Lastly, the final upper respiratory scourge, acute sinusitis. The prevalence of bacterial infection during acute sinusitis is estimated to be only 2 percent to 10 percent, yet more than 80 percent of the 4 million annual outpatients who visit for acute sinusitis receive antibiotics.⁸ Sinusitis is, understandably, frustrating for patients and clinicians, with persistent symptoms lasting several weeks in many cases. However, antibiotics simply don’t provide much value. In clinical trials, only half of patients improved within the first week, and nearly 30 percent continued to have symptoms past 14 days.⁹ However, allocation to the antibiotic group did not increase overall cure versus placebo, and antibiotics decreased the duration of symptoms for only one in 20 patients. Considering there are no reliable clinical signs specific for bacterial versus viral etiologies, and it is challenging to select patients for whom intervention will substantially increase the chance of cure, antibiotics are best used judiciously for only the most exceptional cases.

Further compounding all these sins, physicians are persistently using a nuclear antibiotic arsenal for these extraordinarily straightforward conditions, which is akin to smashing a teacup with a sledgehammer. For each of these conditions, in the vanishingly small subset where antibiotics are indicated, narrow-spectrum antibiotics are absolutely sufficient. The first-line antibiotic for each of these conditions is penicillin or an equivalent beta-lactam antibiotic, yet these classes represent fewer than 20 percent of antibiotic prescriptions for sinusitis. Group A Streptococcus is universally susceptible to penicillin, but despite this, penicillin’s use in acute pharyngitis continues to drop. Extended-spectrum macrolides, such as azithromycin, and fluoroquinolones are experiencing corresponding increases as penicillin falls out of favor. Azithromycin, in particular, has such a long half-life that its unfettered use is responsible for a rapid rise in macrolide-resistant Streptococcus pneumoniae.¹⁰ It is estimated that more than $250 million in direct and indirect costs in the United States alone are associated with clinical treatment failures secondary to macrolide-resistant pneumococcus.¹¹ Fluoroquinolones, on the other hand, are bactericidal antibiotics with a broad spectrum of activity. The resulting effect on the natural symbiotic flora of the human body predisposes patients to such overgrowth of pathogens such as Clostridium difficile along with other adverse effects such as tendinopathies and delirium in the elderly. Antibiotic spectrums of activity are part of the basic preclinical medical school curriculum; sadly, many, if not most, clinicians have forgotten this portion of their education.

If you’re routinely prescribing for these conditions, please stop. If you supervise residents, nurse practitioners, or physician assistants, ensure they stop as well. Institute a quality-improvement program at your facility to track and provide feedback on antibiotic prescribing rates. Create educational materials targeted at patients to reduce the expectation of antibiotics.