When a patient walks into my office after five failed antibiotic courses, the first thing that goes through my mind isn’t clinical. It’s human. I’m worried about what happened to the healthy bacteria in her nose, the protective organisms that have been defending her sinuses since the day she was born. I’m worried about her gut. And honestly, I’m worried about something bigger than both: the generations of kids and grandkids who will one day need antibiotics that may no longer work because we kept writing prescriptions that weren’t necessary.

That’s not a criticism of the physician who prescribed them. I ask every one of these patients the same question: Did any of those doctors take a culture before starting you on an antibiotic? The answer is almost always no. And it’s almost always no because the system those physicians work in doesn’t give them the time or the tools to do it differently.

What the system doesn’t give primary care providers

The average primary care visit runs about 18 minutes. After documentation, medication reconciliation, and addressing the conditions that sit at the top of the triage list (diabetes, heart disease, hypertension, cancer screening), there might be three or four minutes left for the patient who mentioned sinus pressure at the end of the intake form. That’s not enough time to scope a nose and take a proper culture. And the doctor almost certainly doesn’t know that this same patient was seen at an urgent care last month, a different urgent care six weeks before that, and a telehealth provider at midnight the week before, each one prescribing without the full picture. So everybody treated the same infection with a different antibiotic, and nobody saw what was building inside.

In July 2025, the American Academy of Otolaryngology-Head and Neck Surgery updated its Adult Sinusitis Clinical Practice Guideline for the first time in a decade. The message was clear: Watchful waiting, not antibiotics, is now the recommended first response for uncomplicated acute bacterial rhinosinusitis in otherwise healthy adults. The field drew a line. But that line only helps if primary care has a clear pathway to stay on the right side of it.

What’s actually growing inside

When patients ask me why their urgent care doctor didn’t pick a better antibiotic, I give them the honest answer: Those providers made the best first-line decision they could with what they had. The problem is what happened after the first course failed. Each round that didn’t fully clear the infection gave the surviving bacteria exactly what they needed (time and selective pressure to build a biofilm). Once that structure sets up, oral antibiotics can’t reach it. Not at any dose you can safely give a human being. The bacteria aren’t just surviving. They’re living inside a fortress that standard cultures often can’t even detect. And in patients who’ve been through multiple courses, I’m seeing fungal co-infections, organisms that moved in precisely because the antibiotics wiped out the bacteria that had been keeping them in check.

It doesn’t stop at the sinuses, either. Depending on the drug, a single antibiotic course can take months to years for the gut to recover from. A 2026 study of nearly 15,000 adults found significant microbiome changes persisting four to eight years after certain antibiotic courses. Stack four or five rounds on top of each other and you start to understand why these patients feel terrible in ways that go beyond congestion: the fatigue, the brain fog, the anxiety, the insomnia. The gut microbiome produces neurotransmitters and talks to the brain through pathways we’re still mapping. When you strip that ecosystem, the fallout isn’t limited to the GI tract.

What changes with the right tools

For patients with recurrent or refractory sinus infections, we use next-generation DNA sequencing. Standard cultures only grow what survives lab conditions. Sequencing identifies everything: every bacterial and fungal species, including the biofilm-adapted organisms and polymicrobial communities that cultures miss. When those results come back showing resistant bugs and fungal co-infection, patients get frustrated. They want to know why nobody found this sooner. I tell them the truth: Nobody had the tools. A swab from an urgent care can’t give you what an endoscopically guided specimen processed through DNA sequencing gives you. That’s not a failure of the provider. That’s the system.

Once we know what’s actually living in the sinus, we can go after it directly, usually a compounded antibiotic rinse delivered into the cavity at concentrations that biofilm can’t withstand. We stop guessing. We stop cycling through drugs that were never going to work. We fix the environment instead of carpet-bombing it.

One thing that takes thirty seconds

I’m not asking primary care to add anything to an already impossible day. I’m asking for one referral, for any patient who has failed two or more antibiotic courses for the same sinus complaint. That takes thirty seconds. It’s faster than writing a sixth prescription and a lot less expensive than managing what comes after.

If it helps, I’ll send a poster. Put it in the waiting room. Put it in the exam rooms. Let it do the patient education while you handle the problems that need your full attention. The message is simple: Repeated antibiotic courses carry real costs to the gut, to the immune system, and to the community. That doesn’t need eighteen minutes to land. It needs a poster on the wall and a doctor willing to put their name on it.

The CDC reports more than 2.8 million antimicrobial-resistant infections in the United States every year, killing more than 35,000 Americans. Global projections show AMR deaths rising nearly 70 percent by 2050. Those numbers are being built one unnecessary sinus prescription at a time, in exam rooms where good doctors don’t have enough time or infrastructure to do it differently. That’s a system problem. And fixing it starts with a thirty-second referral and a poster on the wall.

Franklyn R. Gergits is a board-certified otolaryngologist and fellowship-trained otolaryngic allergist with a clinical focus in rhinology and airway disorders and more than 30 years of clinical experience. He is affiliated with HonorHealth Scottsdale Shea Medical Center and is the founder of Sinus & Allergy Wellness Center of North Scottsdale.

Dr. Gergits performs in-office balloon sinuplasty, turbinate reduction, NEUROMARK posterior nasal nerve ablation, and Eustachian tube dilation under local anesthesia. He performed the first balloon sinuplasty in Pennsylvania and holds dual Entellus Centers of Excellence certifications.

His recent scholarly work includes “Posterior Sinonasal Syndrome: A Pepsin-Mediated Hypothesis for Chronic Rhinosinusitis” and “The Continuous Mucosal Liquid Layer: A Unified Hypothesis for Airway-Digestive Immune Surveillance, Mucociliary Transport, and Disease Susceptibility.” His ORCID profile is available at ORCID. He also publishes patient education and clinical commentary through the Airway & Sinus Wellness Review and shares updates through Facebook, Instagram, LinkedIn, X, YouTube, and TikTok.