What’s New in Acute Sinusitis: Antibiotics vs. Watchful Waiting

Think every sinus infection needs an antibiotic? Think again.

Updated guidelines for acute bacterial rhinosinusitis are sparking discussions about when antibiotics are truly warranted—and pharmacy teams play a key role in helping guide practice. 

In this episode, TRC Healthcare Assistant Editor and Clinical Pharmacist Gina Corley, PharmD, explains new recommendations for “watchful waiting,” when to initiate antibiotics, supportive care measures to try, and more.

You’ll also hear practical pearls on first-line therapy, dosing strategies for amoxicillin and amoxicillin/clavulanate, and safe alternatives for penicillin-allergic patients. Plus, Gina shares tips for counseling patients and reducing antibiotic resistance while improving outcomes.

This is an excerpt from our December 2025 Pharmacy Essential Updates continuing education webinar series.

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CE Information:

TRC Healthcare offers CE credit for this podcast for pharmacist subscribers at our platinum level or higher and pharmacy technician subscribers. Log in to your Pharmacist’s Letter or Pharmacy Technician’s Letter account and look for the title of this podcast in the list of available CE courses. None of the speakers have anything to disclose.

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Clinical Resources from Pharmacist’s Letter, Pharmacy Technician’s Letter, and Prescriber Insights: 

• Article: Keep A “Watch and Wait” Approach for Acute Sinusitis
• Chart: Managing Beta-Lactam Allergies
• Chart: Antibiotic Therapy: When Are Shorter Courses Better?

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Transcript

This transcript is automatically generated. 

00:00:04 Narrator

Welcome to Clinical Capsules from TRC Healthcare, your trusted source for practical, evidence-based updates.

00:00:10 Narrator

On this episode, Assistant Editor and Clinical Pharmacist Gina Corley shares updated guideline recommendations about acute bacterial rhinosinusitis, including when to start antibiotics, which agents are first-line, and what supportive care measures can make a difference… in an excerpt from our popular Pharmacy Essential Updates webinar series.

00:00:30 Narrator

This podcast offers Continuing Education credit for pharmacists and pharmacy technicians. Please log in to your Pharmacist’s Letter or Pharmacy Technician’s Letter account and look for the title of this podcast in the list of available CE courses.

00:00:43 Narrator

None of the speakers have anything to disclose. 

00:00:46 Narrator

Catch new episodes of Clinical Capsules every 2nd and 4th Tuesday—bringing concise, actionable insights from TRC experts straight to your ears.

00:00:55 Narrator

Let’s take a closer look…

00:01:03 Gina Corley

Now let's talk about recent updates to the acute bacterial rhinosinusitis guidelines for adults.

00:01:11 Gina Corley

Before we begin, I want to make a quick note that acute bacterial rhinosinusitis is often just referred to as sinusitis or acute sinusitis. So you'll hear me use these terms interchangeably throughout the presentation.

00:01:25 Gina Corley

And as our article says, you'll see more watchful waiting for adult patients with acute bacterial rhinosinusitis due to updated guidelines. So today we'll find out when they are needed, what you can recommend first line, and which agents to avoid.

00:01:43 Gina Corley

And to help us start thinking about this, here's a patient case. Jen is a 43 year old female patient who has symptoms of a cold, including facial pressure, fever of 102, runny nose, cough and headache. When asked how long she's had symptoms for, she says about 10 days and her symptoms haven't improved at all.

00:02:04 Gina Corley

After seeing her prescriber, she's diagnosed with sinusitis.  Should an antibiotic be recommended in this situation?

00:02:14 Gina Corley

We will go through some things to consider when helping to decide if an antibiotic is needed, and then we'll come back and revisit this case.

00:02:23 Gina Corley

So let's start off with some background about acute sinusitis. Sinusitis is the inflammation of the tissues lining your sinuses, which are structures in your face that are normally filled with air. When these structures get infected with bacteria or viruses or irritated with allergies, it causes them to get blocked up with fluid.

00:02:45 Gina Corley

This is what creates the facial pressure and pain that people often complain of, along with a stuffy nose and other symptoms.

00:02:53 Gina Corley

Many people think antibiotics are needed for sinusitis infections, but the reality is that less than 10% of cases are bacterial and the rest are viral. Therefore, the majority of cases should not be treated immediately with antibiotics. Plus a lot of sinusitis cases resolve on their own in about a week or so.

00:03:17 Gina Corley

So how do we know if a sinus infection is bacterial or viral? Like we mentioned, most sinusitis cases are viral, but if symptoms persist for 10 or more days without improvement, or if they start to worsen after initially improving, we can start to think about a bacterial cause.

00:03:38 Gina Corley

In the past, antibiotics were typically started ASAP for patients who presented with severe symptoms.

00:03:45 Gina Corley

This could include fever of 102˚ or greater, nasal discharge with pus or mucus, or facial pain for three to four days.

00:03:56 Gina Corley

But now new guidelines recommend watchful waiting for three to five days without antibiotics in most healthy adults who have been diagnosed with acute sinusitis, regardless of symptoms severity.

00:04:08 Gina Corley

However, these patients should continue to follow up with their provider, especially if their symptoms get worse after the watchful waiting period.

00:04:19 Gina Corley

So as you can imagine, some patients may be upset or even angry about not being prescribed an antibiotic.

00:04:28 Gina Corley

For these patients, we want to point out that while antibiotics can be beneficial in some cases, the benefits don't always outweigh the risks and watchful waiting can help avoid some of the side effects or the other downsides if antibiotics aren't truly needed.

00:04:45 Gina Corley

Some of the risks with antibiotics can include drug interactions, along with developing antibiotic resistance. Plus, they can also lead to a Clostridium difficile, or C diff infection, which is a bacterial infection in the colon that can cause severe diarrhea and can even lead to life threatening colon damage.

00:05:09 Gina Corley

So now let's highlight some supportive care measures we can try. We know that in viral cases, we want to treat the symptoms since antibiotics won't help, but patients can still use some of these supportive care measures during a bacterial infection as well. If they want some added symptom relief.

00:05:27 Gina Corley

This can mean an NSAID like ibuprofen or something like acetaminophen for fever or headache.

00:05:35 Gina Corley

Or patients can try a nasal steroid like fluticasone or triamcinolone to help reduce swelling in the nasal passages. But keep in mind that nasal steroids don't have a lot of data behind them that shows they help with sinusitis, plus they can cause nasal itching and nose bleeds.

00:05:56 Gina Corley

Patients can also try nasal irrigations to rinse out their sinuses. This involves using a saline solution with a neti pot or a rinse bottle to flush out the nasal passages and reduce mucus and congestion.

00:06:11 Gina Corley

If patients try this, we want to make sure they use distilled, sterile or some other type of filtered water and never just plain tap water. Since tap water can contain traces of germs and pesticides.

00:06:24 Gina Corley

We also want to encourage drinking plenty of fluids, especially ones that contain electrolytes so patients don't get dehydrated if patients ask about using a decongestant, we can point them towards a nasal decongestant, such as oxymetazoline.

00:06:42 Gina Corley

It has more data for acute sinusitis than pseudoephedrine, but the evidence isn't strong for either option.

00:06:52 Gina Corley

If patients decide to try oxymetazoline, make sure they know to limit use to three days to avoid rebound congestion, which is where nasal congestion actually worsens after initially improving with the spray.

00:07:09 Gina Corley

So now let's talk about which antibiotics you can expect to see in patients who do need them. And if pharmacists and techs, we can help ensure the right antibiotic is used for the right amount of time as first line therapy. We can generally recommend amoxicillin or amoxicillin clavulanate both agents cover streptococcus pneumoniae, which is the most common bacteria that causes sinusitis.

00:07:35 Gina Corley

Generally, amoxicillin will be given to patients with mild to moderate symptoms, whereas amoxicillin clavulanate will be reserved for patients with more severe symptoms, or patients who are immunocompromised or have a chance of bacterial resistance. Since it covers bacteria, that may not be susceptible to amoxicillin alone.

00:07:56 Gina Corley

But keep in mind amoxicillin clavulanate can cause more side effects such as stomach upset or diarrhea, so we want to tell patients to take it with food to lessen these symptoms, but we can also tell patients to take plain amoxicillin with food as well.

00:08:16 Gina Corley

So if patients get prescribed amoxicillin or amoxicillin clavulanate. Let's go over what doses you can expect to see.

00:08:24 Gina Corley

For amoxicillin, expect to see 500 milligrams every 8 hours, or 875 milligrams every 12 hours, both for five to seven days. And then patients who get prescribed amoxicillin clavulanate will have similar doses. Since this Med is dosed on the amoxicillin component, but each tablet will also contain 125 milligrams of clavulanate.

00:08:50 Gina Corley

So we can expect to see 500 milligrams per 125 milligrams every 8 hours or 875 milligrams per 125 milligrams every 12 hours for five to seven days in these patients.

00:09:06 Gina Corley

And then I also wanted to point out that in rare cases, you may see high-dose amoxicillin clavulanate XR prescribed, which is 2 grams per 125 milligrams by mouth twice per day.

00:09:19 Gina Corley

This is usually reserved for patients who are at risk for a penicillin-resistant infection, such as those who are over 65, have severe symptoms, or have recently been hospitalized.

00:09:32 Gina Corley

But keep in mind that amoxicillin may not be appropriate in some patients, such as those with a penicillin allergy.

00:09:39 Gina Corley

For patients with a non-severe reaction to penicillin, such as a non-itchy rash, we can suggest cefixime or cefpodoxime, both with or without clindamycin.

00:09:51 Gina Corley

In patients who have had a severe reaction to amoxicillin, such as hives or trouble breathing, we can suggest doxycycline, since we usually want to avoid both penicillins and cephalosporins in these patients, and then looking at some other meds that you might be wondering about, we want to save fluoroquinolones such as levofloxacin or moxifloxacin.

00:10:16 Gina Corley

As a last resort, due to FDA's black box warning of serious adverse events such as tendon rupture and peripheral neuropathy, and then we want to emphasize that trimethoprim sulfamethoxazole along with macrolides are usually not effective due to high rates of resistance.

00:10:36 Gina Corley

And then I know that I have mentioned the duration of therapy was five to seven days of antibiotics. When it comes to amoxicillin or amoxicillin clavulanate. But we can also suggest this duration for any antibiotic therapy that patients get for acute sinusitis.

00:10:53 Gina Corley

Since data shows similar success rates and less side effects compared to the previous duration of therapy, which was 10 days and then we also want to advise patients to follow up with their prescriber if symptoms don't improve within three to five days after starting their antibiotic since they may need to try something else to get rid of their symptoms.

00:11:16 Gina Corley

So now let's go back to our patient Jen. Based upon what we know now, looking at her symptoms and how long she's felt sick, would we want to start an antibiotic for her?

00:11:27 Gina Corley

And the answer is no, we would not. Jen does meet the criteria for a severe infection due to her 102° fever.

00:11:37 Gina Corley

And we can likely expect a bacterial infection since she's had symptoms for 10 days. So now this is the time when we would want to start watchful waiting and hold off for another three to five days before prescribing antibiotics.

00:11:52 Gina Corley

Remember, current guidelines recommend watchful waiting, regardless of symptom severity in most healthy adult patients.

00:12:01 Gina Corley

And then just a few practice pearls to go over, we want to check e-Rx notes for antibiotics just in case the prescriber advises it to be put on hold in case the patient starts feeling better.

00:12:15 Gina Corley

Be ready to fill the prescription if the patient gets worse or symptoms don't improve in the next couple of days and then we want to watch the name strength and sigs of antibiotics closely.

00:12:28 Gina Corley

For instance, amoxicillin and amoxicillin clavulanate look and sound similar, and they can both be dosed in a couple different ways for sinusitis. We also want to double check that the prescribed quantity matches the day's supply, keeping in mind that the days supply should usually be between five to seven days.

00:12:48 Gina Corley

Lastly, we can use stickers or labels to reinforce proper use. For instance, we can add a take with foods sticker to an amoxicillin prescription bottle to remind patients they should eat before taking this Med.

00:13:03 Gina Corley

And then to wrap up, I wanted to tell you about our resource titled “Antibiotic Therapy: When Are Shorter Courses Better?” This highlights the benefits of shorter durations of therapy such as minimized risk of antibiotic resistance, reduced adverse effects and improved adherence.

00:13:23 Gina Corley

Plus, it also has a chart that lists common infections along with the most appropriate antibiotic therapy duration.

00:13:32 Narrator

Thanks for listening—we hope today’s episode gave you practical insights you can use right away.

00:13:38 Narrator

Now that you’ve listened, pharmacists and pharmacy technicians can receive CE credit. Just log into your Pharmacist’s Letter or Pharmacy Technician’s Letter account and look for the title of this podcast in the list of available CE courses.

00:13:49 Narrator

We’ve linked the resources we mentioned—and more on today’s topic—right in the show notes. Those links will take you straight to our websites, where you’ll find even more concise, evidence-based charts, articles, and tools.

00:14:01 Narrator

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00:14:18 Narrator

Have a question or a topic suggestion? Reach out using the ‘send us a text’ link in the show notes or email ContactUs@TRChealthcare.com. Your perspective matters—share your thoughts anytime to help shape future episodes.

00:14:32 Narrator

Thanks for listening… stay sharp, stay current—and join us next time on Clinical Capsules!