What role do antibiotics play in the management of chronic rhinosinusitis, and when should they be considered?

Role of antibiotics in chronic rhinosinusitis: Antibiotics are not routinely recommended for the management of chronic rhinosinusitis, as symptoms persist for 12 weeks or longer and the evidence supporting their efficacy is low or very low quality. Short-term antibiotics have uncertain benefits in adults with chronic sinusitis or acute exacerbations, and gastrointestinal side effects are common. In children, there is no high-level evidence supporting the use of either short- or long-term antibiotics for chronic sinusitis.

When to consider antibiotics: Antibiotics should be considered only after specialist advice, particularly before initiating long-term antibiotic therapy, due to potential adverse effects, risk of increasing bacterial resistance, and low specificity of primary care diagnosis. They may be considered if there is suspicion of bacterial infection with features such as symptoms lasting more than 10 days, discoloured or purulent nasal discharge, severe localized pain (often unilateral), fever above 38°C, or marked deterioration after an initial milder phase (double sickening). A back-up antibiotic prescription may be preferred in these cases.

Overall, management focuses on addressing triggers, symptomatic treatment, nasal irrigation, and intranasal corticosteroids rather than routine antibiotic use. Referral to specialists is advised if symptoms do not improve after 6–12 weeks or if there are complicating factors such as immunocompromise, nasal polyps, or suspected resistant bacteria.

Summary: Antibiotics have a limited role in chronic rhinosinusitis and should be reserved for cases with clear bacterial infection signs or after specialist consultation due to limited evidence of benefit and potential harms.

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