What is the treatment for a patient with greenish nasal discharge and headache, suggesting possible bacterial sinusitis, in the Philippines?

Treatment for Greenish Nasal Discharge and Headache in the Philippines

For a patient with greenish nasal discharge and headache suggesting acute bacterial sinusitis, start with amoxicillin 500 mg twice daily for 10-14 days as first-line therapy. 1

Confirming the Diagnosis

Before prescribing antibiotics, ensure the patient meets criteria for acute bacterial rhinosinusitis rather than viral upper respiratory infection:

• Persistent symptoms ≥10 days without improvement (nasal discharge, congestion, facial pain/pressure, or headache) 1, 2
• Severe symptoms for ≥3 consecutive days (fever >39°C/102°F, purulent nasal discharge, facial pain) 1, 2
• "Double sickening" - initial improvement followed by worsening after 3-5 days 1, 2

The greenish/purulent nasal discharge combined with headache suggests bacterial infection, particularly if symptoms have persisted beyond 7-10 days. 3, 2

First-Line Antibiotic Treatment

Amoxicillin remains the gold standard first-line antibiotic for uncomplicated acute bacterial sinusitis:

• Standard dose: 500 mg twice daily for adults 1
• Higher dose for severe infection: 875 mg twice daily 1
• Treatment duration: 10-14 days, or until symptom-free for 7 days 1, 4

Amoxicillin provides excellent coverage against the three most common pathogens: Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. 3, 5

Alternative Options for Penicillin Allergy

If the patient has documented penicillin allergy:

• For non-severe/non-Type I allergy (rash): Second-generation cephalosporins (cefuroxime) or third-generation cephalosporins (cefpodoxime, cefdinir) are safe and effective 1
• For severe Type I hypersensitivity (anaphylaxis): Levofloxacin 500 mg once daily for 10 days or moxifloxacin 400 mg once daily for 10 days 1
• Doxycycline 100 mg once daily for 10 days is an acceptable alternative but has higher failure rates (20-25%) due to limited activity against H. influenzae 1

Critical caveat: Azithromycin should NOT be used for acute bacterial sinusitis due to resistance rates exceeding 20-25% for both S. pneumoniae and H. influenzae. 1, 6

When to Switch to Second-Line Therapy

Reassess the patient at 3-5 days: 1

If no improvement or worsening occurs, switch to:

• Amoxicillin-clavulanate 875 mg/125 mg twice daily for 10-14 days (provides coverage against β-lactamase-producing organisms) 1
• Respiratory fluoroquinolones (levofloxacin 500 mg daily or moxifloxacin 400 mg daily) if amoxicillin-clavulanate fails or for complicated sinusitis 1

Adjunctive Symptomatic Treatment

All patients should receive symptomatic relief measures regardless of antibiotic use:

• Intranasal corticosteroids (mometasone, fluticasone, or budesonide) twice daily - strongly recommended to reduce mucosal inflammation 1
• Analgesics (acetaminophen or NSAIDs) for pain and headache 1
• Saline nasal irrigation for symptomatic relief 1
• Decongestants (pseudoephedrine or topical oxymetazoline) - topical agents should not exceed 3-5 days to avoid rebound congestion 1, 4
• Adequate hydration, warm facial packs, sleeping with head elevated 1

Critical Pitfalls to Avoid

• Do not use azithromycin - resistance rates are too high (20-25%) making it ineffective 1, 6
• Do not use clindamycin as monotherapy - it lacks activity against H. influenzae and M. catarrhalis 1
• Do not prescribe antibiotics for <10 days of symptoms unless severe symptoms are present, as most cases are viral 2
• Do not continue ineffective antibiotics beyond 3-5 days - reassess and switch therapy 1
• Do not order imaging (X-rays or CT) for uncomplicated acute sinusitis - diagnosis is clinical 7, 8

When to Refer or Escalate Care

Consider referral to an otolaryngologist if: 1, 7

• No improvement after two courses of appropriate antibiotics
• Suspected complications (orbital cellulitis, meningitis, severe headache with neurologic signs)
• Recurrent sinusitis (≥3 episodes per year)
• Symptoms refractory to usual treatment

Special Considerations for the Philippines

While specific Philippine formulary availability may vary, the international guidelines above apply universally. Amoxicillin is widely available and affordable in the Philippines, making it the ideal first-line choice. 1 If cost is a concern, standard-dose amoxicillin (500 mg twice daily) is effective for most uncomplicated cases and less expensive than combination products. 1