Most sinus infections in Philadelphia are viral and resolve in 7-10 days without antibiotics. Antibiotics are appropriate when symptoms persist beyond 10 days, worsen after initial improvement (double-worsening pattern), or are severe at onset (high fever, severe pain). Standard treatment when warranted is amoxicillin-clavulanate or doxycycline. Symptom-based care (saline irrigation, intranasal steroids, decongestants, NSAIDs) helps in both viral and bacterial cases. Fishtown Medicine evaluates and treats sinus complaints same day for members.
When sinus symptoms are likely viral
Most sinusitis is viral and self-limited. Features that suggest viral over bacterial:
- Duration less than 10 days.
- Symptoms peaking around day 3-5 and improving.
- Mild to moderate facial pain.
- Clear or thick discharge (color does not reliably distinguish viral from bacterial).
- No high fever.
When antibiotics are warranted
Per the IDSA guidelines:
- Persistent symptoms beyond 10 days without improvement.
- Severe symptoms at onset: fever over 102°F, severe facial pain, purulent nasal discharge for 3-4 consecutive days at the start of illness.
- Double-worsening pattern: initial improvement at days 5-6 followed by worsening with new fever, headache, or nasal discharge.
First-line treatment
When antibiotics are indicated:
- Amoxicillin-clavulanate (Augmentin) 875/125 mg twice daily for 5-7 days. First-line in most cases.
- Doxycycline 100 mg twice daily for 5-7 days. Alternative for penicillin allergy.
- Levofloxacin 500 mg daily for 5-7 days. Reserved for treatment failure or specific contraindications.
Macrolides (azithromycin) are no longer first-line due to resistance.
Symptomatic management
Works in both viral and bacterial cases:
- Saline nasal irrigation (Neti pot, NeilMed sinus rinse) with sterile water. Effective and underused.
- Intranasal corticosteroids (fluticasone, mometasone) - daily use, can be added during acute illness.
- Topical decongestants (oxymetazoline) for short-term use only (3 days max) to avoid rebound.
- Oral decongestants (pseudoephedrine) for short-term use.
- NSAIDs for pain.
- Hydration and rest.
When to escalate
ENT referral or emergent evaluation for:
Fishtown Medicine
A 90-minute conversation with Dr. Ash. A written plan you can actually follow.
- Visual changes, eye swelling, severe headache, neck stiffness, altered mental status (concerning for orbital or intracranial extension).
- Recurrent sinusitis (4+ episodes per year).
- Treatment failure despite appropriate antibiotics.
- Chronic sinusitis (symptoms more than 12 weeks).
How sinus care works at Fishtown Medicine
For members, message the practice with symptoms. We triage, evaluate by video or in person, and prescribe symptomatic management or antibiotics as indicated. Most cases resolve in a single visit.
We coordinate with ENT for recurrent or chronic sinusitis.
What it costs
Membership covers all visits and ongoing management; see pricing for current rates. All visits and ongoing management are included.
Key Takeaways
- Most sinusitis is viral and self-limited.
- Antibiotics are appropriate when specific criteria are met.
- Symptomatic management helps in all cases.
- Fishtown Medicine handles sinus visits same day for members.
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Frequently Asked Questions
Common Questions
Deep-Dive Questions
Ready when you are
Dr. Ash reads every intake himself, and answers questions personally - usually within a few hours.
