In a 51-year-old woman with persistent nasal congestion and productive cough after a viral upper respiratory infection, no fever, sinus pain, or dyspnea, and minimal improvement after a 3‑day prednisone course, which antibiotic is appropriate—amoxicillin or amoxicillin‑clavulanate?

Should You Prescribe Antibiotics for This Patient?

No, you should not prescribe antibiotics at this time. This patient's presentation is consistent with a prolonged viral upper respiratory infection without clear evidence of bacterial superinfection, and antibiotics are not indicated.

Clinical Reasoning Against Antibiotic Use

Your patient does not meet the established criteria for bacterial rhinosinusitis requiring antibiotics. The key clinical decision points are:

Absence of Bacterial Infection Criteria

This patient fails to meet any of the three validated criteria for acute bacterial rhinosinusitis (ABRS):

• Persistent symptoms >10 days without improvement – While she has ongoing symptoms, you don't specify the total duration exceeds 10 days 1
• Severe symptoms – She lacks fever >39°C, and while she has purulent discharge, she doesn't have facial pain lasting ≥3 consecutive days 1, 2
• "Double sickening" – She reports improvement in sore throat, not worsening after initial improvement 1

The Steroid Trial Does Not Justify Antibiotics

The lack of response to 3 days of prednisone does not indicate bacterial infection. Short-course oral corticosteroids are used as adjunctive therapy for mucosal edema, not as a diagnostic test for bacterial infection 1. The absence of steroid response simply means the inflammatory component didn't respond—it doesn't differentiate viral from bacterial causes.

What This Clinical Picture Actually Represents

Post-Viral Syndrome

This presentation is classic for post-infectious upper airway cough syndrome (previously called post-nasal drip):

• Improvement in acute symptoms (sore throat better) with persistent nasal congestion and productive cough is the hallmark of post-viral inflammation 1
• Dark mucus production alone does not indicate bacterial infection—viral URIs commonly produce purulent-appearing secretions 1
• Ongoing fatigue is expected with viral illness and can persist for 7-10 days 2, 3

The Natural History Argument

Fewer than 2% of viral URIs are complicated by bacterial rhinosinusitis 1. Most acute rhinosinusitis resolves spontaneously within 7-10 days without antibiotics 2, 3. The number needed to treat with antibiotics is 18 for one patient to be cured rapidly, while the number needed to harm from antibiotic adverse effects is only 8 1.

Appropriate Management Strategy

Continue Supportive Care

Recommend the following evidence-based symptomatic treatments:

• Analgesics (acetaminophen or NSAIDs) for discomfort 1, 2
• Intranasal saline irrigation to help clear secretions 1
• Adequate hydration and rest 1
• Consider first-generation antihistamine plus decongestant (e.g., pseudoephedrine) specifically for post-infectious cough 1
• Intranasal corticosteroids may provide additional benefit 1

Watchful Waiting with Clear Return Precautions

Instruct the patient to return or call if:

• Symptoms persist beyond 10 days total without any improvement 1
• Development of high fever >39°C with severe facial pain lasting ≥3 consecutive days 1, 2
• Worsening of symptoms after initial improvement (double sickening) 1
• Development of severe headache, visual changes, or signs of complicated sinusitis 1

If Antibiotics Become Necessary Later

When to Prescribe

Only if she returns meeting one of the three ABRS criteria listed above should you consider antibiotics 1.

Antibiotic Selection If Indicated

If antibiotics become necessary, amoxicillin-clavulanate is the preferred first-line agent:

• The 2012 IDSA guidelines recommend amoxicillin-clavulanate as the preferred empirical antibiotic for ABRS due to coverage of ampicillin-resistant Haemophilus influenzae and Moraxella catarrhalis 1
• However, some societies (American Academy of Allergy, Asthma & Immunology and American Academy of Family Physicians) recommend plain amoxicillin as first-line, noting that no direct evidence proves amoxicillin-clavulanate is superior 1
• For poor response to initial therapy, high-dose amoxicillin-clavulanate (90 mg/kg amoxicillin component, up to 2g every 12 hours) provides better coverage against resistant organisms 1

Common Pitfall to Avoid

The presence of purulent nasal discharge alone does not indicate bacterial infection. Viral URIs routinely produce thick, colored mucus as part of the normal inflammatory response 1. Prescribing antibiotics based solely on mucus color leads to unnecessary antibiotic exposure, adverse effects, and contributes to antimicrobial resistance 1, 2.