What is the treatment for sinusitis in a 12-year-old?

Treatment of Sinusitis in a 12-Year-Old

For a 12-year-old with acute bacterial sinusitis, initiate amoxicillin 45 mg/kg/day (divided twice daily) for 10-14 days as first-line therapy, reserving high-dose amoxicillin-clavulanate (90 mg/kg/day) for severe cases, treatment failures, or high-risk patients. 1

Confirming the Diagnosis

Before initiating antibiotics, ensure the diagnosis meets criteria for acute bacterial sinusitis rather than a simple viral upper respiratory infection 2:

• Persistent pattern: Nasal discharge or daytime cough lasting ≥10 days without improvement 2
• Severe pattern: Fever ≥39°C (102.2°F) for ≥3 consecutive days with thick, colored nasal discharge 2
• Worsening pattern: Initial improvement from a viral cold followed by new fever (≥38°C) or substantially increased cough/nasal discharge 2

Fewer than 1 in 15 children with cold symptoms actually develop bacterial sinusitis 2.

First-Line Antibiotic Selection

Amoxicillin remains the preferred first-line agent due to its effectiveness against Streptococcus pneumoniae, favorable safety profile, and low cost 1, 3:

• Standard dose: 45 mg/kg/day divided twice daily (maximum 1.5-4 g/day) 1
• Duration: 10-14 days 1, 2

For children with persistent symptoms (the most common presentation), you may choose either immediate antibiotic therapy or an additional 3-day observation period, depending on symptom severity and quality of life impact 2. However, all children with severe or worsening patterns should receive immediate antibiotics 2.

High-Risk Situations Requiring Amoxicillin-Clavulanate

Use high-dose amoxicillin-clavulanate (90 mg/kg/day of amoxicillin component) as first-line therapy for 1, 2:

• Recent antibiotic use (within 30 days)
• Daycare attendance
• Age <2 years
• Geographic areas with high rates of resistant S. pneumoniae or H. influenzae
• Severe presentation requiring immediate coverage of β-lactamase-producing organisms

The French guidelines also recommend amoxicillin-clavulanate, second-generation cephalosporins (cefuroxime-axetil), or third-generation cephalosporins (cefpodoxime-proxetil) as first-line options 2.

Treatment Failure Management

Reassess at 72 hours 1, 2. If symptoms worsen or fail to improve:

• Switch to high-dose amoxicillin-clavulanate (90 mg/kg/day) if not already prescribed 1
• Alternative second-line options include cefpodoxime-proxetil (8 mg/kg/day in two doses) 2 or cefuroxime-axetil 2
• Consider intramuscular ceftriaxone for severe cases or compliance issues 1

The 72-hour checkpoint is critical because continued deterioration suggests either resistant organisms or complications requiring more aggressive intervention 2, 1.

Adjunctive Therapies

Recommended adjuncts to improve symptoms and quality of life 1:

• Saline nasal irrigation: Promotes drainage and removes debris 2, 1
• Analgesics/antipyretics: For pain and fever management 1
• Intranasal corticosteroids: May reduce ostial inflammation and promote drainage, though evidence in children is limited 2, 1

Avoid the following due to insufficient evidence or potential harm 2, 1:

• Antihistamines (unless concurrent allergic rhinitis is present) 2
• Oral or topical decongestants 2, 1
• Mucolytics 2, 1

Critical Warning Signs Requiring Urgent Evaluation

Immediately refer for imaging and possible hospitalization if any of these complications develop 2, 1:

• Periorbital or orbital swelling/cellulitis
• Proptosis or impaired extraocular movements
• Severe headache with photophobia
• Altered mental status or seizures
• Visual changes
• Focal neurological signs
• High fever unresponsive to antipyretics

Orbital and intracranial complications, though uncommon, carry significant morbidity and mortality risk 2.

Special Considerations for Penicillin Allergy

For patients with penicillin allergy 2, 3:

• Cephalosporins: Cefpodoxime-proxetil or cefuroxime-axetil (if no history of severe/immediate hypersensitivity) 2
• Macrolides: Azithromycin or clarithromycin (though resistance is increasing) 3
• Clindamycin: Consider for suspected anaerobic involvement 3

Duration and Follow-Up

Standard treatment duration is 10-14 days 1, 2, though some sources suggest treating for 7 days after symptom resolution to individualize therapy while ensuring at least 10 days total 2. The American Academy of Pediatrics guidelines emphasize that shorter courses (5 days) with certain cephalosporins have shown efficacy in adults but lack pediatric validation 2.