What is the recommended treatment for a patient presenting with acute sinusitis, characterized by green nasal discharge and fever?

Treatment of Acute Bacterial Sinusitis with Green Nasal Discharge and Fever

For a patient presenting with acute sinusitis characterized by green nasal discharge and fever, initiate antibiotic therapy with amoxicillin 500 mg twice daily (or high-dose 875 mg twice daily for severe infection) for 10-14 days, as this presentation meets criteria for acute bacterial rhinosinusitis requiring immediate treatment. 1, 2

Clinical Criteria Supporting Antibiotic Initiation

This patient meets the criteria for acute bacterial rhinosinusitis (ABRS) requiring antibiotics based on:

• Severe symptoms: High fever (>39°C) with purulent (green) nasal discharge lasting at least 3 consecutive days qualifies as severe presentation warranting immediate antibiotic therapy 1, 2
• The combination of fever and purulent discharge indicates bacterial rather than viral etiology 1

First-Line Antibiotic Selection

Amoxicillin is the preferred first-line agent:

• Standard dosing: 500 mg twice daily for adults 2
• High-dose option: 875 mg twice daily for more severe infections or areas with high antibiotic resistance 2, 3
• Duration: 10-14 days until symptom-free for 7 days 1, 2, 4

Alternative first-line options for penicillin allergy:

• Cephalosporins: cefuroxime, cefpodoxime, cefprozil, or cefdinir 2, 4
• For severe beta-lactam allergy: clarithromycin or azithromycin 4

Second-Line Treatment for Non-Response

If no improvement after 3-5 days, switch to:

• Amoxicillin-clavulanate (875/125 mg twice daily) for better coverage against beta-lactamase-producing organisms 1, 2
• This provides coverage for ampicillin-resistant Haemophilus influenzae and Moraxella catarrhalis 1

Alternative second-line options:

• Respiratory fluoroquinolones (levofloxacin 500 mg daily or moxifloxacin) for frontal, ethmoidal, or sphenoidal sinusitis 2, 5
• Doxycycline as an alternative 1

Adjunctive Therapies

Recommended supportive measures:

• Intranasal corticosteroids to reduce inflammation and potentially decrease antibiotic use 1, 2
• Intranasal saline irrigation 1
• Analgesics for pain and antipyretics for fever 1
• Adequate hydration, warm facial packs, sleeping with head elevated 2

Short-term oral corticosteroids may be considered for:

• Marked mucosal edema 2
• Failure to respond to initial treatment 2

Important Clinical Pitfalls

Avoid these common errors:

• Do not use imaging (X-rays or CT) for routine diagnosis of uncomplicated acute sinusitis 6
• Do not prescribe antibiotics for viral rhinosinusitis (common cold) - the number needed to harm (8) exceeds the number needed to treat (18) 1
• Watchful waiting without antibiotics is NOT appropriate for this patient given severe symptoms with high fever and purulent discharge 1

The controversy regarding amoxicillin vs. amoxicillin-clavulanate as first-line:

• IDSA recommends amoxicillin-clavulanate as preferred agent due to resistance concerns 1
• However, American Academy of Family Physicians and American Academy of Allergy, Asthma & Immunology recommend amoxicillin as first-line, noting no direct evidence that amoxicillin-clavulanate is superior 1, 2
• In real-world practice, starting with amoxicillin is appropriate for this severe presentation, reserving amoxicillin-clavulanate for treatment failures 2, 4

Follow-Up and Reassessment

Evaluate response at 3-5 days:

• If improving: continue current antibiotic for full 10-14 day course 2
• If partial response: continue for additional 10-14 days or switch to broader spectrum agent 2
• If no improvement or worsening: switch to amoxicillin-clavulanate or fluoroquinolone 2

Refer to otolaryngologist if:

• Seriously ill or deteriorating despite antibiotic therapy 1
• Recurrent episodes 1
• Symptoms persist after maximal medical therapy 6
• Suspected complications (orbital, intracranial, or bony involvement) 6