Can a healthcare provider prescribe steroids for bacterial sinusitis?

Can a Healthcare Provider Prescribe Steroids for Bacterial Sinusitis?

Yes, healthcare providers can prescribe topical intranasal corticosteroids for bacterial sinusitis as adjunctive therapy to antibiotics, but should avoid systemic (oral) corticosteroids. 1, 2

Topical Intranasal Corticosteroids: Recommended

Topical intranasal corticosteroids (such as mometasone or fluticasone) are recommended as adjunctive therapy for symptomatic relief in acute bacterial rhinosinusitis (ABRS). 1, 2

• The American Academy of Otolaryngology-Head and Neck Surgery recommends analgesics, topical intranasal steroids, and/or nasal saline irrigation for symptomatic relief of ABRS. 1
• Intranasal steroids provide modest but clinically meaningful symptom improvement, with a number needed to treat of 14 for resolution or improvement at 15-21 days. 1, 3
• These agents work by reducing inflammatory cell infiltration and mucosal edema, providing relief of facial pain, nasal congestion, and other symptoms. 1, 4
• Adverse events are rare and mild (epistaxis, headache, nasal itching), making the risk-benefit profile favorable. 1

Dosing and Duration

• Standard dosing is typically 200 μg daily (e.g., mometasone furoate 200 μg twice daily or fluticasone propionate equivalent). 1, 4
• Higher doses (mometasone 400 μg twice daily) may provide greater benefit, with evidence showing a significant dose-response relationship. 1, 3
• Treatment courses of 21 days show greater therapeutic benefit than shorter 14-15 day courses. 3

Systemic (Oral) Corticosteroids: NOT Recommended

Oral corticosteroids should NOT be prescribed for bacterial sinusitis. 1, 2

• The European Position Paper on Rhinosinusitis (EPOS 2020) advises against the use of systemic corticosteroids in acute rhinosinusitis due to lack of meaningful benefit and potential harm. 1
• The American Academy of Otolaryngology-Head and Neck Surgery explicitly discourages systemic steroids, noting they have "questionable or unproven efficacy." 1
• When used as monotherapy, oral corticosteroids are completely ineffective for acute sinusitis. 5, 6
• Even when combined with antibiotics, oral corticosteroids provide only modest short-term benefit (number needed to treat of 7), but with significant risk of attrition bias in the evidence. 1, 5
• The small potential benefit does not justify the cost and risk of systemic side effects (nausea, vomiting, gastric complaints). 1, 5

Critical Distinction: Viral vs. Bacterial Sinusitis

This recommendation applies specifically to bacterial sinusitis. The distinction matters:

• Bacterial sinusitis (ABRS) is diagnosed when symptoms persist beyond 10 days without improvement, symptoms are severe (high fever ≥39°C with purulent nasal discharge for 3-4 consecutive days), or there is "double worsening" (initial improvement followed by worsening). 2
• Viral rhinosinusitis typically peaks within 3 days and resolves within 10-14 days. 2
• For viral rhinosinusitis, topical intranasal steroids may provide modest relief (66% improved with placebo vs. 73% with steroid at 14-21 days), but systemic steroids show no benefit at 7-14 days. 1

Practical Algorithm for Steroid Use in Bacterial Sinusitis

1. Confirm diagnosis of ABRS (symptoms >10 days, severe symptoms, or double worsening). 2
2. Prescribe antibiotic therapy (e.g., amoxicillin) as primary treatment. 2
3. Add topical intranasal corticosteroid (mometasone 200 μg twice daily or equivalent) for symptomatic relief. 1
4. Continue for 21 days for optimal benefit. 3
5. Add analgesics (acetaminophen or ibuprofen) and nasal saline irrigation for additional symptom control. 1, 2
6. Avoid oral corticosteroids entirely—they add no meaningful benefit and carry unnecessary risks. 1

Common Pitfalls to Avoid

• Do not prescribe oral/systemic corticosteroids for bacterial sinusitis—the evidence does not support their use and guidelines explicitly discourage them. 1
• Do not use colored nasal discharge alone as justification for antibiotics or steroids—coloration reflects neutrophils, not bacteria. 1
• Do not confuse viral and bacterial sinusitis—most cases presenting before 10 days are viral and do not require antibiotics. 2
• Do not use topical decongestants for more than 3-5 days to avoid rebound congestion (rhinitis medicamentosa). 1, 4