Management of Sore Throat, Sinus Congestion, and Cough

Do NOT Prescribe Antibiotics for This Presentation

This clinical picture—sore throat with cough and nasal congestion—is viral in >98% of cases and antibiotics provide no benefit while causing harm. 1

Patients presenting with sore throat plus cough, nasal congestion, conjunctivitis, hoarseness, diarrhea, or oropharyngeal lesions have a viral illness and should not receive antibiotics or further testing. 1
The presence of cough is a negative predictor for Group A Streptococcus (the only bacterial pathogen requiring antibiotics in pharyngitis), making bacterial infection highly unlikely. 1, 2, 3
Most acute rhinosinusitis (98–99.5%) is viral and resolves spontaneously within 7–10 days without antibiotics. 4, 5

Diagnostic Criteria: When Antibiotics Are Actually Indicated

For Pharyngitis (Strep Throat)

Use the Modified Centor Criteria to determine who needs testing:

Fever by history
Tonsillar exudates
Tender anterior cervical adenopathy
Absence of cough 1, 2, 3

If <3 criteria are present: Do NOT test or treat—manage symptomatically only. 2, 3

If ≥3 criteria are present: Perform rapid antigen detection test (RADT) or throat culture; prescribe antibiotics only if positive. 1, 2, 3

For Bacterial Sinusitis

Antibiotics are indicated only when one of these three patterns is met:

Persistent symptoms ≥10 days without improvement (purulent nasal discharge plus obstruction or facial pain/pressure) 4, 5
Severe symptoms ≥3–4 consecutive days with fever ≥39°C, purulent discharge, and facial pain 4, 5
"Double sickening": initial improvement from a viral URI followed by worsening within 10 days 4, 5

Your patient does not meet any of these criteria.

Recommended Symptomatic Management (First-Line for This Patient)

Analgesics and Antipyretics

Acetaminophen, ibuprofen, or aspirin for pain and fever control 1, 2, 3
Throat lozenges for local relief 1, 2

Nasal Symptoms

Saline nasal irrigation 2–3 times daily to clear mucus and reduce congestion 4, 5
Intranasal corticosteroids (mometasone, fluticasone, or budesonide) twice daily to reduce mucosal inflammation; supported by strong evidence from multiple RCTs 4
Oral or topical decongestants (pseudoephedrine or oxymetazoline); limit topical agents to ≤3 days to avoid rebound congestion 4

Patient Education

Reassure the patient that typical viral sore throat and rhinosinusitis resolve in <7–10 days without antibiotics. 1, 2, 5
Provide return precautions: seek re-evaluation if symptoms persist beyond 10 days, worsen after initial improvement, or if severe features develop (high fever ≥39°C for ≥3 days, severe unilateral facial pain, difficulty swallowing, drooling, neck swelling). 1, 4, 2

Why Azithromycin (or Any Antibiotic) Is Inappropriate Here

Azithromycin is NOT first-line even for confirmed Group A Streptococcus pharyngitis; it is reserved only for patients with documented penicillin allergy. 2, 3
Over 60% of adults with sore throat receive unnecessary antibiotic prescriptions despite most cases being viral. 2
Antibiotics for viral illness cause harm (diarrhea in 40–43% of patients, allergic reactions, antimicrobial resistance) without providing benefit. 1, 4
The modest benefit of antibiotics for confirmed bacterial pharyngitis (1–2 days symptom reduction, NNT=6 at day 3) does not justify empiric therapy without testing. 2, 3

If Bacterial Infection Is Later Confirmed

For Group A Streptococcal Pharyngitis (if RADT/culture positive)

First-line: Penicillin V 250–500 mg PO twice or three times daily for 10 days 2, 3, 6
Alternative (if penicillin allergy): Cephalosporins (cefuroxime, cefpodoxime) or macrolides (azithromycin, erythromycin) 2, 3, 6

For Acute Bacterial Sinusitis (if criteria met after 10 days)

First-line: Amoxicillin-clavulanate 875 mg/125 mg PO twice daily for 5–10 days 4, 7
Alternative (if penicillin allergy):
- Non-severe allergy: Second- or third-generation cephalosporins (cefuroxime, cefpodoxime, cefdinir) for 10 days 4, 7
- Severe (anaphylactic) allergy: Respiratory fluoroquinolones (levofloxacin 500 mg once daily for 10–14 days or moxifloxacin 400 mg once daily for 10 days) 4, 7

Critical Pitfalls to Avoid

Do NOT prescribe antibiotics based on purulent nasal discharge alone—this reflects neutrophilic inflammation common to viral disease, not bacterial infection. 4, 5
Do NOT prescribe antibiotics for symptoms <10 days unless severe features (fever ≥39°C with purulent discharge for ≥3 consecutive days) are present. 4, 5
Do NOT obtain imaging (X-ray or CT) for uncomplicated acute rhinosinusitis; up to 87% of viral URIs show sinus abnormalities on imaging, leading to unnecessary interventions. 4
Do NOT use azithromycin empirically—it has no role in viral illness and is not first-line even for bacterial pharyngitis. 2, 8, 3

Red Flags Requiring Urgent Evaluation

Refer immediately if any of the following develop:

Difficulty swallowing, drooling, or neck tenderness/swelling (peritonsillar abscess, epiglottitis, Lemierre syndrome) 1, 2
Severe headache, visual changes, periorbital swelling, altered mental status (orbital cellulitis, meningitis, intracranial abscess) 4, 7
Unilateral tonsillar bulge with uvular deviation 2
Severe pharyngitis in adolescents/young adults (consider Fusobacterium necrophorum) 1, 2

What antibiotic is appropriate for an adult with acute pharyngitis, sinusitis, and cough?

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