waiting and supportive treatment, antibiotic treatment with either amoxicillin or amoxicillin-clavulanic acid is recommended.

Educating patients about the reasons for watchful waiting—and providing a means to access antibiotic treatment, if needed, without requiring another clinic visit—will be critical to successful implementation of this guidance. You can start by explaining the rationale behind the recommendation, as well as the potential harm that can occur with unnecessary antibiotic treatment.

“One statistic I’ve been quoting to my patients is that it takes 19 prescriptions of antibiotics to basically improve the outcomes for one patient, but only eight prescriptions to create an adverse outcome—a negative side effect like an allergic reaction, diarrhea, C. diff colitis,” Dr. Payne said. “We’re hurting more people than helping if we’re not being judicious.”

In some cases, providing a “pocket prescription”—a prescription for antibiotics that a patient can take to the pharmacy if symptoms persist past a specified number of days—may provide the security they need to give watchful waiting a chance. You could also encourage patients who use your clinic’s electronic communication system to send you an update after a few days of watchful waiting; if needed, you can then submit a prescription for antibiotics. The recommended duration of antibiotic therapy for bacterial ARS is now five to seven days, down from the seven to 10 days of antibiotics recommended in the 2015 guidelines.

The 2025 iteration also explicitly states that antibiotics should not be prescribed simply to satisfy payer requirements. Although previous guidelines recommended maximal medical therapy before obtaining a CT scan or proceeding to surgery, that approach no longer makes sense given medicine’s current understanding of chronic rhinosinusitis as an inflammatory condition.