What is the appropriate antibiotic choice for a patient presenting with bloody/greenish nasal discharge, purulent nasal discharge (PND), and left ear pain for approximately 2 weeks?

From the Guidelines

For a patient with bloody/greenish nasal discharge, post-nasal drip (PND), and left ear pain for approximately 2 weeks, the recommended first-line antibiotic treatment is amoxicillin-clavulanate (Augmentin) 875/125 mg twice daily for 5-7 days, as suggested by the 2012 IDSA clinical practice guidelines 1. This presentation suggests acute bacterial rhinosinusitis, likely with involvement of the left Eustachian tube causing referred ear pain. Amoxicillin-clavulanate is preferred over amoxicillin alone due to increasing prevalence of beta-lactamase producing organisms like Haemophilus influenzae and Moraxella catarrhalis.

Some key points to consider in the management of this patient include:

• The patient's symptoms have persisted for more than 10 days, which increases the likelihood of a bacterial cause 1.
• The presence of bloody/greenish nasal discharge and post-nasal drip suggests significant inflammation and purulence, which supports the use of antibiotics 1.
• Adjunctive treatments, such as nasal saline irrigation, intranasal corticosteroids (e.g., fluticasone 1-2 sprays per nostril daily), and analgesics as needed, can help alleviate symptoms and potentially decrease antibiotic use 1.
• If symptoms don't improve within 72 hours of antibiotic therapy, or if symptoms worsen at any point, the patient should be reevaluated for possible complications or alternative diagnoses 1.

For penicillin-allergic patients, alternatives include doxycycline 100 mg twice daily for 5-7 days or a respiratory fluoroquinolone like levofloxacin 750 mg daily for 5 days. It's essential to note that the American Academy of Otolaryngology–Head and Neck Surgery emphasizes watchful waiting (without antibiotic therapy) as initial management for all patients with uncomplicated ABRS, regardless of severity 1. However, given the patient's symptoms and duration of illness, antibiotic treatment is warranted in this case.

From the FDA Drug Label

Acute bacterial sinusitis 500 mg QD × 3 days The FDA-approved dosage for azithromycin in the treatment of acute bacterial sinusitis is 500 mg once daily for 3 days. Given the symptoms of bloody/greenish nasal discharge, PND, and left ear pain for approximately 2 weeks, azithromycin may be considered as an antibiotic choice. Key points:

• The patient's symptoms suggest a possible bacterial infection.
• Azithromycin is approved for the treatment of acute bacterial sinusitis.
• The recommended dose is 500 mg once daily for 3 days 2.

From the Research

Symptoms and Diagnosis

• The patient presents with bloody/greenish nasal discharge, postnasal drip (PND), and left ear pain for approximately 2 weeks, which may indicate acute bacterial sinusitis (ABS) 3.
• The symptoms of ABS can be categorized into three clinical presentations: onset with persistent symptoms, onset with severe symptoms, and onset with worsening symptoms 3.
• Postnasal drip (PND) is a common clinical complaint that may be caused by various conditions involving the nose and throat, and its treatment should be guided by associated symptoms 4.

Bacterial Causes and Antibiotic Treatment

• The predominant bacterial species implicated in acute sinusitis are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis in children 3, 5.
• The increasing prevalence of penicillin-resistant S. pneumoniae, and beta-lactamase-producing H. influenzae and M. catarrhalis, should be considered when choosing antibiotics 3.
• Therapy for ABS may be initiated with high-dose amoxicillin or amoxicillin-clavulanate, and alternatives include cefuroxime, cefpodoxime, or cefdinir 3.
• In cases of serious drug allergy, clarithromycin or azithromycin may be prescribed 3.

Bacterial Colonization and Viral Infection

• The presence and density of S. pneumoniae, H. influenzae, and M. catarrhalis in the nasopharynx of children increase during periods of both symptomatic and asymptomatic viral infection 6.
• The carriage of these bacterial pathogens is common in young children, and the rate of carriage may be influenced by factors such as pneumococcal immunization 7.