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Practice Change Page

Avoid prescribing antibiotics in acute rhinosinusitis

BMJ 2014; 349 doi: (Published 17 October 2014) Cite this as: BMJ 2014;349:g5703
  1. Wytske J Fokkens, professor of otorhinolaryngology, clinical epidemiologist1,
  2. Ruth Hoffmans, otorhinolaryngologist in training1,
  3. Mike Thomas, professor of primary care research2
  1. 1Department of Otorhinolaryngology, Academic Medical Centre, Amsterdam, Netherlands
  2. 2Department of Primary Care Research, University of Southampton, UK
  1. Correspondence to: W J Fokkens w.j.fokkens{at}
  • Accepted 13 August 2014

Change Page aims to alert clinicians to the immediate need for a change in practice to make it consistent with current evidence. The series advisers are Sera Tort, clinical editor, and David Tovey, editor in chief, the Cochrane Library. We welcome any suggestions for future articles (

Key points

  • Only consider prescribing antibiotics in patients with symptoms of acute rhinosinusitis (ARS), for instance with at least three of the following more severe symptoms: purulent secretion, high fever, severe (unilateral) facial pain, prolonged illness (7 days or more), and/or “double sickening.”

  • The prescription of antibiotics does not prevent serious complications in ARS

Acute rhinosinusitis (ARS) is an acute inflammatory condition of the nose and sinuses that is characterised by sudden nasal blockage, discharge, facial pain, or pressure and reduction in smell in adults or cough in children.1 It is common, having a global prevalence of 6-15%,1 2 and it is usually managed in primary care. Despite consistent evidence of spontaneous resolution and recommendations to restrict antibiotics to severe illness, more than 80% of people with ARS receive antibiotics in Europe and North America.2 3 4 5 Prescription rates might be lower (30%) in Asia, although over the counter availability of antibiotics in some settings makes accurate figures difficult to ascertain.2 High prescribing results in pressure for antibiotic resistance and in adverse events. However, the primary cause of ARS is postviral inflammation. Fewer than 2% of patients have the more severe presentation of “bacterial ARS,” a clinical rather than microbiological diagnosis characterised by discoloured discharge, severe local unilateral pain, fever (>38ºC), raised levels of inflammatory markers (erythrocyte sedimentation rate and C reactive protein) and/or “double sickening” (deterioration after an initial milder illness).1 The gold standard diagnostic test of true bacterial ARS is a positive culture from an invasive …

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