What is the next step in managing a pediatric patient with a history of upper respiratory tract infection (URTI) presenting with fever, frontal tenderness, and purulent discharge after 3 days of runny nose?

Management of Acute Bacterial Sinusitis in a Pediatric Patient

Start amoxicillin immediately (Option B). This pediatric patient meets the diagnostic criteria for severe-onset acute bacterial sinusitis, which mandates antibiotic therapy rather than observation or symptomatic management alone.

Diagnostic Criteria Met

This patient fulfills the severe-onset acute bacterial sinusitis criteria defined by the American Academy of Pediatrics:

• Fever ≥39°C (102.2°F) for at least 3 consecutive days 1
• Purulent (thick, colored, opaque) nasal discharge present concurrently 1
• Frontal tenderness indicating sinus involvement 1
• Duration of 3 days following URTI symptoms 1

The AAP explicitly states that this presentation "is not consistent with the well-documented pattern of acute viral URI" and therefore represents bacterial infection requiring treatment 1.

Why Antibiotics Are Mandatory (Not Optional) in This Case

Severe-onset acute bacterial sinusitis requires immediate antibiotic therapy, not observation 1. The AAP guidelines distinguish three presentations:

• Persistent symptoms (>10 days): Antibiotics OR observation for 3 additional days may be offered 1
• Severe-onset (this patient): Antibiotic therapy is mandatory 1
• Worsening course: Antibiotic therapy is mandatory 1

The rationale for mandatory treatment in severe cases includes 1:

• Higher bacterial density presumed in severe presentations
• Theoretically higher risk of suppurative complications (orbital cellulitis, intracranial abscess)
• Number needed to treat of 3-5 children for clinical cure 1

First-Line Antibiotic Selection

Amoxicillin (with or without clavulanate) is the first-line treatment 1:

• The AAP Key Action Statement 4 explicitly recommends amoxicillin as first-line therapy when antibiotics are indicated 1
• Targets the major bacterial pathogens: Streptococcus pneumoniae (30%), nontypeable Haemophilus influenzae (20%), and Moraxella catarrhalis (20%) 1
• FDA-approved for upper respiratory tract infections including sinusitis 2

Dosing for severe infection 2:

• 45 mg/kg/day divided every 12 hours OR
• 40 mg/kg/day divided every 8 hours
• Continue for 10-14 days 1, 2

Why Other Options Are Incorrect

Option A (CT scan): Imaging is not required for diagnosis of uncomplicated acute bacterial sinusitis 1, 3. CT is reserved for:

• Suspected orbital or intracranial complications 1
• Patients with altered mental status, severe headache, or proptosis 1
• Treatment failures requiring surgical evaluation 1

Option C (Reassurance alone): Inappropriate because severe-onset presentation mandates antibiotic therapy, not watchful waiting 1. Observation is only acceptable for persistent (not severe) presentations 1.

Option D (Ibuprofen alone): While symptomatic treatment with antipyretics is appropriate as adjunctive therapy 1, it cannot replace antibiotics in severe bacterial sinusitis 1. Ibuprofen addresses fever and pain but does not treat the underlying bacterial infection.

Adjunctive Measures

While starting amoxicillin, also provide 1, 3:

• Antipyretics (ibuprofen or acetaminophen) for fever and pain relief 1
• Intranasal saline irrigation may alleviate symptoms 1
• Intranasal corticosteroids may be helpful as adjunct 1
• Avoid antihistamines unless concurrent allergic rhinitis is present 1

Follow-Up and Safety Net

Reassess in 3-5 days 1:

• If no improvement, consider switching to high-dose amoxicillin-clavulanate 1
• If worsening or development of orbital signs (periorbital swelling, proptosis, impaired extraocular movements), obtain urgent CT and consider hospitalization 1

Return precautions 3:

• Worsening symptoms at any time
• Development of orbital swelling, vision changes, or severe headache
• Persistent fever beyond 48-72 hours of antibiotic therapy

Common Pitfalls to Avoid

• Do not delay antibiotics in severe-onset presentations while "observing" - this increases risk of complications 1
• Do not rely on imaging for diagnosis in straightforward cases - clinical criteria are sufficient 1, 3
• Do not use broad-spectrum antibiotics (like amoxicillin-clavulanate) as first-line unless risk factors for resistance exist 1
• Do not confuse this with persistent sinusitis (>10 days mild symptoms), which allows observation as an option 1