Oral Amoxicillin Is the Appropriate Next Step
For this 7-year-old with 12 days of purulent nasal discharge, daytime cough, low-grade fever, and frontal tenderness, oral amoxicillin is the definitive treatment indicated. This child meets the American Academy of Pediatrics (AAP) criteria for persistent acute bacterial sinusitis—symptoms lasting more than 10 days without improvement—and requires antibiotic therapy rather than observation or supportive care alone. 1
Why This Child Requires Antibiotics Now
The 12-day duration of purulent nasal discharge with daytime cough and fever meets the AAP definition of persistent acute bacterial sinusitis, which mandates antibiotic treatment rather than watchful waiting. 2, 1
The AAP explicitly states that antibiotics should be prescribed for children with persistent illness (>10 days without improvement), and while a 3-day observation period is permitted for persistent cases, antibiotic treatment is strongly favored once the 10-day threshold is exceeded. 1
The number needed to treat with antibiotics is only 3–5 to achieve clinical cure in persistent bacterial sinusitis, demonstrating substantial benefit over no treatment. 1
Supportive care alone (Option A) is explicitly not appropriate once symptoms persist beyond 10 days, because the condition is bacterial rather than viral and antibiotics provide significantly higher cure rates. 1
First-Line Antibiotic: Standard-Dose Amoxicillin
Oral amoxicillin at 45 mg/kg/day divided into 2 doses is the AAP-recommended first-line antibiotic for uncomplicated persistent acute bacterial sinusitis in children. 2, 1, 3
The major bacterial pathogens are Streptococcus pneumoniae (
30%), non-typeable Haemophilus influenzae (30%), and Moraxella catarrhalis (~10%), and standard-dose amoxicillin provides excellent coverage for most cases. 1, 4High-dose amoxicillin (80–90 mg/kg/day) is reserved for children with specific risk factors: age <2 years, daycare attendance, antibiotic use within the past 4–6 weeks, or geographic areas with high prevalence of resistant S. pneumoniae. 2, 1 This 7-year-old without these risk factors should receive standard dosing initially.
Treatment duration is 10–14 days total, or until symptom-free for 7 days. 2, 1, 3
Why Not the Other Options?
Option C (Nasal Corticosteroids): Adjunct Only, Not Monotherapy
Intranasal corticosteroids reduce mucosal inflammation and improve symptom resolution, but they have no antibacterial activity and should never be used as monotherapy when bacterial sinusitis is diagnosed. 1, 5
Nasal corticosteroids should be added alongside antibiotics to enhance outcomes, not prescribed instead of antibiotics. 1, 5
Option D (Sinus X-ray): Not Indicated for Uncomplicated Cases
The AAP and American College of Radiology explicitly state that sinus X-rays are not recommended for uncomplicated acute bacterial sinusitis because imaging does not change management. 2, 1
More than 50% of children with viral upper-respiratory infections show abnormal sinus radiographs, and 42% of healthy children have sinus abnormalities on imaging, rendering X-rays non-specific and unhelpful. 1
Imaging is reserved exclusively for suspected complications—periorbital swelling, proptosis, severe headache, altered mental status, or neurologic signs—none of which are present in this child. 2, 1, 6
Frontal Sinus Tenderness: Does It Change Management?
Frontal sinusitis in children is uncommon because the frontal sinuses are not fully developed until age 7–8 years, so "frontal bone tenderness" in a 7-year-old likely represents maxillary or ethmoid disease with referred pain. 6
French guidelines emphasize that frontal, ethmoidal, or sphenoidal sinusitis requires definitive antibiotic treatment, and some experts prefer amoxicillin-clavulanate for these locations due to broader coverage. 6 However, the AAP recommends starting with standard amoxicillin and escalating to amoxicillin-clavulanate only if the child fails to improve after 72 hours. 2, 1
Given the child's uncomplicated presentation (no periorbital swelling, normal eye exam, no severe systemic toxicity), standard amoxicillin remains appropriate first-line therapy. 2, 1
Monitoring After Starting Amoxicillin
Reassess the child 72 hours after starting amoxicillin for worsening symptoms (new fever, increased discharge, severe headache) or lack of improvement, which would warrant escalation to high-dose amoxicillin-clavulanate. 1, 6
Watch for signs of orbital complications (periorbital swelling, proptosis, ophthalmoplegia) or intracranial complications (altered mental status, severe headache, focal neurologic deficits), which require immediate imaging and specialist consultation. 2, 1, 6
Common Pitfalls to Avoid
Do not delay antibiotics in favor of prolonged observation once symptoms exceed 10 days—the AAP permits a 3-day observation period for persistent cases, but this child is already at day 12 and clearly meets criteria for treatment. 1
Do not obtain sinus imaging in uncomplicated cases—the diagnosis is clinical, and X-rays will not alter management. 2, 1
Do not prescribe nasal corticosteroids alone—they are adjunctive therapy only and lack antibacterial activity. 1, 5
Do not start with amoxicillin-clavulanate unless the child has risk factors for resistant organisms (age <2, daycare, recent antibiotics)—standard amoxicillin is first-line for uncomplicated cases. 2, 1
Summary Algorithm
- Confirm persistent acute bacterial sinusitis: purulent nasal discharge + daytime cough >10 days without improvement. 2, 1
- Prescribe oral amoxicillin 45 mg/kg/day divided BID for 10–14 days. 2, 1, 3
- Add intranasal corticosteroids as adjunctive therapy to reduce inflammation. 1, 5
- Reassess at 72 hours: if worsening or no improvement, switch to high-dose amoxicillin-clavulanate (80–90 mg/kg/day). 1, 6
- Reserve imaging for suspected complications only (periorbital swelling, neurologic signs). 2, 1, 6
Answer: B – Oral amoxicillin