What is the recommended treatment for bacterial rhinitis?

Treatment of Bacterial Rhinitis (Acute Bacterial Rhinosinusitis)

For mild bacterial rhinitis without recent antibiotic use, start with amoxicillin 1.5-4g/day for 10-14 days, but only after confirming symptoms have persisted ≥7-10 days or meet criteria for bacterial infection—most cases are viral and require only symptomatic treatment. 1, 2, 3

Distinguishing Bacterial from Viral Infection

Before prescribing antibiotics, confirm the patient meets criteria for acute bacterial rhinosinusitis (ABRS), as 40-60% of cases are viral and resolve spontaneously 1, 4:

• Persistent symptoms ≥7-10 days without improvement (purulent nasal discharge, nasal obstruction, facial pain/pressure) 1, 2, 4
• Severe symptoms for ≥3 consecutive days: fever >39°C (102.2°F), purulent nasal discharge, and facial pain 4, 3
• "Double sickening": initial improvement followed by worsening symptoms, new fever, or increased purulent discharge within 10 days 4, 3

Critical pitfall: Purulent (colored) nasal discharge alone does NOT indicate bacterial infection—it reflects neutrophil presence that occurs in both viral and bacterial infections 4. Fewer than 1 in 15 patients with viral upper respiratory infections develop true bacterial rhinosinusitis 4.

First-Line Antibiotic Treatment

For Mild Disease (No Recent Antibiotic Use in Past 4-6 Weeks)

Preferred agents targeting Streptococcus pneumoniae and Haemophilus influenzae 1:

• Amoxicillin 1.5-4g/day divided doses for 10-14 days (or until well for 7 days) 2, 3, 5
• Amoxicillin-clavulanate 1.75-4g/250mg per day for enhanced coverage 3

For penicillin allergy 1, 2, 3:

• Trimethoprim-sulfamethoxazole (note: 20-25% bacteriologic failure rate) 3
• Doxycycline 1, 3, 5

For Moderate Disease or Recent Antibiotic Exposure

Use broader-spectrum agents 1, 2, 5:

• High-dose amoxicillin-clavulanate 2, 5
• Respiratory fluoroquinolones (levofloxacin, moxifloxacin) 1
• Second-generation cephalosporins (cefuroxime, cefpodoxime) 1, 2

Symptomatic Treatment (Preferred Initial Approach for Mild Cases)

Most patients improve without antibiotics—symptomatic treatment is preferred for mild symptoms 1, 2:

• Analgesics/antipyretics for pain and fever 1, 2
• Nasal saline irrigation (effective and safe) 4, 5
• Oral or topical decongestants (limit topical use to ≤3 days to avoid rebound congestion) 5, 6
• Intranasal corticosteroids (especially with allergic component or mucosal edema) 2, 4, 6
• Adequate hydration, rest, warm facial packs, head elevation 2

Treatment Monitoring and Adjustment

Reassess at 72 hours 2, 3:

• If improving: Continue current antibiotic until completion (10-14 days total or 7 days after symptom resolution) 2, 7
• If not improving: Switch to broader-spectrum antibiotics (high-dose amoxicillin-clavulanate, respiratory fluoroquinolone, or second-generation cephalosporin) 2, 5
• For treatment failures or severe infections: Consider ceftriaxone 1g IM/IV daily for 5 days 3

When to Avoid Antibiotics

Do NOT prescribe antibiotics for 1, 4, 3:

• Symptoms lasting <7 days (likely viral) 1, 4
• Mild symptoms without specific bacterial criteria 1, 2
• Colored nasal discharge as the sole finding 4

Rationale: Antibiotics show only modest benefit over placebo (most patients improve regardless), cause adverse effects (28% higher rate than placebo), and drive antimicrobial resistance that persists up to 12 months 1, 4.

Critical Pitfalls to Avoid

• Overtreatment of viral rhinosinusitis: 85-98% of clinically suspected cases receive antibiotics, but most are viral 1, 3
• Using broad-spectrum agents as first-line: Reserve for moderate disease or treatment failures to minimize resistance 1, 3
• Inadequate treatment duration: Must complete 10-14 days or until well for 7 days 2, 7
• Ignoring warning signs: Periorbital edema, diplopia, severe headache, or altered mental status require immediate evaluation for complications 4, 6

Special Considerations

Refer to otolaryngology if 2, 6:

• Symptoms persist beyond 28 days despite appropriate therapy 4
• Recurrent episodes (≥4 per year) 2
• Suspected complications (orbital/intracranial involvement) 6
• Underlying structural abnormalities or nasal polyps 2

Patient education: Instruct patients to return if symptoms worsen after initial improvement, high fever develops, or no improvement occurs within 3-5 days of treatment 2.