Treatment for Acute Rhinitis
Most patients with acute rhinitis should receive supportive care only, as the condition is typically viral and self-limited, with antibiotics reserved exclusively for those meeting specific bacterial infection criteria. 1
Initial Assessment: Viral vs. Bacterial Differentiation
The critical first step is determining whether the rhinitis is viral (common cold) or bacterial, as this fundamentally changes management:
Treat as viral rhinitis (supportive care only) when:
- Symptoms present for less than 7-10 days 1, 2, 3
- Mild symptoms without high fever 1
- No "double sickening" pattern 1
Consider bacterial rhinosinusitis when ANY of these criteria are met:
- Symptoms persist beyond 10 days without improvement 1, 2
- Severe symptoms: fever >39°C (>101°F) with purulent nasal discharge and facial pain for ≥3 consecutive days 1, 2
- "Double sickening": initial improvement followed by worsening after 5 days 1, 2
Supportive Care (First-Line for Viral Rhinitis)
For viral rhinitis, provide symptomatic relief with:
- Analgesics for pain (acetaminophen, NSAIDs) 1, 3
- Antipyretics for fever 1
- Saline nasal irrigation 1, 3
- Oral or topical decongestants (short-term use only to avoid rhinitis medicamentosa) 1, 3
- Intranasal corticosteroids may provide symptomatic relief 1
- Antihistamines tailored to symptoms 1
Critical pitfall: Antibiotics provide no benefit for viral rhinitis and cause more harm than good—the number needed to harm (8) is less than the number needed to treat (18) for bacterial cases. 1
Antibiotic Therapy (Only for Confirmed Bacterial Rhinosinusitis)
When bacterial infection criteria are met:
First-line antibiotic:
Alternative agents (penicillin allergy):
For treatment failures or high-risk patients (recent antibiotics, severe disease):
- Amoxicillin-clavulanate (preferred by IDSA for resistance concerns, though no direct evidence of superiority) 1
- Respiratory fluoroquinolone 1
Reassess at 72 hours: If no improvement, switch to broader-spectrum antibiotics or consider complications. 2
Adjunctive Therapies for Bacterial Rhinosinusitis
Add to antibiotic regimen:
- Intranasal saline irrigation 1
- Intranasal corticosteroids (shown to alleviate symptoms and potentially decrease antibiotic use) 1
- Analgesics and decongestants as needed 1
Special Considerations for Nonallergic Rhinitis
If allergic component is suspected or confirmed:
- Second-generation H1 antihistamines (cetirizine, fexofenadine, desloratadine, loratadine) for mild intermittent symptoms 5
- Intranasal corticosteroids for moderate-to-severe persistent symptoms 1, 5
- Intranasal antihistamines (azelastine, olopatadine) 1, 5
For vasomotor rhinitis:
- Intranasal corticosteroids and intranasal antihistamines for congestion and rhinorrhea 1
- Intranasal anticholinergics for predominant rhinorrhea (e.g., gustatory rhinitis) 1
- Avoid aggravating irritants 1
For rhinitis medicamentosa:
- Discontinue nasal decongestant sprays immediately 1
- Treat with intranasal or short-course (5-7 days) oral corticosteroids 1
When to Refer to Specialist
Refer to allergist/immunologist or otolaryngologist when:
- Symptoms persist despite appropriate treatment 1
- Complications develop (sinusitis, otitis media, nasal polyps) 1
- Comorbid asthma or chronic sinusitis 1
- Systemic corticosteroids required 1
- Quality of life significantly impaired 1
- Recurrent episodes requiring multiple medications 1
Critical Pitfalls to Avoid
Do not:
- Prescribe antibiotics for symptoms <7 days or mild viral illness (85-98% of suspected cases receive unnecessary antibiotics) 2
- Use imaging routinely—reserve CT for suspected complications or treatment failures 1, 4
- Use prolonged topical decongestants (>3-5 days) due to rebound congestion risk 1
- Administer parenteral corticosteroids (single or recurrent doses contraindicated due to systemic side effects) 1