Best Antibiotic for Purulent Nasal Discharge in Children
Amoxicillin or high-dose amoxicillin-clavulanate is the best first-line antibiotic for children with purulent nasal discharge caused by acute bacterial sinusitis. 1
Confirm Bacterial Sinusitis Before Prescribing Antibiotics
Before starting antibiotics, confirm the child meets criteria for acute bacterial sinusitis rather than viral upper respiratory infection, as purulent nasal discharge alone does not distinguish bacterial from viral infection 2:
- Persistent symptoms: Nasal discharge (any quality) or daytime cough lasting ≥10 days without improvement 1
- Severe onset: Fever ≥39°C AND purulent nasal discharge present concurrently for ≥3 consecutive days 1
- Worsening course: New fever ≥38°C or substantial increase in nasal discharge/cough after initial improvement 1
Most cases of purulent nasal discharge are viral and resolve spontaneously within 7-10 days without antibiotics 1, 2. Do not prescribe antibiotics for symptoms lasting <10 days unless severe criteria are met 1.
First-Line Antibiotic Selection
Standard-Dose Amoxicillin (Uncomplicated Cases)
Amoxicillin 45 mg/kg/day divided into 2 doses is first-line for children ≥3 months with uncomplicated acute bacterial sinusitis 1, 3. This targets Streptococcus pneumoniae (30% of cases), Haemophilus influenzae (30%), and Moraxella catarrhalis (20%) 1.
High-Dose Amoxicillin-Clavulanate (High-Risk Children)
Amoxicillin-clavulanate 90 mg/kg/day of amoxicillin component with 6.4 mg/kg/day clavulanate in 2 divided doses is recommended for children with 1, 4:
- Age <2 years 1, 4
- Daycare attendance 1, 4
- Recent antibiotic use within past 4-6 weeks 1, 4
- Geographic areas with high prevalence of resistant S. pneumoniae 1, 4
- Severe symptoms at presentation 5
The clavulanate component provides coverage against β-lactamase-producing H. influenzae (20-30% of strains) and M. catarrhalis (nearly 100% of strains) 1, 6.
Treatment Duration
Treat for 10-14 days total 1, 4. The American Academy of Pediatrics explicitly requires 10-14 days for children, despite adult data supporting shorter courses 4. Continue treatment until symptom-free for 7 days 4.
Penicillin-Allergic Children
For documented penicillin allergy, use second- or third-generation cephalosporins 1, 4:
The risk of cross-reactivity between penicillin and second/third-generation cephalosporins is negligible 4, 3. Do not use azithromycin due to resistance rates exceeding 20-25% for both S. pneumoniae and H. influenzae 4, 7.
When Initial Therapy Fails
Reassess at 72 hours 1, 5, 3. If worsening or no improvement, switch to 1, 4:
- High-dose amoxicillin-clavulanate (90 mg/kg/day amoxicillin component) if not already prescribed 1, 4
- Ceftriaxone 50 mg/kg IM/IV once daily for children unable to tolerate oral medications or with treatment failure 4, 3
Critical Pitfalls to Avoid
- Do not prescribe antibiotics for viral rhinosinusitis lasting <10 days unless severe symptoms (fever ≥39°C with purulent discharge for ≥3 days) are present 1, 5
- Do not use first-generation cephalosporins (cephalexin) due to inadequate coverage against H. influenzae 4
- Do not use azithromycin or clarithromycin as first-line therapy due to 20-25% resistance rates 4, 7
- Do not obtain imaging (CT scan) for uncomplicated acute bacterial sinusitis 5, 3
Adjunctive Therapies
- Intranasal corticosteroids reduce mucosal inflammation and improve symptom resolution 4, 3
- Saline nasal irrigation provides symptomatic relief 4
- Analgesics (acetaminophen, ibuprofen) for pain and fever 4