What is the best treatment for a patient with sinus pressure, drainage, green sputum, and headache for 2 days?

Symptomatic Treatment Without Antibiotics is the Best Initial Approach

For a patient with only 2 days of sinus symptoms (pressure, drainage, green sputum, headache), the best treatment is symptomatic management without antibiotics, as this presentation is almost certainly viral rhinosinusitis that will resolve spontaneously. 1

Why Antibiotics Should NOT Be Started Now

Bacterial sinusitis cannot be diagnosed at 2 days. The diagnosis of acute bacterial rhinosinusitis (ABRS) requires one of three specific patterns 1, 2:

• Persistent symptoms ≥10 days without improvement 1
• Severe symptoms (fever ≥39°C with purulent discharge) for ≥3 consecutive days 1, 2
• "Double sickening" - worsening after initial improvement from a viral URI 1, 2

This patient meets none of these criteria. At 2 days, approximately 98-99.5% of acute rhinosinusitis cases are viral and will resolve within 7-10 days without any intervention 2. Green or purulent nasal discharge does not indicate bacterial infection—it simply reflects neutrophil activity and is common in viral infections 1, 2.

Recommended Symptomatic Treatment

Provide the following evidence-based symptomatic measures 1, 2:

• Analgesics: Acetaminophen or ibuprofen for pain and fever relief 1
• Saline nasal irrigation: Washes out mucus and provides symptom relief 1
• Decongestants:
  • Oral (pseudoephedrine) or topical nasal sprays for congestion 1
  • Limit topical decongestants to ≤3 days to avoid rebound congestion 1
• Adequate hydration and sleeping with head elevated 2

Intranasal corticosteroids (mometasone, fluticasone, budesonide) can reduce symptoms after 15 days of use, though the benefit is modest (number needed to treat = 14) 1, 2.

Watchful Waiting Strategy

The appropriate management is "watchful waiting" for up to 7 days 1, 2:

• Reassess symptoms at 7-10 days 1
• Start antibiotics only if:
  • No improvement by 10 days 1
  • Worsening at any time 1
  • Development of severe symptoms (high fever ≥39°C with purulent discharge for ≥3 days) 1, 2

You can provide a "safety-net" prescription for antibiotics that the patient fills only if symptoms persist beyond 7-10 days or worsen 1.

If Antibiotics Become Necessary Later

If bacterial sinusitis is confirmed after 10 days, first-line treatment is 1, 3, 2:

• Amoxicillin 500 mg twice daily (mild disease) or 875 mg twice daily (moderate disease) for 5-10 days 1, 2
• Amoxicillin-clavulanate 875/125 mg twice daily for 5-10 days (preferred if recent antibiotic use or moderate disease) 1, 2

For penicillin allergy 3, 2:

• Non-severe allergy: Cefpodoxime, cefuroxime, or cefdinir 3
• Severe/anaphylactic allergy: Levofloxacin 500 mg daily or moxifloxacin 400 mg daily for 10 days 3

Critical Pitfalls to Avoid

• Never prescribe antibiotics for symptoms <10 days unless severe criteria are met—this contributes to antimicrobial resistance without clinical benefit 1, 2
• Do not use mucus color alone to determine need for antibiotics 2
• Avoid antihistamines and oral steroids routinely—they have side effects without proven benefit in acute viral rhinosinusitis 1
• Number needed to treat with antibiotics is 10-15 to get one additional person better after 7-15 days, highlighting that most patients improve without antibiotics 1