How should I manage an adult with a runny nose (rhinorrhea) due to a viral upper‑respiratory infection or allergic rhinitis, including symptomatic treatment and indications for bacterial sinusitis?

Managing a Runny Nose in Adults

For viral upper‑respiratory infection (the vast majority of cases), provide symptomatic relief with analgesics, saline nasal irrigation, and intranasal corticosteroids—antibiotics are never indicated. For bacterial sinusitis (diagnosed only when symptoms persist ≥10 days, are severe ≥3–4 days, or worsen after initial improvement), add amoxicillin‑clavulanate while continuing symptomatic measures. 1

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Step 1: Distinguish Viral Rhinosinusitis from Bacterial Sinusitis

Viral Rhinosinusitis (98–99.5% of Cases)

• Symptoms last <10 days with gradual improvement: nasal congestion, clear‑to‑cloudy discharge, sneezing, sore throat, mild facial pressure. 1
• No high fever (temperature <39°C / 102.2°F) and no severe unilateral facial pain. 1
• Colored nasal discharge alone does NOT indicate bacterial infection—color reflects neutrophils, not bacteria. 1
• Symptoms typically peak within 3 days and resolve within 7–10 days (up to 15 days in 7–13% of cases). 2, 3

Acute Bacterial Rhinosinusitis (ABRS)—Diagnose When ANY ONE Pattern Is Present

1. Persistent symptoms ≥10 days without improvement: purulent nasal discharge plus either nasal obstruction or facial pain/pressure/fullness. 1
2. Severe symptoms ≥3–4 consecutive days: fever ≥39°C with purulent discharge and facial pain at illness onset. 1
3. "Double sickening": initial improvement from a viral URI followed by new‑onset fever, worsening nasal discharge, or markedly increased cough within 10 days. 1, 4

Clinical clues favoring bacterial infection: unilateral maxillary tooth pain, facial pain worsening when bending forward, unilateral sinus tenderness on exam. 4

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Step 2: First‑Line Symptomatic Treatment (For ALL Patients—Viral or Bacterial)

Core Symptomatic Measures (Strong Evidence)

• Analgesics/antipyretics (acetaminophen or ibuprofen) for pain and fever control—pain relief is a major goal since discomfort is often the primary reason patients seek care. 1, 2, 3
• Saline nasal irrigation 2–3 times daily provides low‑risk relief of congestion, facilitates mucus clearance, and can be used multiple times daily. 1, 2, 3
• Intranasal corticosteroids (mometasone, fluticasone, or budesonide) twice daily reduce mucosal inflammation and provide modest symptom relief after 15 days of use (number needed to treat = 14); supported by strong evidence from multiple randomized controlled trials. 1, 5, 2, 3, 6

Additional Symptomatic Options

• Oral decongestants (pseudoephedrine) may provide relief but use with caution in patients with hypertension, cardiac arrhythmia, angina, cerebrovascular disease, bladder neck obstruction, glaucoma, or hyperthyroidism. 1, 2, 3
• Topical nasal decongestants (oxymetazoline) should be limited to ≤3–5 days to avoid rebound congestion (rhinitis medicamentosa). 1, 2, 3
• First‑generation antihistamines (brompheniramine) combined with decongestants may provide symptomatic relief through a drying effect, though evidence for efficacy specifically in viral rhinitis is limited. 1, 2
• Newer‑generation non‑sedating antihistamines (loratadine, cetirizine) are relatively ineffective for treating common cold symptoms and do not reduce rhinorrhea in viral infections. 2, 7
• Intranasal anticholinergics (ipratropium bromide nasal spray) effectively reduce rhinorrhea but have no effect on other nasal symptoms; minimal side effects (possible nasal membrane dryness). 2

What NOT to Do

• Never prescribe antibiotics for viral rhinosinusitis—they are completely ineffective for viral illness, do not provide direct symptom relief, add to treatment costs, put patients at risk of adverse events, and contribute to antimicrobial resistance. 1, 2, 3
• Systemic corticosteroids have not been shown effective for viral rhinosinusitis and should not be used. 1, 3
• Guaifenesin and dextromethorphan are commonly used, but evidence of clinical efficacy is lacking. 2

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Step 3: Antibiotic Therapy for Confirmed Bacterial Sinusitis

First‑Line Antibiotic (Adults Without β‑Lactam Allergy)

• Amoxicillin‑clavulanate 875 mg/125 mg orally twice daily for 5–10 days (or until symptom‑free for 7 consecutive days, typically 10–14 days total) provides 90–92% predicted clinical efficacy against Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. 1, 5, 7, 8
• High‑dose regimen (2 g/125 mg twice daily) is indicated when risk factors are present: recent antibiotic use (≤4–6 weeks), age >65 years, daycare exposure, moderate‑to‑severe symptoms, comorbidities (diabetes, chronic organ disease), or immunocompromised state. 1, 5

Alternatives for Penicillin Allergy

• Non‑severe (non‑Type I) allergy: second‑generation cephalosporin (cefuroxime‑axetil) or third‑generation cephalosporins (cefpodoxime‑proxetil, cefdinir, cefprozil) for 10 days; cross‑reactivity with penicillins is negligible (<1%). 1, 5, 8
• Severe (Type I/anaphylactic) allergy: respiratory fluoroquinolones—levofloxacin 500 mg once daily for 10–14 days or moxifloxacin 400 mg once daily for 10 days—both achieve 90–92% predicted efficacy against multidrug‑resistant S. pneumoniae and β‑lactamase‑producing organisms. 1, 5
• Doxycycline 100 mg once daily for 10 days offers lower efficacy (77–81%) and a 20–25% bacteriologic failure rate due to limited H. influenzae coverage; acceptable only when cephalosporins and fluoroquinolones are contraindicated. 1, 5

Antibiotics to Avoid

• Macrolides (azithromycin, clarithromycin): 20–25% resistance rates in S. pneumoniae and H. influenzae. 1, 5
• Trimethoprim‑sulfamethoxazole: ≈50% resistance in S. pneumoniae and ≈27% in H. influenzae. 1, 5
• First‑generation cephalosporins (cephalexin): inadequate because ≈50% of H. influenzae strains produce β‑lactamase. 1, 5

Watchful Waiting Option

• For adults with uncomplicated ABRS and reliable follow‑up, initial observation without antibiotics is appropriate; initiate antibiotics only if there is no improvement by day 7 or if symptoms worsen at any time. The number needed to treat (NNT) is 10–15 to achieve one additional cure compared with placebo. 1, 5

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Step 4: Monitoring, Reassessment, and Escalation

Early Reassessment (Days 3–5)

• If there is no clinical improvement (persistent purulent drainage, unchanged facial pain, or worsening), switch to high‑dose amoxicillin‑clavulanate 2 g/125 mg twice daily or a respiratory fluoroquinolone (levofloxacin or moxifloxacin). 1, 5

Day 7 Reassessment

• Persistent or worsening symptoms require: (1) confirmation of ABRS diagnosis, (2) exclusion of complications (orbital cellulitis, meningitis, intracranial abscess), (3) imaging (CT) only if complications are suspected, and (4) referral to an otolaryngologist. 1, 5

Expected Timeline of Recovery

• Noticeable improvement should occur within 3–5 days of appropriate therapy, with complete resolution by 10–14 days or when the patient is symptom‑free for 7 consecutive days. 1, 5

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Step 5: When to Refer to Otolaryngology

• No improvement after 7 days of appropriate second‑line antibiotic therapy. 1, 5
• Worsening symptoms at any point (increasing facial pain, fever, purulent drainage). 1, 5
• Suspected complications: severe headache, visual changes, periorbital swelling/erythema, proptosis, diplopia, altered mental status, cranial nerve deficits. 1, 5
• Recurrent sinusitis (≥3 episodes per year) requiring evaluation for underlying allergic rhinitis, immunodeficiency, or anatomic abnormalities. 1, 5, 9

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Common Pitfalls to Avoid

• Do not prescribe antibiotics for symptoms <10 days unless severe features (fever ≥39°C with purulent discharge for ≥3 consecutive days) are present. 1, 4
• Avoid routine imaging (X‑ray or CT) for uncomplicated acute rhinosinusitis; up to 87% of viral URIs show sinus abnormalities on imaging, leading to unnecessary interventions. 1, 4
• Ensure adequate treatment duration (≥5 days for adults, ≥10 days for children) to prevent relapse. 1, 5
• Fluoroquinolones should not be used as first‑line therapy in patients without documented β‑lactam allergy to limit resistance development. 1, 5
• Gastrointestinal adverse effects with amoxicillin‑clavulanate are common: diarrhea in 40–43% of patients, severe diarrhea in 7–8%. 1, 5
• Prolonged use of topical decongestants beyond 3–5 days can lead to rebound congestion. 1, 2, 3
• Underutilizing simple measures like saline irrigation and adequate hydration can deprive patients of significant relief. 2, 3

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Special Populations

• Children <3 years: avoid decongestants and antihistamines; focus on saline irrigation and analgesics. 2, 3
• Patients with chronic conditions (asthma, COPD): monitor closely for symptom progression and consider earlier intervention if respiratory status deteriorates. 3, 9
• Pregnant patients: doxycycline is contraindicated; use cephalosporins or fluoroquinolones with caution. 5

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Patient Education

• Viral rhinosinusitis typically resolves within 7–10 days (up to 15 days in some cases) without antibiotics. 2, 3
• Return precautions: instruct patients to return if symptoms worsen or fail to improve within 3–5 days of treatment, if high fever develops or persists, or if severe headache, facial swelling, or visual changes occur. 3
• Intranasal corticosteroids may start to provide relief the first day but take several days to build up to full effectiveness; use regularly once daily for lasting relief. 6
• Fluticasone propionate nasal spray does not cause a "rebound effect" and can be used for up to 6 months (age ≥12 years) or up to 2 months per year (age 4–11 years) before checking with a doctor. 6