When is it recommended to start antibiotics (abx) for suspected viral sinusitis in a 2-year-old patient with recurrent fever and respiratory symptoms?

From the Guidelines

Antibiotics are not yet indicated for this 2-year-old patient with suspected viral sinusitis, as the symptoms have only persisted for 3 days after a brief resolution. The patient's presentation of fever, cough, runny nose, and bilateral ear pain for only 3 days does not meet the criteria for acute bacterial sinusitis as defined by the clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years 1. According to this guideline, the diagnosis of acute bacterial sinusitis is made when a child presents with persistent illness lasting more than 10 days without improvement, a worsening course after initial improvement, or severe onset with concurrent fever and purulent nasal discharge for at least 3 consecutive days. Key points to consider in this patient's management include:

• The patient's symptoms do not currently meet the criteria for severe onset or worsening course, as defined by the guideline 1.
• Most cases of sinusitis in children are viral and resolve without antibiotics within 7-10 days.
• Supportive care with nasal saline irrigation, adequate hydration, and acetaminophen or ibuprofen for pain and fever is appropriate at this stage.
• If symptoms persist beyond 10 days or worsen significantly, first-line treatment would be amoxicillin (45-90 mg/kg/day divided twice daily) for 10-14 days, or amoxicillin-clavulanate if there are risk factors for resistant organisms, as recommended by the guideline 1. The rationale for delaying antibiotics is to avoid unnecessary antibiotic use that contributes to resistance while allowing time for viral infections to resolve naturally, as the majority will improve without antibiotics 1.

From the Research

Diagnosis and Treatment of Suspected Sinusitis

• The patient's symptoms, such as fever, cough, runny nose, and bilateral ear pain, are consistent with viral sinusitis 2.
• However, the recurrence of fever and persistence of symptoms may indicate a bacterial infection.
• According to the study by 2, antibiotics should be considered for patients with 3 or more days of severe symptoms, significant worsening after 3 to 5 days of symptoms, or 7 or more days of symptoms.

Recommendations for Antibiotic Treatment

• The study by 2 suggests that amoxicillin is as effective as amoxicillin-clavulanate as a first-line treatment for acute bacterial rhinosinusitis.
• For patients with a beta-lactam allergy, appropriate antibiotics include doxycycline or a respiratory fluoroquinolone; clindamycin plus a third-generation cephalosporin is an option for children with non-type I hypersensitivity to beta-lactam antibiotics 2.
• Other studies, such as 3 and 4, compare the efficacy of different antibiotics, including azithromycin and amoxicillin/clavulanate, in the treatment of acute sinusitis.

Considerations for Pediatric Patients

• The study by 5 discusses the management of acute sinusitis in children and suggests that treatment with amoxicillin 45 mg/kg/day in two divided doses may be used in selected patients with symptoms that are persistent and not improving.
• The study by 6 provides guidance on the diagnosis and treatment of sinusitis in children, including the recommendation to treat acute bacterial sinusitis with antibiotics based on the clinical scenario.