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: persistent symptoms ≥10 days without improvement, severe onset with high fever and purulent discharge for 3-4 consecutive days, or worsening symptoms after initial improvement ("double-sickening"). 1, 2
Three Diagnostic Clinical Presentations
1. Persistent Symptoms (Most Common)
- Nasal discharge OR nasal congestion lasting ≥10 days without any evidence of clinical improvement 1, 2
- Daytime cough persisting ≥10 days 2
- Facial pain, pressure, or fullness lasting ≥10 days 2
- Key distinction: Duration ≥10 days with no improvement, not worsening 2
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, 2
- This presentation indicates more aggressive bacterial infection requiring prompt treatment 1
3. "Double-Sickening" Pattern
- Initial viral URI symptoms that improve for 5-6 days, then worsen with new onset of fever, headache, or increased nasal discharge 1, 2
- This biphasic pattern strongly suggests secondary bacterial superinfection 1
Physical Examination Findings
- Purulent nasal discharge on examination (not just patient-reported) 2
- Maxillary tooth pain or tenderness to percussion 2
- Unilateral maxillary sinus tenderness on palpation 2
Risk Factors for Resistant Organisms
These factors should prompt consideration of high-dose amoxicillin-clavulanate or second-line therapy:
- Recent antibiotic use within past 4-6 weeks 1, 2, 3
- Age <2 years or >65 years 1, 2
- Daycare attendance 1, 2
- Prior hospitalization in past 5 days 1, 2
- Chronic comorbidities (diabetes, immunocompromised state) 1, 2
Critical Diagnostic Pitfalls to Avoid
- Do not diagnose ABRS based solely on colored nasal discharge—this occurs commonly in viral rhinosinusitis 1
- Imaging is not recommended for uncomplicated ABRS due to high prevalence of abnormal findings in viral rhinosinusitis 3
- Symptoms lasting <10 days are typically viral and do not warrant antibiotics unless meeting severe onset criteria 1
- The presence of risk factors for resistant organisms should lower your threshold for using high-dose amoxicillin-clavulanate as first-line therapy rather than standard-dose amoxicillin 1, 3