Management of Infectious Rhinitis in Adults
Distinguish Viral from Bacterial Rhinosinusitis Before Treatment
Most acute infectious rhinitis (98-99.5%) is viral and resolves spontaneously within 7-10 days without antibiotics—reserve antibiotics only for confirmed bacterial rhinosinusitis. 1
Diagnostic Criteria for Bacterial Rhinosinusitis
Prescribe antibiotics only when the patient meets one of these three patterns:
- Persistent symptoms ≥10 days without improvement: purulent nasal drainage plus nasal obstruction or facial pain/pressure/fullness 1
- Severe symptoms ≥3-4 consecutive days: fever ≥39°C (102.2°F) with purulent nasal discharge and facial pain 1, 2
- "Double sickening": initial improvement from a cold followed by worsening symptoms within 10 days 1
If symptoms last less than 10 days and are not worsening, this is viral rhinitis—do not prescribe antibiotics. 1
First-Line Treatment for Viral Rhinitis (Symptomatic Care Only)
For viral rhinitis (symptoms <10 days without severe features):
- Analgesics: acetaminophen or ibuprofen for pain and fever 1, 2
- Saline nasal irrigation: 2-3 times daily to clear mucus and provide symptomatic relief 1, 2, 3
- Intranasal ipratropium bromide 0.06%: two sprays per nostril 2-3 times daily for rhinorrhea (runny nose) relief—does not relieve congestion or sneezing 4
- Oral or topical decongestants: pseudoephedrine or oxymetazoline (limit topical use to ≤3 days to avoid rebound congestion) 1, 2
Do not prescribe antibiotics for viral rhinitis—they provide no benefit and contribute to antimicrobial resistance. 1
First-Line Antibiotic Treatment for Bacterial Rhinosinusitis
When bacterial rhinosinusitis is confirmed by the criteria above:
Amoxicillin-clavulanate 875 mg/125 mg orally twice daily for 5-10 days is the preferred first-line antibiotic, with 90-92% predicted clinical efficacy against Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. 1, 2
High-Dose Regimen for Specific Risk Factors
Use high-dose amoxicillin-clavulanate (2 g/125 mg twice daily) in patients with:
- Recent antibiotic use within the past 4-6 weeks 2
- Age >65 years 2
- Moderate-to-severe symptoms 2
- Comorbid conditions or immunocompromised state 2
Treatment Duration
- Continue for 5-10 days or until symptom-free for 7 consecutive days (typically 10-14 days total) 1, 2
- Recent evidence supports 5-7 day courses with comparable efficacy and fewer adverse effects 2
Alternatives for Penicillin Allergy
Non-Severe (Non-Type I) Penicillin Allergy
Use second- or third-generation cephalosporins (cross-reactivity is negligible): 1, 2
Dose for 10 days. 2
Severe (Type I/Anaphylactic) Penicillin Allergy
Use respiratory fluoroquinolones: 1, 2
- Levofloxacin 500 mg once daily for 10-14 days, OR
- Moxifloxacin 400 mg once daily for 10 days
These provide 90-92% predicted efficacy against multidrug-resistant S. pneumoniae. 2
Avoid These Antibiotics
- Azithromycin and macrolides: 20-25% resistance rates for S. pneumoniae and H. influenzae 1, 2
- Trimethoprim-sulfamethoxazole: 50% resistance in S. pneumoniae, 27% in H. influenzae 2
- First-generation cephalosporins (cephalexin): inadequate coverage against H. influenzae (50% produce β-lactamase) 2
Essential Adjunctive Therapies (Add to All Patients)
These improve outcomes regardless of antibiotic use:
- Intranasal corticosteroids (mometasone, fluticasone, or budesonide) twice daily: reduce mucosal inflammation and accelerate symptom resolution—supported by strong evidence from multiple RCTs 1, 2
- Saline nasal irrigation 2-3 times daily: provides symptomatic relief and clears mucus 1, 2, 3
- Analgesics (acetaminophen or ibuprofen): for pain and fever control 1, 2
- Adequate hydration and warm facial compresses 2
Watchful Waiting Strategy (No Immediate Antibiotics)
For adults with uncomplicated bacterial rhinosinusitis when reliable follow-up is assured:
- Initial observation without antibiotics is appropriate 1, 2
- Start antibiotics only if no improvement by day 7 or if symptoms worsen at any time 1, 2
- This reduces unnecessary antibiotic exposure while maintaining safety 2
Monitoring and Reassessment
Reassess at 3-5 Days
If no clinical improvement, switch to: 2
- High-dose amoxicillin-clavulanate (2 g/125 mg twice daily), OR
- Respiratory fluoroquinolone (levofloxacin or moxifloxacin)
If symptoms worsen at any time, evaluate urgently for complications (orbital cellulitis, meningitis, brain abscess). 2
Reassess at 7 Days
If symptoms persist or worsen: 2
- Reconfirm the diagnosis using clinical criteria
- Exclude complications
- Consider CT imaging only if complications are suspected—do not obtain routine imaging for uncomplicated cases 1
When to Refer to Otolaryngology
Refer when: 2
- No improvement after 7 days of appropriate second-line antibiotics
- Worsening symptoms at any point during treatment
- Suspected complications (severe headache, visual changes, periorbital swelling, altered mental status)
- Recurrent rhinosinusitis (≥3 episodes per year)—requires evaluation for underlying allergic rhinitis, immunodeficiency, or anatomic abnormalities
Critical Pitfalls to Avoid
- Do not prescribe antibiotics for symptoms <10 days unless severe features are present (fever ≥39°C with purulent discharge for ≥3 consecutive days) 1
- Do not obtain routine CT or X-ray for uncomplicated acute rhinosinusitis—87% of viral URIs show sinus abnormalities on imaging 1, 2
- Do not use fluoroquinolones as first-line therapy in patients without documented β-lactam allergies—reserve them to prevent resistance development 1, 2
- Ensure adequate treatment duration (≥5 days for adults) to prevent relapse 2
- Reassess early (3-5 days)—delaying changes in non-responders allows complications to develop 2