Acute Nasopharyngitis in Pediatric Patients
Primary Recommendation
Antibiotics should NOT be prescribed for acute nasopharyngitis (common cold) in children, as this is a viral illness that resolves spontaneously and antibiotic use provides no benefit while increasing risks of adverse effects and antimicrobial resistance. 1
Distinguishing Viral Nasopharyngitis from Bacterial Complications
The critical first step is determining whether the child has uncomplicated viral nasopharyngitis or has developed a bacterial complication requiring antibiotics:
Uncomplicated Viral Nasopharyngitis (Common Cold)
- Clear to cloudy nasal discharge that typically improves by 10 days 1
- Low-grade fever for 1-2 days 1
- Cough and congestion without worsening 1
- Management: Symptomatic relief only—NO antibiotics 1
Bacterial Complications Requiring Antibiotics
Acute Bacterial Sinusitis is diagnosed when symptoms meet one of three patterns 1:
- Persistent symptoms (most common): Nasal discharge or daytime cough lasting ≥10 days without improvement 1
- Worsening symptoms: New or worsening fever, cough, or nasal discharge after initial improvement from a viral URI 1
- Severe symptoms: Fever ≥39°C (102.2°F) with purulent nasal discharge for ≥3 consecutive days 1
Treatment Algorithm for Acute Bacterial Sinusitis
First-Line Antibiotic Therapy
For children ≥2 years with mild-to-moderate disease, no recent antibiotics (past 4-6 weeks), and not in daycare:
- Amoxicillin 45 mg/kg/day divided twice daily 1
- In communities with high penicillin-resistant S. pneumoniae prevalence (>10%), use amoxicillin 80-90 mg/kg/day divided twice daily (maximum 2 g/dose) 1
For children <2 years, moderate-to-severe illness, recent antibiotic use, or attending daycare:
- High-dose amoxicillin-clavulanate 90 mg/kg/day of amoxicillin component with 6.4 mg/kg/day clavulanate, divided twice daily (maximum 2 g/dose) 1
Alternative Options for Penicillin Allergy
For non-Type I hypersensitivity reactions:
- Cefdinir, cefuroxime axetil, or cefpodoxime proxetil 1
- Recent evidence shows cross-reactivity risk with second- and third-generation cephalosporins is negligible 1
For Type I immediate hypersensitivity reactions:
- These agents have limited effectiveness with 20-25% bacterial failure rates 1
- Options include clindamycin (if S. pneumoniae confirmed) or levofloxacin (in select cases) 1
- Avoid azithromycin and TMP-SMX due to high resistance rates 1
Special Circumstances
For children unable to tolerate oral medications or unlikely to be adherent:
- Ceftriaxone 50 mg/kg IM/IV as single dose 1
- Switch to oral therapy after 24 hours if clinical improvement observed 1
Duration of Therapy
- Treat for 7 days after symptom resolution, with a minimum of 10 days total 1
- This individualized approach prevents prolonged unnecessary antibiotic exposure 1
Reassessment Criteria
Reassess within 72 hours if:
- Worsening symptoms (progression of initial signs or new symptoms) 1
- No improvement (lack of reduction in presenting symptoms) 1
If treatment failure at 72 hours:
- Switch to high-dose amoxicillin-clavulanate if initially on amoxicillin alone 1
- Consider respiratory fluoroquinolone or ceftriaxone for persistent failure 1
- Reevaluate diagnosis—may need imaging or ENT consultation 1
Critical Pitfalls to Avoid
- Do not prescribe antibiotics for viral nasopharyngitis symptoms alone—this includes runny nose, cough, and congestion without meeting bacterial sinusitis criteria 1
- Do not use imaging (X-ray, CT, MRI) to distinguish viral from bacterial infection in uncomplicated cases 1
- Do not use azithromycin or TMP-SMX as first-line therapy due to high resistance rates of S. pneumoniae and H. influenzae 1
- Watchful waiting for 3 additional days is acceptable for persistent symptoms in children >2 years with good quality of life 1