What is the first-line treatment for acute sinusitis in pediatric patients?

From the Guidelines

The first line treatment for acute sinusitis in pediatrics is supportive care, including adequate hydration, analgesics for pain relief, and saline nasal irrigation, with antibiotics reserved for severe, worsening, or persistent cases. When antibiotics are indicated, amoxicillin alone or in combination with clavulanate is the first-line antibiotic choice 1. The dosage of amoxicillin can range from 45-90 mg/kg/day divided into two doses for 10-14 days. For children with penicillin allergy, alternatives include cefdinir, cefuroxime, or cefpodoxime 1. Some key points to consider in the management of acute sinusitis in pediatrics include:

• The diagnosis of acute bacterial sinusitis is made when a child presents with persistent illness, worsening course, or severe onset 1.
• Antibiotics should be prescribed in children with severe, worsening, or persistent acute bacterial sinusitis 1.
• Amoxicillin with or without clavulanate is the first-line treatment of acute bacterial sinusitis 1.
• The optimal duration of antimicrobial therapy for patients with acute bacterial sinusitis has not received systematic study, but recommendations based on clinical observations have varied widely, from 10 to 28 days of treatment 1.
• Patients who are acutely ill and appear toxic when first seen can be managed with intravenous cefotaxime or ceftriaxone, with referral to an otolaryngologist if the patient’s condition worsens or fails to show improvement within 48 hours 1. It's essential to note that most cases of acute sinusitis in children are viral in origin and resolve spontaneously within 7-10 days, and unnecessary antibiotic use contributes to bacterial resistance and exposes children to potential side effects without clinical benefit.

From the FDA Drug Label

The recommended dose of azithromycin for oral suspension for the treatment of pediatric patients with acute bacterial sinusitis is 10 mg/kg once daily for 3 days. The first line treatment for acute sinusitis in pediatrics is azithromycin at a dose of 10 mg/kg once daily for 3 days 2.

• Key points:
  • The dosage is based on the patient's weight.
  • The treatment duration is 3 days.
  • Azithromycin can be taken with or without food.

From the Research

Diagnosis and Treatment of Acute Sinusitis in Pediatrics

• The diagnosis of acute bacterial sinusitis is mainly clinical and based on stringent criteria, including persistent symptoms and signs of a URI beyond 10 days, without appreciable improvement 3.
• The routine use of roentgenograms to confirm the diagnosis of uncomplicated sinusitis is not recommended for children 6 years or younger but may be considered for children older than 6 years 4.

First Line Treatment

• Amoxicillin-clavulanate, at a standard dose of 45 mg/kg/day orally, is the drug of choice for most cases of uncomplicated ABS in children in whom antibacterial resistance is not suspected 3.
• Alternatively, oral amoxicillin 90 mg/kg/day can be administered 3.
• For those with severe ABS or uncomplicated acute sinusitis who are at risk for severe disease or antibiotic resistance, oral high-dose amoxicillin-clavulanate (90 mg/kg/day) is the drug of choice 3.
• Azithromycin in single daily dose of 10 mg/kg during three days showed same efficiency as amoxicillin-clavulanate given three times per day in dose of 45 mg/kg during ten days 5.

Considerations

• The current rates of antimicrobial resistance among commonly implicated pathogens should be considered in therapeutic decisions 6.
• Haemophilus influenzae (non-typeable), Streptococcus pneumoniae, and Moraxella catarrhalis are the major pathogens in uncomplicated ABS in otherwise healthy children 3.
• In complicated ABS, polymicrobial infections are common 3.