Pertinent Positives for Acute Bacterial Rhinosinusitis
The diagnosis of acute bacterial rhinosinusitis (ABRS) requires identifying one of three specific clinical presentations that distinguish bacterial from viral infection. 1
Three Diagnostic Presentations (Any One Qualifies)
1. Persistent Symptoms Without Improvement
- Nasal discharge (purulent or non-purulent) or nasal congestion lasting ≥10 days without any evidence of clinical improvement 1
- Daytime cough (may be worse at night) persisting ≥10 days 1
- Facial pain, pressure, or fullness lasting ≥10 days 1
- Key distinction: The critical feature is duration ≥10 days with no improvement, not worsening 1
2. Severe Onset Symptoms
- High fever ≥39°C (102°F) AND purulent nasal discharge lasting at least 3-4 consecutive days at the beginning of illness 1
- Facial pain or pressure (unilateral or bilateral) for 3-4 consecutive days 1
- This presentation indicates severe disease from the outset, not gradual worsening 1
3. "Double-Sickening" Pattern (Worsening After Initial Improvement)
- Initial viral URI symptoms that improve for 5-6 days, then worsen with new onset of fever, headache, or increased nasal discharge 1
- New or worsening facial pain/pressure after initial improvement 1
- New or worsening cough after initial improvement 1
- The biphasic pattern is pathognomonic: improvement followed by deterioration 1
Additional Pertinent Positives That Support Diagnosis
Physical Examination Findings
- Purulent nasal discharge on examination (anterior rhinoscopy or posterior pharynx) 1
- Maxillary tooth pain or tenderness to percussion 1
- Unilateral maxillary sinus tenderness on palpation 1
- Facial pain that worsens when bending forward (suggests maxillary involvement) 2
- Pain peaking in evening/night with pulsatile quality (maxillary sinusitis) 2
Risk Factors for Bacterial Infection
- Recent antibiotic use within past 4-6 weeks (increases risk of resistant organisms) 1
- Age <2 years or >65 years 1
- Daycare attendance 1
- Prior hospitalization in past 5 days 1
- Chronic comorbidities (diabetes, immunocompromised state) 1
- Smoking 3
Critical Diagnostic Caveats
Imaging is NOT required for diagnosis in routine cases but may be indicated when complications are suspected or diagnosis is uncertain in older children (>6 years) and adults. 4 The diagnosis remains primarily clinical based on the three presentations above. 1
Avoid misdiagnosing viral URI as ABRS: Most viral URIs resolve within 7-10 days, so symptoms <10 days without severe features or worsening pattern should be managed symptomatically without antibiotics. 1