Prescription for Adult Bacterial Ear Ache, Sinus, and Lung Congestion with Productive Cough
First-Line Antibiotic Regimen
For an adult with presumed bacterial acute otitis media, acute bacterial sinusitis, and acute bacterial bronchitis/pneumonia, prescribe amoxicillin-clavulanate 875 mg/125 mg orally twice daily for 10 days as the single most appropriate first-line regimen. 1, 2
This combination provides 90–92% predicted clinical efficacy against the three principal respiratory pathogens—Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis—which are responsible for the majority of bacterial infections across all three anatomic sites (ear, sinus, and lower respiratory tract). 1, 2
The clavulanate component is essential because 30–40% of H. influenzae and 90–100% of M. catarrhalis produce β-lactamase, rendering plain amoxicillin ineffective against these organisms. 1, 2
Rationale for Combined Coverage
Acute Otitis Media
Amoxicillin-clavulanate is the preferred first-line agent when no bacteriological markers are available, providing suitable coverage against pneumococcal infection and β-lactamase-producing H. influenzae. 1
Treatment duration for otitis media is 8–10 days in adults. 1
Acute Bacterial Sinusitis
Amoxicillin-clavulanate 875 mg/125 mg twice daily for 5–10 days is the guideline-recommended first-line regimen for acute bacterial rhinosinusitis, with treatment continued until symptom-free for 7 consecutive days (typically 10–14 days total). 1, 2, 3
Bacterial sinusitis should only be diagnosed when symptoms persist ≥10 days without improvement, severe symptoms (fever ≥39°C with purulent discharge) last ≥3–4 consecutive days, or "double sickening" (worsening after initial improvement) occurs. 1, 2, 3
Approximately 98–99.5% of acute rhinosinusitis is viral and resolves spontaneously within 7–10 days; antibiotics should not be prescribed for symptoms <10 days unless severe features are present. 1, 2, 3
Community-Acquired Pneumonia / Acute Bronchitis
For community-acquired pneumonia without risk factors or serious symptoms, oral amoxicillin 3 g/day is the initial recommended treatment for suspected pneumococcal origin, especially in adults over 40 years of age. 1
However, acute bronchitis in otherwise healthy adults is viral in 89–95% of cases and does not require antibiotics—antibiotics provide minimal benefit (reducing cough by only half a day) while exposing patients to adverse effects and contributing to resistance. 4
The presence of purulent sputum does not indicate bacterial infection, as it occurs in 89–95% of viral bronchitis cases. 4
If the productive cough represents true bacterial pneumonia (confirmed by fever >37.8°C, tachycardia >100 bpm, polypnea >25/min, chest pain, focal signs on auscultation, or radiographic infiltrate), then amoxicillin-clavulanate provides appropriate coverage. 1
Diagnostic Confirmation Before Prescribing
Rule Out Viral Bronchitis
Before diagnosing bacterial pneumonia or bronchitis, exclude pneumonia by checking for heart rate >100 bpm, respiratory rate >24 breaths/min, oral temperature >38°C, and abnormal chest examination findings (rales, egophony, tactile fremitus). 4
If these are absent and the patient has only productive cough with congestion, the condition is likely viral acute bronchitis and antibiotics should be withheld. 4
Fever persisting beyond 3 days strongly suggests bacterial superinfection or pneumonia rather than simple viral bronchitis and warrants reassessment. 4
Confirm Bacterial Sinusitis
Antibiotics for sinusitis are indicated only when persistent symptoms ≥10 days, severe symptoms ≥3–4 days (fever ≥39°C with purulent discharge and facial pain), or "double sickening" occurs. 1, 2, 3
Purulent nasal discharge alone does not indicate bacterial infection—it reflects inflammatory cells common to viral disease. 1, 2
Confirm Bacterial Otitis Media
Acute otitis media is diagnosed by otoscopic signs of purulent middle ear effusion combined with acute onset of symptoms (ear pain, fever, irritability). 1
Treatment Duration and Monitoring
Continue amoxicillin-clavulanate for 10 days to ensure adequate coverage across all three infection sites (otitis media requires 8–10 days, sinusitis requires 5–10 days or until symptom-free for 7 days, and pneumonia requires 10–14 days). 1, 2
Reassess at 3–5 days: If no clinical improvement (persistent fever, ear pain, purulent nasal drainage, or worsening respiratory symptoms), switch to a respiratory fluoroquinolone (levofloxacin 500 mg once daily or moxifloxacin 400 mg once daily) for 10–14 days. 1, 2
Reassess at 7 days: Persistent or worsening symptoms warrant confirmation of diagnosis, exclusion of complications (mastoiditis, orbital cellulitis, meningitis, empyema), and consideration of imaging or specialist referral. 1, 2
Essential Adjunctive Therapies
For Sinusitis
Intranasal corticosteroids (mometasone, fluticasone, or budesonide) twice daily significantly reduce mucosal inflammation and accelerate symptom resolution—supported by strong evidence from multiple randomized controlled trials. 1, 2
Saline nasal irrigation 2–3 times daily provides symptomatic relief and aids mucus clearance. 1, 2
For Bronchitis/Pneumonia
If the productive cough is confirmed viral bronchitis (not pneumonia), provide symptomatic treatment only: antitussives (codeine or dextromethorphan) for bothersome dry cough, β2-agonist bronchodilators only if wheezing is present, and elimination of environmental cough triggers. 4
Inform patients that cough typically lasts 10–14 days and may persist up to 3 weeks even without antibiotics. 4
For All Conditions
Analgesics (acetaminophen or ibuprofen) for pain and fever control. 1, 2
Penicillin-Allergic Patients
Non-Severe (Non-Type I) Allergy
Use a second- or third-generation cephalosporin (cefuroxime-axetil, cefpodoxime-proxetil, or cefdinir) for 10 days—cross-reactivity with penicillin is negligible. 1, 2
Severe (Type I/Anaphylactic) Allergy
Use a respiratory fluoroquinolone: levofloxacin 500 mg once daily for 10–14 days or moxifloxacin 400 mg once daily for 10 days, providing 90–92% predicted efficacy against multidrug-resistant pathogens. 1, 2
Alternatively, for sinusitis and otitis media in penicillin-allergic patients, erythromycin-sulfafurazole may be used. 1
Critical Pitfalls to Avoid
Do not prescribe antibiotics for uncomplicated acute bronchitis in otherwise healthy adults—respiratory viruses cause 89–95% of cases, and antibiotics provide no clinical benefit while causing significant adverse effects (diarrhea in 40–43% of patients). 4
Do not prescribe antibiotics for sinusitis symptoms <10 days unless severe features (fever ≥39°C with purulent discharge for ≥3 consecutive days) are present—98–99.5% of acute rhinosinusitis is viral. 1, 2, 3
Do not use macrolides (azithromycin, clarithromycin) as first-line therapy—resistance rates are 20–25% for both S. pneumoniae and H. influenzae. 1, 2
Do not use trimethoprim-sulfamethoxazole—resistance is ~50% in S. pneumoniae and ~27% in H. influenzae. 1, 2
Do not use first-generation cephalosporins (cephalexin)—inadequate coverage against H. influenzae because ~50% of strains produce β-lactamase. 1, 2
Ensure adequate treatment duration (minimum 10 days) to prevent relapse and resistance development. 1, 2
When to Refer or Escalate Care
Refer to otolaryngology or pulmonology if:
- No improvement after 7 days of appropriate second-line antibiotic therapy 1, 2
- Worsening symptoms at any point (increasing pain, fever, respiratory distress) 1, 2
- Suspected complications (mastoiditis, orbital cellulitis, meningitis, empyema, severe headache, visual changes, periorbital swelling, altered mental status) 1, 2
- Recurrent infections (≥3 episodes per year) requiring evaluation for underlying allergic rhinitis, immunodeficiency, or anatomic abnormalities 1, 2