Antibiotics are no longer first-line treatment for many upper respiratory tract infections. Currently, the American Academy of Pediatrics and the American Academy of Family Physicians are promoting new guidelines for treatment of acute otitis media, proposing that antibiotics not always be used.^1,2 Similarly, acute bronchitis, which in the past was almost always treated with antibiotics, is now recognized as a viral disease that generally should be treated with only supportive methods.³

In this issue, Scheid and Hamm present two excellent articles on acute bacterial rhinosinusitis (ABRS).^4,5 They correctly state that most patients with upper respiratory infections do not have ABRS but, instead, have viral sinusitis. The question is, how should physicians manage this condition? At this time, physicians are still prescribing antibiotics for most patients whom they diagnose with sinusitis.

As described in Scheid and Hamm’s articles, there are numerous methodologically rigorous clinical prediction rules that physicians may use for guidance when examining patients. The problem with these guidelines is that they are drawn from studies of patients in subspecialty clinics, and they measure disease-oriented findings documented by sinus radiographs, computed tomography, and bacterial growth from sinus puncture. What family physicians and patients truly need to provide guidance is practical or pragmatic clinical trials that test prediction rules under clinical conditions similar to what actually occurs in the primary care outpatient setting.⁶

During the office visit, the problem family physicians face is deciphering which patients will benefit from antibiotics and which ones have viral infections and need only symptomatic treatment. Any treatment ultimately is based on the precept of doing more good than harm. Family physicians are familiar with this struggle because it is at the root of what they do every day while treating patients, but for some reason this strategy has not been applied consistently in the treatment of upper respiratory infections.

If our goal in treating ABRS was to prevent serious complications, such as brain abscesses, then we would be willing to treat many patients unnecessarily to prevent even one brain abscess. Scheid and Hamm never mention such unlikely complications, and I applaud them for this. This omission on their part implicitly tells the reader that this is not the true worry of patients and physicians—that, generally, symptomatic improvement is the true goal of treatment in patients with ABRS. If our goal is to cure something as common and self-limited as purulent nasal discharge, we may not be willing to treat as many patients to help one because we know that antibiotics will help very few of them and that nearly two thirds of patients will continue having symptoms such as cough and nasal discharge for up to three weeks.⁷

In conjunction with our patients, we need to decide (1) what our goals are when we encounter patients with sinusitis-like symptoms and (2) why we continue to treat these patients with antibiotics if that treatment does not accomplish our goals. Patient-oriented clinical trials still are needed to identify a subset of patients that are likely to benefit from antibiotic treatment. Meanwhile, it is likely that physicians soon will approach the treatment of ABRS in a fashion similar to that of acute otitis media and bronchitis, and that antibiotics will no longer be the first-line treatment option.