What is the treatment for pediatric sinusitis?

From the Guidelines

The treatment for pediatric sinusitis typically involves a combination of supportive care and, in some cases, antibiotics, with amoxicillin being the first-line antibiotic choice, as recommended by the American Academy of Pediatrics 1.

Key Considerations

• For mild cases, supportive measures include adequate hydration, saline nasal sprays or irrigation, and pain relievers such as acetaminophen or ibuprofen.
• Nasal decongestants may provide temporary relief but should not be used for more than 3 days to avoid rebound congestion.
• For bacterial sinusitis, amoxicillin is typically prescribed at 45-90 mg/kg/day divided into two doses for 10-14 days.
• For children with penicillin allergies or in areas with high resistance rates, alternatives include amoxicillin-clavulanate (40 mg/kg/day of amoxicillin component), cefdinir, cefuroxime, or, in severe cases, clindamycin.

Management Approach

• Children with severe symptoms, high fever, facial swelling, or who appear toxic should be evaluated promptly for possible complications requiring hospitalization.
• Children who fail to improve after 48-72 hours of initial therapy may need to switch antibiotics.
• Chronic sinusitis may require longer antibiotic courses (3-4 weeks) and possibly referral to an ENT specialist.

Rationale

• Most cases of pediatric sinusitis are viral and self-limiting, but bacterial infections require antibiotics to prevent complications such as orbital or intracranial spread of infection.
• The choice of antibiotic should be guided by the severity of the illness, the presence of underlying conditions, and the likelihood of resistance, as outlined in the clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years 1.

From the FDA Drug Label

Safety and effectiveness in the treatment of pediatric patients with acute bacterial sinusitis under 6 months of age have not been established Use of azithromycin for the treatment of acute bacterial sinusitis in pediatric patients (6 months of age or greater) is supported by adequate and well-controlled studies in adults, similar pathophysiology of acute sinusitis in adults and pediatric patients, and studies of acute otitis media in pediatric patients Use of cefdinir for the treatment of acute maxillary sinusitis in pediatric patients (age 6 months through 12 years) is supported by evidence from adequate and well-controlled studies in adults and adolescents, the similar pathophysiology of acute sinusitis in adult and pediatric patients, and comparative pharmacokinetic data in the pediatric population

The treatment for pediatric sinusitis includes:

• Azithromycin: for pediatric patients 6 months of age or greater, with a dosage regimen of 10 mg/kg on Days 1 to 3 2
• Cefdinir: for pediatric patients 6 months through 12 years, with evidence from adequate and well-controlled studies in adults and adolescents 3 Key considerations:
• Safety and effectiveness have not been established for pediatric patients under 6 months of age for both azithromycin and cefdinir
• Dosage regimens and administration should follow the recommended guidelines for each medication

From the Research

Diagnosis of Pediatric Sinusitis

• 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 4
• Imaging studies may be necessary to confirm a diagnosis of acute bacterial sinusitis in children >6 years of age 5
• The following diagnostic criteria are utilized: persistent nasal congestion/cough lasting >10 days, worsening of classic viral URI symptoms at days 5-7, and severe onset and purulent nasal discharge for at least 3 consecutive days 6

Treatment of Pediatric Sinusitis

• Amoxicillin is customarily used as first-line therapy for uncomplicated acute bacterial rhinosinusitis 7
• For patients who are allergic to amoxicillin, second- or third-generation oral cephalosporins may be used as first-line therapy 7
• High-dose amoxicillin-clavulanate (90 mg/kg/d of the amoxicillin component) has been recommended for high-risk children who show no improvement after treatment with the usual dose of amoxicillin (45 mg/kg/d) 7, 4
• The optimal duration of therapy is unknown, but some recommend treatment until the patient becomes free of symptoms and then for an additional 7 d 8
• Typical length of antibiotic therapy for providers is 10 days and 14 days, with ENT providers prescribing 7 days past any symptom 6

Antibiotic Options

• 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 4
• Oral amoxicillin 90 mg/kg/day can be administered as an alternative 4
• Cefdinir, cefpodoxime, and cefuroxime are also considered appropriate for the initial treatment of acute bacterial rhinosinusitis in children 7, 8
• Clarithromycin and azithromycin may be prescribed in cases of serious drug allergy 8, 6