What is the recommended treatment for infant sinusitis?

Treatment of Infant Sinusitis

For infants with sinusitis, antibiotics should be prescribed if the child has persistent symptoms (nasal discharge or cough for at least 10 days without improvement) or severe symptoms (high fever ≥39°C/102.2°F with purulent nasal discharge for ≥3 consecutive days). 1, 2

Diagnosis Criteria

Acute bacterial sinusitis in infants should be diagnosed based on one of the following clinical presentations:

• Persistent illness: Nasal discharge of any quality or cough (or both) for at least 10 days without evidence of improvement
• Severe illness: High fever (≥39°C/102.2°F) with purulent nasal discharge for at least 3 consecutive days
• Worsening illness: Initial improvement followed by worsening symptoms ("double-sickening")

Antibiotic Treatment

First-line therapy:

• Amoxicillin-clavulanate is the recommended first-line treatment 2, 3
  • Standard dose: 45 mg/kg/day divided in two doses for 5-7 days
  • High-dose: 90 mg/kg/day of amoxicillin component for high-risk infants (those in daycare or who have recently received antibiotics) 2, 4

For penicillin-allergic patients:

• Cefdinir, cefpodoxime, or cefuroxime are appropriate alternatives 2, 4
• For true penicillin allergy with anaphylaxis, consider azithromycin 10 mg/kg once daily for 3 days 3

Dosing for infants with acute bacterial sinusitis:

Based on weight 3:

• For 5 kg infant: 2.5 mL of 100 mg/5 mL suspension daily for 3 days
• For 10 kg infant: 5 mL of 100 mg/5 mL suspension daily for 3 days

Management Approach

1. For persistent symptoms (≥10 days without improvement):

   • Either prescribe antibiotics OR
   • Offer additional observation for 3 days 1

2. For severe symptoms (high fever with purulent discharge for ≥3 days):

   • Immediate antibiotic therapy is recommended 1, 2

3. Treatment failure:

   • If no improvement after 72 hours of therapy, consider:
     • Switching to a broader-spectrum antibiotic
     • Reevaluating the diagnosis
     • Specialist referral 2

Adjunctive Treatments

• Saline nasal irrigation is beneficial and safe for symptom relief 2
• Adequate hydration to thin mucus secretions
• Acetaminophen or ibuprofen for pain and fever control
• Intranasal corticosteroids may help reduce inflammation, though evidence in infants is limited 2

Warning Signs for Complications

Urgent medical attention is needed if the infant develops:

• Eye swelling or impaired extraocular muscle function
• Persistent high fever despite antibiotics
• Severe headache or altered mental status
• Worsening symptoms after initial improvement 1

Important Considerations

• European guidelines note that antibiotics do not significantly reduce symptoms in post-viral rhinosinusitis and have more adverse events 1
• However, American guidelines recommend antibiotics for persistent or severe symptoms in children 1, 2
• The benefit-to-harm assessment favors antibiotic use in infants with clear signs of bacterial sinusitis, as the number needed to treat is 3-5 1
• Complications of sinusitis, though rare, can be serious in infants, particularly orbital complications in those under 5 years 1

Remember to reassess the infant after 3-5 days of treatment to determine if the current therapy is effective or if adjustments are needed.