What is the appropriate next step in management for a patient with persistent purulent nasal discharge, daytime cough, low-grade fever, and frontal bone tenderness?

Management of Acute Bacterial Rhinosinusitis with Persistent Symptoms

This patient meets criteria for acute bacterial rhinosinusitis (ABRS) and requires oral amoxicillin therapy (Answer B) along with adjunctive symptomatic measures. 1, 2

Clinical Diagnosis of ABRS

This patient fulfills the diagnostic criteria for ABRS based on persistent symptoms lasting ≥10 days (12 days in this case) without improvement, which is one of three validated presentations that distinguish bacterial from viral rhinosinusitis 1, 3:

• Persistent symptoms: Purulent nasal discharge and daytime cough for 12 days without clinical improvement 1
• Low-grade fever and frontal bone tenderness: Additional supportive features of bacterial infection 1, 3
• Absence of complications: No periorbital swelling or abnormal eye examination rules out orbital complications that would require imaging or hospitalization 1, 3

The other two ABRS presentations (not applicable here) are: severe onset with high fever ≥39°C and purulent discharge for 3-4 consecutive days, or "double-sickening" with worsening after initial improvement 1, 3.

First-Line Antibiotic Therapy

Amoxicillin is the recommended first-line antibiotic for uncomplicated ABRS due to its efficacy, safety profile, and cost-effectiveness 1, 2, 4:

• Dosing: 500 mg three times daily for 7-10 days (or 875 mg twice daily for moderate-severe disease) 5, 2
• Rationale: Provides targeted coverage against the two most common pathogens—Streptococcus pneumoniae and Haemophilus influenzae 6, 7
• Duration: Treatment should continue for at least 48-72 hours beyond symptom resolution, with minimum 7-10 days total 5, 2

For penicillin-allergic patients, alternatives include doxycycline, trimethoprim-sulfamethoxazole, or macrolides (azithromycin/clarithromycin) 2, 4.

Adjunctive Symptomatic Therapy

While antibiotics address the bacterial infection, concurrent symptomatic measures improve patient comfort and facilitate recovery 2:

• Intranasal corticosteroids: Reduce mucosal inflammation and improve symptom resolution 2, 3
• Analgesics: Acetaminophen or NSAIDs for facial pain and fever 2
• Saline nasal irrigation: Helps clear purulent secretions 2, 4
• Short-term decongestants (≤3 days topical or oral): Provide temporary relief of nasal obstruction 2, 4

Why Other Options Are Incorrect

Option A (Supportive care only) would be appropriate for viral rhinosinusitis lasting <10 days, but this patient's 12-day duration of persistent symptoms without improvement mandates antibiotic therapy 1, 3. The EPOS 2020 guidelines show antibiotics are effective specifically in patients meeting ABRS criteria (RR 1.36 for cure, 95% CI 1.16-1.59) 1.

Option C (Nasal corticosteroids alone) is insufficient as monotherapy for ABRS, though they should be added as adjunctive treatment 2, 3.

Option D (Sinus X-ray) is not recommended for routine uncomplicated ABRS 1, 3, 8. Plain radiographs have poor sensitivity (air-fluid levels seen in only 60% of cases) and specificity (mucosal thickening is nonspecific) 8. Imaging is reserved for: suspected complications (orbital/intracranial involvement), failure to respond to appropriate antibiotics after 3-5 days, recurrent episodes requiring evaluation of anatomic abnormalities, or pre-surgical planning 1, 3, 8.

Critical Follow-Up and Monitoring

Reassess the patient if symptoms do not improve within 3-5 days of starting antibiotics 2:

• No improvement or worsening: Switch to broader-spectrum antibiotic (amoxicillin-clavulanate 875/125 mg twice daily) to cover beta-lactamase-producing organisms 2, 4
• Warning signs requiring immediate evaluation: Development of periorbital edema, visual changes, diplopia, severe headache, altered mental status, or high spiking fevers suggesting complications 1, 3
• Expected timeline: Complete symptom resolution may take 10-14 days even with appropriate treatment 2

Common Pitfalls to Avoid

Do not prescribe antibiotics for colored nasal discharge alone without meeting temporal criteria (≥10 days persistent, severe onset, or double-sickening), as purulent discharge occurs in both viral and bacterial rhinosinusitis 3. The yellow-green color reflects neutrophil accumulation, not bacterial infection per se 3.

Do not use first-generation cephalosporins or macrolides as first-line therapy when amoxicillin is appropriate, as this contributes to unnecessary broad-spectrum antibiotic use and resistance 2, 4.

Do not obtain routine imaging in uncomplicated cases, as CT findings of mucosal thickening occur in 40% of asymptomatic adults and lead to overdiagnosis 8.