Management of Acute Bacterial Rhinosinusitis
Start amoxicillin (Option B) for this patient who meets diagnostic criteria for acute bacterial rhinosinusitis with 3 days of fever, frontal tenderness, and purulent discharge following a URTI.
Clinical Diagnosis
This patient fulfills the criteria for acute bacterial rhinosinusitis (ABRS) based on the presence of:
- Purulent nasal discharge (a major symptom) 1
- Frontal tenderness/facial pain (a major symptom) 1
- Fever (a minor symptom supporting bacterial infection) 1, 2
- Symptoms following URTI with severe onset presentation 2, 3
The European Position Paper on Rhinosinusitis (EPOS 2020) defines ABRS as requiring two major symptoms (purulent discharge and facial pain/tenderness) OR one major and one minor symptom (frontal headache or fever >37.5°C), which this patient clearly meets 1. The American Academy of Otolaryngology-Head and Neck Surgery specifically identifies severe onset with high fever and purulent nasal discharge for 3-4 consecutive days as one of three diagnostic presentations warranting antibiotic therapy 2, 3, 4.
Why Antibiotics Are Indicated
Antibiotics are appropriate because this patient presents with severe symptoms rather than persistent symptoms. The three clinical presentations warranting antibiotics are: (1) persistent symptoms ≥10 days without improvement, (2) severe onset with high fever and purulent discharge for 3-4 consecutive days, or (3) worsening after initial improvement ("double-sickening") 2, 3, 4. This patient meets the second criterion with fever and purulent discharge at day 3 2.
Multiple randomized controlled trials demonstrate that antibiotics provide benefit specifically in patients meeting ABRS criteria, with a relative risk of 1.36 for cure (95% CI 1.16-1.59) compared to placebo 1.
First-Line Antibiotic Choice
Amoxicillin is the recommended first-line antibiotic for uncomplicated ABRS due to its efficacy, safety profile, and cost-effectiveness 2, 5, 6, 4.
Dosing Recommendations:
- Standard dose: 500 mg three times daily for 7-10 days 1, 2, 5
- High-dose option: 875 mg twice daily or 500 mg three times daily for severe infections 5
- The American Academy of Otolaryngology-Head and Neck Surgery and American College of Allergy, Asthma, and Immunology both recommend amoxicillin as first-line therapy 2, 4
Studies show amoxicillin is as effective as amoxicillin-clavulanate for first-line treatment in patients without beta-lactam allergy 6.
Why Other Options Are Incorrect
CT scan (Option A) is not indicated because imaging is not recommended for routine uncomplicated ABRS 2, 7, 4. The American College of Radiology and American Academy of Otolaryngology-Head and Neck Surgery reserve imaging only for suspected complications (orbital cellulitis, meningitis, abscess) or failure to respond to antibiotics 2, 7, 4. This patient has no warning signs such as periorbital swelling, severe headache, altered mental status, or neurological symptoms that would warrant imaging 7.
Reassurance alone (Option C) is inappropriate because this patient meets criteria for bacterial sinusitis requiring antibiotic therapy with severe onset presentation 2, 3, 4. While observation without antibiotics is an option for mild illness (mild pain and temperature <38.3°C) with assured follow-up 4, this patient has fever and meets severity criteria 2.
Ibuprofen alone (Option D) is insufficient as primary management, though it should be included as adjunctive therapy for pain relief 2. The American Academy of Otolaryngology-Head and Neck Surgery recommends assessing and treating pain with analgesics (acetaminophen or NSAIDs) based on severity, but this is supplementary to antibiotic therapy when ABRS is diagnosed 2, 4.
Adjunctive Symptomatic Management
In addition to antibiotics, provide:
- Analgesics: Ibuprofen or acetaminophen for pain and fever relief 2, 4
- Intranasal corticosteroids: May reduce inflammation and improve symptoms 2
- Saline nasal irrigation: Helps clear secretions 2
- Adequate hydration, rest, warm facial packs, and head elevation 2
Note that while one study showed no benefit from topical budesonide in combination with amoxicillin 8, guidelines still suggest intranasal steroids may help with symptom relief 2.
Critical Follow-Up Instructions
Monitor for improvement within 3-5 days of starting antibiotics 2. If no improvement occurs:
- Reassess to confirm ABRS diagnosis 4
- Consider changing to broader-spectrum antibiotic (amoxicillin-clavulanate) 2, 4
- Evaluate for complications or alternative diagnoses 4
Seek immediate medical attention if:
- Symptoms worsen significantly 2
- High fever persists 2
- Severe headache develops 7
- Visual changes occur 2
- Periorbital swelling or facial swelling appears 7
These warning signs suggest potential complications including orbital cellulitis or intracranial extension requiring urgent evaluation 7.
Important Caveats
Complete the full antibiotic course even if symptoms improve, typically 7-10 days, to ensure bacterial eradication and prevent resistance 5, 3. Treatment should continue for a minimum of 48-72 hours beyond symptom resolution 5.
Complete symptom resolution may take 10-14 days even with appropriate antibiotic therapy 2. Patients should understand this expected timeline to avoid premature concern about treatment failure.
For penicillin-allergic patients, alternatives include doxycycline or respiratory fluoroquinolones 2, 6, 4.