What are the treatment options for a progressive cough that started as dry, then produced white phlegm, followed by green phlegm, and is now turning brown, accompanied by nasal congestion, headache, and colored nasal discharge?

Progressive Respiratory Infection with Brown Sputum: Acute Bacterial Rhinosinusitis

You have acute bacterial rhinosinusitis (ABRS) requiring antibiotic therapy, based on your symptom progression over 2 weeks with persistent purulent discharge, unilateral headache, and nasal congestion.

Diagnostic Criteria Met

Your presentation fulfills the clinical criteria for ABRS through the "persistent without improvement" pattern 1:

• Symptoms persisting beyond 10 days without improvement (you're at 2 weeks) 1
• Purulent nasal discharge (green, now brown phlegm) accompanied by nasal obstruction 1
• Facial pain/pressure (unilateral headache) 1
• Nasal congestion 1

The brown discoloration of your phlegm represents old blood mixed with purulent secretions, which can occur with prolonged sinus inflammation and is not uncommon in bacterial sinusitis 1.

Why This Is Bacterial, Not Viral

While viral upper respiratory infections commonly cause colored discharge, the key distinguishing feature is duration 1:

• Uncomplicated viral URIs typically resolve within 5-7 days, with symptoms peaking at days 3-6 1
• Your symptoms have persisted for 14 days and progressed rather than improved 1
• The transition from white to green to brown phlegm over 2 weeks, rather than clearing, indicates bacterial superinfection 1

Recommended Antibiotic Treatment

First-line therapy: Amoxicillin-clavulanate 875mg/125mg twice daily for 5-7 days 1:

• This covers the most common bacterial pathogens: Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 1, 2
• The clavulanate component overcomes β-lactamase resistance present in approximately 30% of H. influenzae and essentially all M. catarrhalis 1

Alternative if penicillin-allergic: Azithromycin 500mg on day 1, then 250mg daily for days 2-5 2:

• FDA-approved for acute bacterial sinusitis 2
• Covers the same pathogens but should be reserved for true penicillin allergy due to increasing macrolide resistance 1

Adjunctive Symptomatic Management

While antibiotics address the bacterial infection, add these measures for symptom relief 1:

• Intranasal saline irrigation to help clear secretions 1
• Oral decongestants (pseudoephedrine 30-60mg every 4-6 hours) to reduce nasal congestion 1
• Analgesics (ibuprofen or acetaminophen) for facial pain and headache 1

When to Seek Urgent Care

Seek immediate medical attention if you develop 1:

• High fever >39°C (102.2°F) 1
• Severe worsening of symptoms 1
• Visual changes, periorbital swelling, or severe headache (suggesting complications) 1
• No improvement after 3-4 days of appropriate antibiotic therapy 1

Why Imaging Is Not Needed

Do not obtain CT or plain radiographs unless complications are suspected 1:

• Radiographic findings have 90% sensitivity but only 61% specificity for bacterial sinusitis 1
• Viral and bacterial causes appear identical on imaging 1
• Clinical criteria alone are sufficient for diagnosis and treatment decisions 1

Critical Pitfall to Avoid

Do not dismiss this as post-infectious cough requiring only supportive care 3, 4:

• Post-infectious cough occurs after URI symptoms resolve and presents with non-purulent secretions 4
• Your ongoing purulent discharge and facial pain indicate active bacterial infection, not post-viral inflammation 1
• Antibiotics are explicitly contraindicated for post-infectious cough but are essential for ABRS 4

Expected Timeline for Improvement

With appropriate antibiotic therapy 1:

• Symptom improvement should begin within 3-4 days 1
• Complete resolution typically occurs within 7-10 days of starting treatment 1
• If symptoms persist beyond 4 weeks despite treatment, this becomes subacute sinusitis requiring re-evaluation 1