Chronic Sinus Infections: New Research Challenges Antibiotic Reliance for Flare-Ups
A growing body of evidence suggests that acute exacerbations of chronic rhinosinusitis (AECRS) – the sudden worsening of symptoms in long-term sinus infections – are frequently overtreated with antibiotics and steroids, despite limited proof of their effectiveness. A recent review published in current Allergy and Asthma Reports highlights the need for clearer definitions, improved diagnostic criteria, and a more nuanced approach to managing these common flare-ups.
Millions of adults suffer from chronic rhinosinusitis (CRS), a persistent inflammation of the nasal passages. Symptoms include nasal congestion, facial pressure, runny nose, and a diminished sense of smell. Many patients experiance periodic “flare-ups” – intensified symptoms lasting several days – historically labeled as AECRS. However, the lack of a standardized definition has hindered research and clinical practice.
The review, expected to be released in full in 2025, found that patients experienced an average of 4.2 AECRS episodes over six months,yet only received antibiotics or steroids 1.6 times during that period. This means roughly two-thirds of exacerbations went undocumented through traditional medical records, exposing a critical blind spot in both research and patient care.
A regulatory definition, utilized in the REOPEN trials, now defines AECRS as an acute worsening of core CRS symptoms lasting at least three days, accompanied by increased medical intervention – such as antibiotics, systemic corticosteroids, or an unscheduled doctor’s visit. While a step forward, the authors caution that this definition still relies heavily on treatment-based triggers and may not capture instances where patients opt for observation or self-management.
Emerging research points to a complex interplay of factors driving AECRS exacerbations. These include viral infections, bacterial overgrowth, shifts in the nasal microbiome, and immune system dysregulation. studies have identified elevated levels of inflammatory markers – including IL-5, IL-6, VEGF, and eosinophil major basic protein – during flare-ups. Microbiome analyses frequently reveal an increased presence of pathogens like Staphylococcus aureus,Pseudomonas aeruginosa,and Streptococcus species. Seasonal patterns also suggest a link to viral infections, with AECRS frequency peaking during winter months.
“It appears that both viruses and bacteria play a role in the development of AECRS,” the researchers wrote. “Viral infections may create a persistent hyper-responsiveness and inflammatory state…which then leads to an increased susceptibility to bacterial infections.”
the burden of AECRS extends beyond physical discomfort. Exacerbations frequently result in missed work, urgent care visits, emergency room trips, and repeat nasal endoscopies.The overuse of antibiotics and steroids carries significant risks, including increased susceptibility to infection, blood clots, fractures, and the growing threat of antimicrobial resistance. Despite these risks, clinicians often prescribe these medications reflexively due to a lack of clear guidelines and pressure to provide symptom relief.
Evidence supporting the benefit of antibiotics for AECRS is surprisingly weak. A double-blind trial found no significant difference in symptoms or quality of life between patients treated with amoxicillin-clavulanate and those receiving a placebo, provided both groups also used intranasal steroids and saline rinses.Furthermore, high rates of antibiotic resistance – found in nearly half of AECRS isolates, many producing β-lactamase – underscore the need for more targeted prescribing practices, culture-guided therapy, and exploration of choice treatments like bacteriophage therapy.
References
- Frederick RM,Lam K,Han JK. Acute exacerbations of chronic rhinosinusitis. Curr Allergy Asthma Rep. Published online December 20, 2025.doi:10.1007/s11882-025-01239-0
- Palmerrr JN, Adappa ND, Chandra RK, et al. Efficacy of EDS-FLU for chronic rhinosinusitis: two randomized controlled trials (ReOpen1 and ReOpen2). 2024;12(4):1049-1061.doi:10.1016/j.jaip.2023.12.016.
