Acute Bacterial Rhinosinusitis
This 10-year-old boy meets diagnostic criteria for acute bacterial sinusitis and should be started on amoxicillin 45 mg/kg/day for 10 days, with reassessment in 72 hours if symptoms worsen or fail to improve. 1, 2
Diagnostic Reasoning
This patient fulfills the persistent illness criterion for acute bacterial sinusitis: 1, 2
- Nasal discharge (thick green) and cough lasting >10 days (1 week total duration) without improvement
- The progression from dry cough to thick green nasal discharge to productive cough over 7 days indicates bacterial superinfection rather than simple viral URI 1
The American Academy of Pediatrics defines three diagnostic patterns for bacterial sinusitis in children: 1
- Persistent symptoms: nasal discharge or daytime cough >10 days without improvement (this patient)
- Severe onset: fever ≥39°C for ≥3 consecutive days with purulent discharge (not present here)
- Worsening course: initial improvement followed by new fever or increased symptoms (not present here)
The physical examination findings support upper airway inflammation: 1, 2
- Swollen right nostril with 25% obstruction
- Nasal fissures (indicating chronic irritation/discharge)
- Swollen tonsils (consistent with postnasal drainage)
Treatment Plan
Immediate Management
Start amoxicillin at 45 mg/kg/day divided twice daily for 10 days. 1, 2 This provides optimal coverage for Streptococcus pneumoniae, the most common bacterial pathogen. 2, 3
Do NOT prescribe: 2
- Intranasal steroids (no benefit in acute bacterial sinusitis)
- Systemic steroids
- Antihistamines (ineffective for bacterial sinusitis)
- Decongestants
Supportive care: 2
- High-volume saline nasal irrigation for mucociliary clearance
- Analgesics (acetaminophen or ibuprofen) for discomfort
When to Use High-Dose Amoxicillin-Clavulanate
Consider amoxicillin-clavulanate 90 mg/kg/day (of amoxicillin component) if: 2
- Recent antibiotic use within past 30 days
- Daycare attendance
- Age <2 years
- Geographic area with high antibiotic resistance
This patient has no documented risk factors, so standard amoxicillin is appropriate first-line. 2
Reassessment Strategy
Reassess at 72 hours for: 1
- Worsening symptoms (increased fever, discharge, or cough)
- Failure to improve
If no improvement or worsening at 72 hours: 1
- Switch to high-dose amoxicillin-clavulanate
- Consider imaging only if complications suspected (orbital symptoms, severe headache, neurologic signs)
What NOT to Do
Do not obtain imaging studies (X-ray or CT) for uncomplicated acute bacterial sinusitis. 1 Imaging does not distinguish viral from bacterial infection and increases costs 4-fold without improving outcomes. 1
Do not diagnose bacterial sinusitis during the first week of URI symptoms unless severe criteria are met (high fever ≥39°C for ≥3 days with purulent discharge). 1 This patient is at day 7, meeting the >10 day threshold for persistent symptoms. 1
Alternative Consideration: Observation Option
The AAP guidelines allow for observation for 3 additional days before starting antibiotics in children with persistent symptoms (not severe or worsening). 1, 2 However, given this patient already has 7 days of symptoms with thick green discharge and productive cough, immediate antibiotic therapy is more appropriate than further observation. 1, 2
Red Flags Requiring Urgent Referral
Refer immediately to ENT or emergency department if: 4
- Periorbital edema or erythema
- Visual changes or proptosis
- Severe headache or altered mental status
- Focal neurologic signs
- These indicate potential orbital or intracranial complications requiring imaging and possible surgical intervention 4
Follow-Up
If symptoms persist beyond 4 weeks despite appropriate antibiotic therapy, consider: 4