Antibiotics for sinusitis without a real diagnosis [PODCAST]

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Most people who get antibiotics for a sinus infection never needed them, and the real problem goes untreated. Franklyn R. Gergits is a board-certified otolaryngologist who sees the patients that three, four, and five rounds of antibiotics did not fix. This episode is based on his article “We prescribe antibiotics for sinusitis without a diagnosis,” published on KevinMD. He separates a sinus infection from a cold, allergies, and COVID, and names the ten-day rule he uses before anyone gets a prescription. You will hear why a patient’s certainty that the antibiotic worked last time is often wrong, what a normal CAT scan should tell you to look for next, and which conditions turn out to be driving the symptoms when the culture keeps coming back clean. He is direct about the pressure clinicians face to write something, and about what patients can try at home before they call. Press play to hear when an antibiotic is the right call, and what to check first when it is not.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today, we welcome back Franklyn Gergits. He’s an otolaryngologist. Today’s KevinMD article is “We prescribe antibiotics for sinusitis without a diagnosis.” Franklyn, welcome back to the show.

Franklyn Gergits: Thanks, Kevin. Thanks for having me.

Kevin Pho: All right, so tell us why you decided to share this latest article of yours on KevinMD.

Franklyn Gergits: Well, Kevin, I’m the last guy, the last doctor taking care of these patients with sinusitis, and we see patients who have had three, four, five antibiotics, and sometimes this happens within a single year. Those patients are coming into the office, and I just realized that we really don’t know what we’re treating. So the patients come in with a presumed diagnosis of sinusitis, and my job is actually to treat them, and sometimes I can’t even get them treated unless I treat them with even more antibiotics. If I can’t even show that the diagnosis was treated effectively, I’ve got to treat it with more antibiotics.

Kevin Pho: So why do you think we got to this point? Obviously, I’m a primary care doctor. I certainly have some theories of my own, but from your perspective as the last line of defense, how did we get to this point?

Franklyn Gergits: I think it goes back to what our training was. If we go back to those time periods, we actually found that a lot of the diagnoses that were established in the protocols for diagnosing sinusitis were never truly confirmed with cultures. So microbiologically, we didn’t know that we were treating patients with sinusitis at that time, and thus the treatment plans were antibiotics, antibiotics, and more antibiotics. And then it got to the point where now we’re treating patients with so many antibiotics that we’re actually starting to harm more patients than we’re helping.

Kevin Pho: You wrote in your article that 84 to 91 percent of sinusitis visits end up with an antibiotic. That is a staggering number.

Franklyn Gergits: Exactly. And most of those patients, if truly diagnosed, should be diagnosed with a virus.

Kevin Pho: So from your standpoint, if a patient is being treated with multiple antibiotics, multiple courses of antibiotics, sometimes more than one antibiotic, what are some of the things that you see as the last line of defense? What are some worst-case scenarios that you see?

Franklyn Gergits: Well, worst-case scenarios are the patients who have just been through so many. We do a culture, and we’ll find out that these patients have a resistant bacteria that may have been missed on the first culture or may have been missed on the PCR testing. Fortunately, we have another option. We can do next-generation sequencing, so we can actually pinpoint with more accuracy what’s causing the problem. But even then, we still have these patients who may look normal on the CT scan, but their bacterial profile is just so erratic and so abnormal that now we’ve got to convince this patient to start to use a different therapy.

We all want to get better fast. They came to see me, and they think that I have the magic potion, but I don’t, unfortunately. So sometimes we have to sit those patients down and do the deep dive, and sometimes we even see that it’s actually more of an inflammatory condition. So now we have to explain to those patients that they may have an underlying diagnosis that was really allergy or an anatomical problem or LPR, and it was never bacterial in the first place.

Kevin Pho: I get patients in my clinic with multiple symptoms or multiple episodes of what seems to be sinusitis, and they always say to me, “Dr. Pho, I was put on this antibiotic in the past, and it worked.” And you wrote in your article that sometimes that’s a fallacy, where it would just get better despite antibiotics. So tell us more about that.

Franklyn Gergits: Absolutely. So that’s the Pollyanna effect. We actually get this antibiotic, and we take that antibiotic, and we feel better afterwards, but it was probably just the natural course of the infection, with or without the antibiotic whatsoever. The downside of that is, what damage are we causing in those patients instead of giving them more conservative treatment, the watchful-waiting approach, versus jumping to an antibiotic right away? I think we really need to pause and pivot and think before we actually prescribe.

Kevin Pho: So give us the presentations of the different forms of upper respiratory infection. What differentiates a sinusitis versus a common cold versus COVID versus allergic rhinitis? From a primary care standpoint, when they see me the first time, what are some of the things that we need to look out for to really suss out the right diagnosis?

Franklyn Gergits: So, thinking about allergy. With allergy, I think of itching, stuffiness, and seasonal symptoms. Maybe it’s actually the pollen that’s in the air. Think back to last year. How did you feel last year? And if this is the time of year when you say, “Oh, geez, I’m going to take the antihistamine again because that helps me,” then think that’s allergy.

With the common cold, we’ve got that fever. We’re feeling achy. We have a lot of lethargy and myalgias and such, but we’re really not having a lot of nasal symptoms as far as green-yellow drainage, facial pressure, facial pain, and loss of smell. When those show up, now we’re starting to move into the diagnosis of sinusitis.

And then the same thing goes with COVID. We still have that COVID diagnosis floating around out there. We may have some loose symptoms, maybe not really the green-yellow drainage, but we still have those COVID swabs in our homes. At home, we’ll just do a little test, and we’ll check and see. And bam, then we get that diagnosis of COVID.

Kevin Pho: I think a lot of times, especially in primary care, there’s a lot of pressure on clinicians to do something, right? Because you have things like patient satisfaction scores, and patients generally don’t like being told, “Oh, just wait a bit, supportive therapy.” I think that there is some pressure on these clinicians to, quote-unquote, do something, or else they get docked on these patient satisfaction scores. And in a lot of cases, it’s reflexively giving an antibiotic.

Franklyn Gergits: And I get that. If I was a patient and I came in, and I know that an antibiotic helped me last time, and I have the same symptoms, I want the same thing. So I get that. That makes total sense. But at the same time, we have to start to maybe just take a little bit of extra time and talk to those patients. If we have that time, just share some information, maybe have a handout that we can share with the patient as well, just to explain the diagnosis of viral infections versus a bacterial infection. And then we can sometimes even share with them the downside of treating them with an antibiotic. If it’s not truly going to be helping them, and it could possibly hurt them, now maybe those patients are willing to say, “OK, I’m going to give it a little bit more time. I’m going to do the nasal rinse. I’m going to do the nasal steroid spray, maybe take some of the analgesics,” and just give it some time. If we can get that 10 days or so from a patient and say, “If it’s not getting any better in that time, give us a call back. Let’s get you on that antibiotic or proper therapy after that time has passed.”

Kevin Pho: So let’s talk about the next step. We are dealing now with a patient with persistent symptoms, and you suspect that it is sinusitis. So now we’re thinking of sending the patient to an otolaryngologist like yourself, maybe some diagnostic tests. With these persistent symptoms, just give us an algorithmic approach in terms of what we need to be thinking about.

Franklyn Gergits: So sometimes we get patients in the office, and they actually have already had a culture, OK? And we’ll get the culture result back, and we’ll look at it, and it may show Staph epidermidis. But the problem is, sometimes those patients have been treated for that bacteria. Well, that’s a good guy. We want those bacteria, the good guys, inside. So if we are just doing an anterior swab, or if we’re doing just the COVID swab in the back of the nasal cavity, the nasopharynx, we’re going to get bacteria back, possibly, but it’s just not going to be the right stuff. So really, in those patients, again, the saline rinse, the steroid nasal sprays.

As far as diagnostic testing goes, if the patients have been treated with appropriate medical therapy, and may have been on a couple of antibiotics, maybe two or three antibiotics in a time period, that’s a great patient for a CT scan. A CT scan can actually give us the information that we need to find out what’s going on inside. And if the CT scan comes back as normal, and our primary care friends are scratching their heads and trying to figure out what’s going on, well, then that’s a good referral for us, because then we can go ahead and do the deep dive and maybe do a little bit more exploration into that LPR diagnosis, or talk about anatomy, and talk to the patients about whether there’s an allergy component to the problem that’s causing that narrow sinus drainage pathway to close down. And then the sinusitis will follow.

So if we can get at those preexisting conditions, the upstream drivers, and try to treat those appropriately, maybe we can start to interfere with or interrupt those. Maybe we get those patients off to the allergist if there’s a long, strong allergy history. Maybe the GI specialist can help us with the reflux and that LPR. And then certainly we can help with the evaluation once we get that result back from the CT scan.

Kevin Pho: So if we send patients to you, you obviously will go through this approach. How often do you find things like anatomical abnormalities, like you said, that would predispose that patient to sinusitis, and what would you do? How often does that lead to some type of procedural option?

Franklyn Gergits: Right. Yeah, and that’s a great question, because we do see that a lot. Sometimes we’ll see the patient in the office, and it’ll be a good day. We have a CT scan machine in our office, so if we do a CT scan today in that office and it’s a good day, we may not see too much going on. But sometimes we’ll ask the patients about the bad day. What does a bad day look like? What does it feel like? So in those clinical situations, if we look inside with a nasal endoscope, we may actually see some of the anatomical problems that are taking place and the soft tissue component that’s compounding the bony abnormalities that we’re seeing on the CT scan. And then some of those patients are great candidates for a simple procedure that we do in the office. It’s under local anesthesia. It’s a gentle opening of those natural sinus drainage pathways, and those patients who go through those procedures are feeling better pretty quickly. And we can interrupt that problem of recurring and chronic sinus infections.

Kevin Pho: All right, so let’s go to the other side of the coin here. When are antibiotics indicated, especially in a primary care setting? When do we need to think about that?

Franklyn Gergits: Oh, no doubt. And I don’t want to take away from the thought process. I don’t want patients not being treated with antibiotics for sinusitis, because that’s not the message at all. Those patients need to be treated. There are patients who come into the office, and they’ve got that fever, the green-yellow drainage. They meet those criteria, and treating those patients with that antibiotic is the right therapy. It’s the patients who fail that therapy. So as long as we’re treating them with that medical therapy, we want to make sure that those patients give us a call back. Let us know how you’re feeling. If you’re not better after 10 days, well, then we have to stop and pivot, and maybe make that referral.

Kevin Pho: So how about initially? What are some initial symptoms or scenarios where an antibiotic is warranted?

Franklyn Gergits: I always think of the patients who have the discolored drainage, the fevers. Patient symptoms of nasal congestion, maybe the facial pressure that worsens when you bend forward to pick something up off the ground. We think of the infection that’s inside there. That hot lining in the sinus cavity now has that mucus inside it, and it’s hitting these nerve endings and triggering more facial pain. Loss of smell is another key indicator during those time periods.

And the patients may have been on antibiotics in the past. Maybe last year they had a problem as well. So basically, just look back into our notes and see the history of these patients before they come in to see us. So it’s not just that knee-jerk, quick reaction of, “Oh gosh, here comes a patient with sinusitis. We’re going to give them that medication.” We can really just spend a little time with the patient and find out what’s going on. The key indicators: the drainage, the facial pressure, dentalgia, teeth pain. Their sleep is off. They’re just congested. And the true facial pain, which is not a migraine. That’s another common misconception, that every sinusitis patient who has a headache has a sinus diagnosis that needs to be treated, but maybe those patients are really migraine patients. In our world, a lot of them are migraine patients.

Kevin Pho: And in terms of specific antibiotic choices, what is the standard of care today?

Franklyn Gergits: It’s still the amoxicillin, the Augmentin, amox-clav. That’s the great first-line antibiotic choice. For patients who might be allergic, maybe we can jump over to the doxycycline as far as that antibiotic goes. Treating with broad-spectrum empiric therapy is still important. It’s still a must-do for those patients who really have that true indication for sinusitis.

Kevin Pho: And looking forward in the coming months to years, what do we have to look forward to in terms of chronic sinusitis or acute sinusitis treatment or diagnosis?

Franklyn Gergits: Now we’re looking at more combined therapies. Sometimes in the office we can actually look at the other triggers, which may be nasal airway obstruction as well. So if the patients aren’t getting the airflow through the nose and getting good-quality sleep, then that can throw us into an imbalance of the autonomic nervous system. So now we’ve got more problems there, and we can treat that by treating the nasal congestion. With patients with brain fog, we know that in those situations, if we get the airway opened up, we not only take care of the sinusitis, but sometimes we have to think about the posterior nasal nerves in the back part of the nose that get activated. And when they’re activated, now the trigeminal nerve is opened up and inflamed and irritated as well. So now we’ve got more conditions that can affect the sinus diagnosis.

So from our end, it could be just a simple anterior component, as far as sinusitis goes, that we can treat pretty easily with a balloon procedure. But if it’s something that’s more complex, maybe we have to take care of the airway, open up the breathing pathway for the patients, and then we can’t forget about those posterior nasal nerves.

Kevin Pho: Now we have patients, of course, listening to you on this podcast, and there are several things that they can do even before seeing a clinician, right? Over-the-counter remedies, and I know you did mention a few, like nasal steroid sprays and rinses. But specifically, what can patients do when they feel that they have a sinus infection, even before seeing a clinician?

Franklyn Gergits: Oh, absolutely. Again, just like you said, the saline rinse, the high-volume saline rinse, is our go-to. And what that does is it just washes everything clean. But then if there is an allergy component to it, think of an antihistamine, if there are definitely some allergy symptoms. Other things that patients may benefit from is just an analgesic, the ibuprofens, the acetaminophen, just to feel better. And then rest. Give yourself some extra time just to take it easy, get the hydration going, and just give your body a chance to recover.

Another thing is the biofilms. We start to think about biofilms inside the nasal cavity, and adding xylitol to the nasal rinses, or a nasal saline spray that’s got xylitol in it, will also help to get the patients hydrated but also help to break up some of those biofilms too.

Kevin Pho: And is that available over the counter, the xylitol?

Franklyn Gergits: It is, yeah. Xylitol is definitely available over the counter.

Kevin Pho: We’re talking to Franklyn Gergits. He’s an otolaryngologist. Today’s KevinMD article is “We prescribe antibiotics for sinusitis without a diagnosis.” Franklyn, let’s end with some of your take-home messages that you want to leave with the KevinMD audience.

Franklyn Gergits: Oh, absolutely. So if you think of that three, four, five, that many antibiotics in one time period, are we dealing with the right diagnosis? Sometimes, getting the patients off to us, we can do that endoscopic culture. Instead of doing the intranasal swab, or the COVID swab in the back of the nasopharynx, where we’re going to get some false positives in those patients, get the best-quality specimen that we can. But remember, you still have to treat those patients. Those patients are treated with antibiotics for that acute sinusitis. That’s very important.

And then finally, the other thing is to remember that the most powerful tool that we have in our armamentarium is the prescription pad. So make sure that we’re using that wisely. We don’t treat patients with cancer without a diagnosis, right? We’re not going to start chemo on those patients. Sinusitis is not cancer by any means, but at the same time, we want to make sure that we’re treating the right patient with the right diagnosis in the right way.

Kevin Pho: Franklyn, as always, thank you so much for sharing your perspective and insight, and thanks again for coming back on the show.

Franklyn Gergits: Anytime, Kevin. Thank you for having me.

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