Cautious Antibiotic Use and Shared Decision Making Emphasized in 2025 Sinusitis Guidelines

The American Academy of Otolaryngology–Head and Neck Surgery Foundation (AAO-HNSF)’s new Clinical Practice Guideline for adult sinusitis emphasizes a cautious approach to antibiotic use and shared decision making for treatment in an update to the previous 2015 recommendations.1

“With sinusitis affecting about 1 in 8 adults in the United States each year, this CPG update empowers both patients and their healthcare providers with evidence-based recommendations that can lead to better outcomes,” Spencer C. Payne, MD, Chair of the Guideline Update Group and Director, Rhinology & Endoscopic Sinus Surgery at University of Virginia School of Medicine, said in a statement.2

The updated guidelines were informed by 194 systematic reviews, and 133 randomized controlled trials. They included 1 strong recommendation on making a differential diagnosis between presumed acute bacterial rhinosinusitis (ABRS) from acute rhinosinusitis caused by viral upper respiratory infections and noninfectious conditions, with a diagnosis of ABRS when symptoms or signs of acute rhinosinusitis persist without evidence of improvement for at least 10 days beyond the onset of upper respiratory symptoms or worsen within 10 days after an initial improvement.

Other recommendations made were watchful waiting without antibiotics for adults with uncomplicated ABRS with assurance of follow-up, amoxicillin with or without clavulanate as first-line therapy for 5-7 days for most adults with ABRS, reassessing and/or changing antibiotic for ABRS upon first-line treatment failure, chronic rhinosinusitis (CRS) and recurrent acute rhinosinusitis (RARS) from isolated episodes of ABRS and other causes of sinonasal symptoms, assessing chronic conditions that would modify management of CRS and RARs, confirming the presence or absence of nasal polyps in a patient with CRS, the use of topical intranasal therapies for symptomatic relief of CRS, and education of patients with CRS with nasal polyps about biologics as a potential option, biologic prescription for the treatment of adults with CRS without polyps

Recommendations were also made againstradiologic imaging for patients who meet diagnostic criteria for ARS (unless a complication or alternative diagnosis is suspected), topical or systemic antifungal therapy for patients with CRS, and antimicrobial therapy for adults with CRS without acute exacerbation OR as a mandatory prerequisite for paranasal sinus imaging or surgery.

Additionally, optional recommendations included the use of analgesics, topical intranasal steroids, and/or nasal saline irrigation for symptomatic relief of viral rhinosinusitis (VRS) and ABRS, and allergy and immune function testing for a patient with CRS or RARS.

“Key changes from the 2015 guideline include expanding ‘watchful waiting’ as the preferred initial approach for most bacterial sinus infections, since most people get better on their own. We’ve also provided clearer guidance on when antibiotics are truly needed, what the first-choice antibiotic should be, and new information about advanced treatments like biologics for chronic sinusitis with nasal polyps. Most importantly, we’ve emphasized that not all sinus symptoms require antibiotics, and there are effective symptomatic treatments like nasal saline rinses and steroid sprays that can provide relief. We encourage patients to have open conversations with their healthcare providers about these options to find the right treatment approach for their specific situation,” Payne said.2

Overall, the updated guidelines emphasize patient education, clearer action statements, expanded external review, shared decision-making, and watchful waiting. Notably, watchful waiting without antibiotics is now recommended for all patients with uncomplicated ABRS and first-line antibiotic therapy has shifted to amoxicillin with or without clavulanate. Additional updates include clarified diagnostic timelines, recognition of aspirin-exacerbated respiratory disease as a modifier in CRS, and new action statements on biologics and the avoidance of empiric antibiotics in CRS management.

REFERENCES

Payne SC, McKenna M, Buckley J, et al. Clinical Practice Guideline: Adult Sinusitis Update. Otolaryngology–Head and Neck Surgery. 2025;173(S1). doi: 10.1002/ohn.1344

The Clinical Practice Guideline Update on Adult Sinusitis Emphasizes Patient Education, Shared Decision-Making, and Evidence-Based Treatment Options. News release. AAO-HNSF. July 31, 2025. https://www.entnet.org/resource/the-clinical-practice-guideline-update-on-adult-sinusitis-emphasizes-patient-education-shared-decision-making-and-evidence-based-treatment-options/