What is the recommended antibiotic for chest congestion, sinusitis, dry cough with phlegm, hearing difficulty, and fever?

Antibiotic Treatment for Combined Respiratory Symptoms

First, Determine If Antibiotics Are Actually Needed

Most cases of chest congestion, cough, and sinusitis are viral and do not require antibiotics—you should only prescribe antibiotics if the patient meets specific bacterial criteria. 1

The presence of fever with sinusitis symptoms suggests bacterial infection if one of these three patterns exists:

• Persistent symptoms: Nasal discharge or cough lasting >10 days without improvement 1
• Severe onset: Fever ≥39°C (102.2°F) with purulent nasal discharge for ≥3 consecutive days 1
• "Double sickening": Initial improvement followed by worsening symptoms after 5-7 days 1

The difficulty hearing likely represents middle ear involvement (otitis media with effusion) secondary to sinusitis, which is common when sinus ostia are obstructed 2.

First-Line Antibiotic Choice

For adults with confirmed acute bacterial sinusitis, amoxicillin 500 mg twice daily (mild disease) or 875 mg twice daily (moderate disease) for 10-14 days is the first-line treatment. 3

For patients with risk factors (recent antibiotic use within 4-6 weeks, age <2 years if pediatric, daycare attendance, or areas with high penicillin-resistant Streptococcus pneumoniae prevalence), high-dose amoxicillin-clavulanate 875 mg/125 mg twice daily should be used instead. 3

The rationale: S. pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis are the primary bacterial pathogens 1. Amoxicillin provides excellent coverage against S. pneumoniae, while the clavulanate component covers β-lactamase-producing H. influenzae and M. catarrhalis 3.

For Penicillin-Allergic Patients

If the patient has a documented penicillin allergy, second-generation cephalosporins (cefuroxime-axetil) or third-generation cephalosporins (cefpodoxime-proxetil or cefdinir) are the preferred alternatives. 3

The risk of cross-reactivity between penicillins and second/third-generation cephalosporins is negligible, making these safe options even for most penicillin-allergic patients 3.

Do NOT use azithromycin or other macrolides as first-line therapy—resistance rates for S. pneumoniae and H. influenzae exceed 20-25%, making them unsuitable for treating acute bacterial sinusitis. 1, 3

For severe beta-lactam allergy (anaphylaxis), respiratory fluoroquinolones (levofloxacin 500 mg once daily or moxifloxacin 400 mg once daily for 10-14 days) should be reserved as second-line therapy. 3

Treatment Duration and Monitoring

Treat for 10-14 days or until symptom-free for 7 days. 3 Shorter 5-7 day courses have comparable efficacy with fewer side effects for uncomplicated cases 3.

Reassess the patient at 3-5 days (adults) or 72 hours (children). 3 If no improvement occurs:

• Switch to high-dose amoxicillin-clavulanate if initially on amoxicillin alone 3
• Switch to respiratory fluoroquinolone if already on amoxicillin-clavulanate 3
• Consider alternative diagnosis or complications 1

Adjunctive Therapies That Actually Help

Intranasal corticosteroids (mometasone, fluticasone, or budesonide twice daily) should be added to antibiotic therapy—they reduce mucosal inflammation and improve symptom resolution. 3

Additional supportive measures include:

• Analgesics (acetaminophen or NSAIDs) for pain and fever 1
• Saline nasal irrigation for symptomatic relief 1
• Oral or topical decongestants (pseudoephedrine) as needed 1
• Adequate hydration and sleeping with head elevated 3

Short-term oral corticosteroids may be considered for patients with marked mucosal edema or who fail initial treatment, but should NOT be given without antibiotics when bacterial infection is suspected. 3

Critical Pitfalls to Avoid

Never prescribe antibiotics for symptoms lasting <10 days unless severe criteria are met (high fever ≥39°C with purulent discharge for ≥3 days)—98-99.5% of acute rhinosinusitis is viral and resolves spontaneously. 1

Do not use mucus color alone to determine antibiotic need—purulent discharge reflects neutrophils, not necessarily bacteria. 3

Avoid fluoroquinolone overuse as first-line therapy—reserve them for treatment failures, severe disease, or documented penicillin allergy to prevent resistance development. 3

Complete the full antibiotic course even after symptoms improve to prevent relapse. 3

When to Refer or Escalate

Refer to otolaryngology or infectious disease if:

• No improvement after two courses of appropriate antibiotics 3
• Suspected complications (orbital cellulitis, meningitis, brain abscess) 1
• Recurrent sinusitis (≥3 episodes per year) 3
• Severe headache, photophobia, seizures, or focal neurologic findings 1
• Proptosis or impaired extraocular muscle function 1