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Primary Care

Why I Didn’t Give You a Z-pak for Your “Sinus Infection”

By February 8, 2014February 21st, 20202 Comments
This infection gets antibiotics

This infection gets antibiotics

Most winter respiratory illnesses are viral (rhinoviruses or adenoviruses). You have nasal congestion (including sinus congestion) with some slightly off-color discharge (whitish or yellowish or greenish) and sense of pressure, sore throat, mild cough, maybe headache, some slight fever (up to 100.5F or so), and mild muscle aches. Starts slowly for several days, blossoms over the next 4-7 days, and subsides over another 3 days, for 7-10 days or a bit longer of illness or minor misery.

That is a typical virus infection. It involves the mouth, the nasal mucous membranes, the sinuses (we have 8 of them), the major windpipes and your muscles in general. The greenish or yellowish tinge to the nasal mucus just means there are white blood cells in the mucus, which comes with viruses (not just with bacteria). We suggest symptomatic therapy because antibiotics (such as azithromycin or amoxicillin) do not kill viruses. Symptomatic therapy includes nasal saline sprays, decongestants such as oral Sudafed or intranasal Afrin, mild cough medication such as Tussin-DM, and analgesic/antipyretics such as aspirin, Tylenol, or Advil/Aleve.

When do we prescribe antibiotics?

So when you call me on day three or day five of an illness with the symptoms in the lead paragraph and say you have a sinus infection, we offer you sympathy and the OTC therapies of paragraph 2.

But you may warrant antibiotics if (1) your illness is more severe and immediately suggestive of a bacterial infection, if (2) it begins to worsen after a week or so rather than dissipate, or if (3) it just appears to linger on for two weeks or more.

  • More severe symptoms — such as localizing facial pain including significant pain in upper teeth, fever over 101F, thicker off-color mucus with blood — suggest bacterial infection beyond a typical virus;
  • Most viral upper respiratory infections begin to abate as they enter the second week, so true worsening symptoms suggest a bacterial superinfection may be coming on;
  • Finally, when nasal congestion and related cough just linger and linger, even if not overly severe, that suggests a chronic bacterial sinus infection (usually the ethmoid sinuses) that may also require antibiotics.

So when any of these three clinical situations unfortunately applies, you will find us quite sympathetic to prescribing you an antibiotic (Zithromax, Augmentin, cefuroxime or others) to deal with a likely bacterial infection.

We are not trying to deprive you or be stingy or put you through any hoops. But antibiotics can occasionally have unheralded serious side effects, and certainly unnecessary use of common antibiotics promotes the development of bacterial resistance to them, which harms us all. We just want to prescribe rationally and effectively for your benefit.



  • John Cottle says:

    I concur and this article is precisely what patients need to be so diplomatically reminded of periodically. Particularly in the case of URIs, the initial similarities in symptoms between viral and bacterial invasion is often so close and laypersons generally believe that their symptoms are more consistent with bacteria.

    While the internet has become the trademark second opinion, it likewise has no capacity to impart clinical diagnostic skills. It’s important to merely watch for signs of change in the presence of these illnesses and sharpen one’s skills regarding when to see your doctor.

  • Erin says:

    Thank you for this! I started coughing a little off yellow mucus after finishing a Z-Pak and became worried. The pain is gone and so is my persistent and painful coughing so… this makes a lot of sense. Decongestants were also on the list of things to take. Thank you!

    (Disclaimer: If it keeps going/gets worse/etc, I promise I won’t not go back to the doctor. The yellow tint literally just started after a week of gross thick clearish white stuff and I would prefer a tiny bit of buttercup yellow to a horror show sinus draining.)

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