What is the recommended treatment for a pediatric patient with a sinus infection?

Treatment of Pediatric Sinus Infections

For children with acute bacterial sinusitis, amoxicillin 45 mg/kg/day (up to 90 mg/kg/day for high-risk cases) for 10-14 days is the first-line treatment, but watchful waiting for 3 days is appropriate for persistent mild symptoms, while severe or worsening presentations require immediate antibiotic therapy. 1

Distinguishing Bacterial Sinusitis from Viral Upper Respiratory Infection

Before treating, confirm the diagnosis using one of three clinical patterns 2, 1:

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

Critical caveat: Fewer than 1 in 15 children develop true bacterial sinusitis after a common cold—thick, colored mucus alone does not indicate bacterial infection 2, 4

First-Line Antibiotic Therapy

Amoxicillin is the preferred initial antibiotic due to effectiveness against Streptococcus pneumoniae, favorable safety profile, and low cost 1:

• Standard dose: 45 mg/kg/day divided twice daily for 10-14 days 1
• High-dose: 90 mg/kg/day for high-risk patients (recent antibiotic use, daycare attendance, age <2 years, or geographic areas with high resistance) 1

Alternative for treatment failure or penicillin allergy (non-type 1 hypersensitivity): Amoxicillin-clavulanate 90 mg/kg/day 2, 1

For type 1 penicillin hypersensitivity: Cefdinir, cefuroxime, or cefpodoxime 2

Avoid trimethoprim/sulfamethoxazole and azithromycin due to high resistance rates among S. pneumoniae and H. influenzae 2, 5

Watchful Waiting vs. Immediate Treatment

For persistent pattern with mild symptoms: Either immediate antibiotics OR watchful waiting for up to 3 additional days is acceptable 2, 1. This decision should consider:

• Quality of life impact on the child and family 2
• Symptom severity 2
• Parental preference after discussing risks/benefits of antibiotics 2

For severe or worsening patterns: Immediate antibiotic treatment is mandatory to achieve faster recovery and prevent complications 2, 1

Monitoring and Treatment Failure

Reassess at 72 hours 2, 1:

• If worsening or no improvement: Switch to high-dose amoxicillin-clavulanate (90 mg/kg/day) 1
• If already on amoxicillin-clavulanate: Consider second-line cephalosporins or intramuscular ceftriaxone 1

Adjunctive Therapies

Recommended adjuncts to improve symptoms and quality of life 1:

• Saline nasal irrigation (not just spray): Improves nasal airflow, quality of life, and symptom scores 2, 4, 6
• Analgesics/antipyretics for symptom relief 1
• Intranasal corticosteroids: May reduce ostial swelling and promote drainage, though data in children are limited 2, 1

Avoid these interventions due to insufficient evidence or potential harm 2, 1:

• Oral or topical decongestants
• Oral or nasal antihistamines (unless concurrent allergic rhinitis)
• Mucolytics

Important exception: Antihistamines may help children with documented atopy and concurrent allergic symptoms, but should not be used solely for sinusitis 2

Red Flags Requiring Urgent Evaluation

Immediately evaluate for complications if any of these are present 2, 1:

• Periorbital or orbital swelling/cellulitis, proptosis, or impaired extraocular movements (orbital complications)
• Severe headache, photophobia, seizures, altered mental status, or focal neurologic signs (intracranial complications)
• High fever unresponsive to antipyretics
• Visual changes

These complications require contrast-enhanced CT or MRI, possible hospitalization, and intravenous antibiotics 2

Duration of Treatment

Treat for 10-14 days total, or alternatively, continue for 7 days after symptoms resolve (whichever ensures at least 10 days of treatment) 2, 1

Imaging Considerations

Do NOT obtain imaging (plain films, CT, MRI, or ultrasound) to distinguish bacterial sinusitis from viral URI 2, 3. Sinus opacification occurs in 68% of children with viral URIs and 42% of healthy children, making imaging unreliable for diagnosis 3

Reserve contrast-enhanced CT or MRI only for suspected orbital or intracranial complications 2