Do Not Prescribe Either Antibiotic for This Presentation
Green sputum, cough, and rhinorrhea do not indicate bacterial infection and should be managed with supportive care alone—antibiotics cause more harm than benefit in this clinical scenario. 1
Why Antibiotics Are Not Indicated
The presence of green or purulent sputum does not signify bacterial infection—purulence is due to inflammatory cells or sloughed mucosal epithelial cells, not bacteria. 1 More than 90% of otherwise healthy patients presenting with acute cough have a viral syndrome. 1
Neither Augmentin (amoxicillin-clavulanate) nor azithromycin should be prescribed because:
- A systematic review of 15 randomized controlled trials found limited evidence to support antibiotics for acute bronchitis and a trend toward increased adverse events in patients treated with antibiotics. 1
- A randomized placebo-controlled trial comparing amoxicillin-clavulanate, ibuprofen, and placebo showed no significant differences in days to cough resolution. 1
- Patients with acute bronchitis treated with azithromycin had significantly more adverse events than those receiving placebo. 1
When to Consider Antibiotics
Antibiotics should only be considered if the patient meets criteria for:
Pneumonia (Rule This Out First)
For healthy immunocompetent adults younger than 70 years, pneumonia is unlikely in the absence of ALL of the following: 1
- Tachycardia (heart rate >100 beats/min)
- Tachypnea (respiratory rate >24 breaths/min)
- Fever (oral temperature >38°C)
- Abnormal chest examination findings (rales, egophony, or tactile fremitus)
Acute Bacterial Rhinosinusitis (Requires Specific Criteria)
Antibiotics are indicated only if symptoms meet one of these three patterns: 1, 2
- Persistent symptoms for more than 10 days without improvement
- Severe symptoms: fever >39°C with purulent nasal discharge or facial pain for ≥3 consecutive days
- Double sickening: worsening after initial improvement following a typical viral URI
If antibiotics are indicated for bacterial rhinosinusitis, amoxicillin-clavulanate is the preferred agent, not azithromycin. 1, 2
Recommended Management
Supportive care is the cornerstone of treatment for this viral respiratory infection: 2
- Analgesics for pain relief
- Antipyretics for fever
- Saline nasal irrigation for nasal congestion
- Intranasal corticosteroids for symptom relief
- Systemic or topical decongestants (phenylephrine) as needed
- Cough suppressants (dextromethorphan or codeine) for cough
- First-generation antihistamines (diphenhydramine) for rhinorrhea
Critical Pitfall to Avoid
Do not be misled by green sputum color—this is the most common reason for inappropriate antibiotic prescribing in acute bronchitis. 1 The American College of Physicians and CDC explicitly state that purulent sputum or color change does not signify bacterial infection. 1
Prescribing antibiotics in this scenario exposes the patient to unnecessary adverse effects (nausea, vomiting, diarrhea, allergic reactions) without clinical benefit and contributes to antibiotic resistance. 1