What is the treatment for bacterial sinusitis (bacterial sinus infection) in children?

Treatment of Bacterial Sinusitis in Children

Amoxicillin with or without clavulanate is the first-line treatment for bacterial sinusitis in children, with dosing adjusted based on risk factors for resistant organisms. 1

Diagnosis and Classification

• Bacterial sinusitis can be diagnosed in children when an upper respiratory infection presents with one of three patterns:
  • Persistent illness: nasal discharge or daytime cough lasting >10 days without improvement 1
  • Worsening course: worsening or new onset of nasal discharge, daytime cough, or fever after initial improvement 1
  • Severe onset: concurrent fever ≥39°C/102.2°F and purulent nasal discharge for at least 3 consecutive days 1

First-Line Antibiotic Treatment

• Standard-dose amoxicillin (45 mg/kg/day in 2 divided doses) is appropriate for uncomplicated cases in communities with low antimicrobial resistance 2, 3
• High-dose amoxicillin or amoxicillin-clavulanate (80-90 mg/kg/day of amoxicillin component with 6.4 mg/kg/day of clavulanate in 2 divided doses) is recommended for:
  • Children younger than 2 years 2, 4
  • Children attending daycare 2, 4
  • Children who have received antibiotics within the previous 4-6 weeks 2, 4
  • Communities with high prevalence of resistant S. pneumoniae 2, 4

Treatment Approach Based on Clinical Presentation

• For severe or worsening acute bacterial sinusitis: antibiotic therapy is always recommended 1
• For persistent acute bacterial sinusitis: either antibiotic therapy or additional observation for 3 days can be considered, with shared decision-making based on symptom severity 1
• For any bacterial sinusitis with orbital or intracranial complications: immediate antibiotic therapy is required 1
• For bacterial sinusitis with coexisting conditions (acute otitis media, pneumonia, adenitis, streptococcal pharyngitis): antibiotic therapy is recommended 1

Alternative Antibiotic Options

• For children with penicillin allergy:
  • Cefdinir, cefuroxime, or cefpodoxime are recommended alternatives 1, 3
  • Clindamycin may be appropriate for penicillin-resistant S. pneumoniae 5
• For children who cannot tolerate oral medication or who are vomiting:
  • A single dose of ceftriaxone 50 mg/kg intramuscularly or intravenously can be given 1, 4
  • After clinical improvement, switch to oral therapy to complete the course 4

Duration of Treatment

• The recommended duration is 10-14 days for most cases 3, 6
• Some experts recommend continuing treatment until the patient is symptom-free for an additional 7 days 2, 7

Monitoring Response and Treatment Failure

• Clinical improvement should be assessed at 72 hours after starting treatment 1, 3
• If no improvement is seen after 72 hours, consider:
  • Changing to a different antibiotic 3
  • Initiating antibiotics if initially managed with observation 1
  • Reevaluating the diagnosis 4

Common Pathogens and Resistance Considerations

• Major pathogens in pediatric bacterial sinusitis include:
  • Streptococcus pneumoniae (30-66% of cases) 5, 6
  • Haemophilus influenzae (20-30% of cases) 5, 6
  • Moraxella catarrhalis (12-28% of cases) 5, 6
• Resistance patterns include:
  • 10-15% of S. pneumoniae isolates being nonsusceptible to penicillin 2
  • 10-42% of H. influenzae and nearly 100% of M. catarrhalis being β-lactamase positive 2
• Trimethoprim/sulfamethoxazole and azithromycin should not be used due to high resistance rates 1

Important Clinical Considerations

• Imaging studies (radiography, CT, MRI, ultrasound) should not be performed to diagnose uncomplicated bacterial sinusitis 1
• Contrast-enhanced CT or MRI should be obtained when orbital or central nervous system complications are suspected 1
• Intranasal corticosteroids may be beneficial as adjunctive therapy to antibiotics 3
• Short courses of systemic corticosteroids may be considered for cases with marked mucosal edema or in those who fail to respond to initial treatment 3, 8