What are the appropriate antibiotics (Abx) for a 3-year-old with sinus infection (infx)?

From the Guidelines

For a 3-year-old with sinusitis, amoxicillin is the first-line antibiotic treatment at a dose of 45-90 mg/kg/day divided twice daily for 10-14 days. This recommendation is based on the guidelines provided by the American Academy of Pediatrics, as outlined in the study published in Pediatrics in 2013 1. The study suggests that amoxicillin is the preferred treatment for uncomplicated acute bacterial sinusitis due to its effectiveness, safety, and narrow microbiologic spectrum.

Key Considerations

• If the child has risk factors for resistant organisms, such as recent antibiotic use or daycare attendance, or lives in an area with a high prevalence of resistant pneumococci, amoxicillin-clavulanate (45 mg/kg/day of the amoxicillin component) is recommended instead 1.
• For penicillin-allergic children, alternatives include cefdinir (14 mg/kg/day once daily), cefuroxime (30 mg/kg/day twice daily), or, in cases of severe penicillin allergy, clindamycin plus cefixime 1.
• Most pediatric sinusitis cases are viral and resolve without antibiotics within 7-10 days, so antibiotics should only be considered if symptoms are severe, persistent, or worsening 1.
• Supportive care with nasal saline irrigation, adequate hydration, and acetaminophen or ibuprofen for pain and fever is also important.
• If there's no improvement after 72 hours of antibiotic therapy, reassessment is necessary to consider alternative diagnoses or resistant organisms 1.

From the FDA Drug Label

Acute Bacterial Sinusitis The recommended dose of azithromycin for oral suspension for the treatment of pediatric patients with acute bacterial sinusitis is 10 mg/kg once daily for 3 days.

OTITIS MEDIA AND ACUTE BACTERIAL SINUSITIS: (3-Day Regimen)

• Dosing Calculated on 10 mg/kg/day Weight100 mg/5 mL200 mg/5 mLTotal mL per Treatment CourseTotal mg per Treatment Course KgLbs.Day 1–3Day 1–3 *Effectiveness of the 5-day or 1-day regimen in pediatric patients with acute bacterial sinusitis has not been established. 5112.5 mL (1/2 tsp) 7.5 mL150 mg 10225 mL (1 tsp) 15 mL300 mg 20445 mL (1 tsp) 15 mL600 mg 30667.5 mL (1 ½ tsp) 22.5 mL900 mg 408810 mL (2 tsp) 30 mL1200 mg 50 and above110 and above12.5 mL (2 ½ tsp) 37. 5 mL1500 mg

For a 3-year-old patient with acute bacterial sinusitis, the recommended dose of azithromycin is 10 mg/kg once daily for 3 days. To determine the dose, you need to know the patient's weight.

• If the patient weighs 10-20 kg (22 lbs), the dose is 10-20 mg/kg = 100-200 mg per day for 3 days.
• If the patient weighs 21-30 kg (46 lbs), the dose is 10 mg/kg = 210-300 mg per day for 3 days.
• If the patient weighs 31-40 kg (68 lbs), the dose is 10 mg/kg = 310-400 mg per day for 3 days.
• If the patient weighs 41 kg or more (90 lbs or more), the dose is 10 mg/kg = 410 mg or more per day for 3 days. The dose should be calculated based on the patient's weight and the recommended dose of 10 mg/kg per day for 3 days 2.

From the Research

Diagnosis of Acute Bacterial Sinusitis in Children

• The diagnosis of acute bacterial sinusitis (ABS) in children is mainly clinical and based on stringent criteria, including persistent symptoms and signs of a URI beyond 10 days, without appreciable improvement; a URI with high fever and purulent nasal discharge at onset lasting for at least 3 consecutive days; and biphasic or worsening symptoms 3.
• Images to confirm the presence of acute sinusitis are necessary in older children (> 6 years) and adults to enhance the certainty of diagnosis 4.

Treatment of Acute Bacterial Sinusitis in Children

• The predominant bacterial species that are implicated in acute sinusitis are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis in children 4, 3.
• Amoxicillin-clavulanate, at a standard dose of 45 mg/kg/day orally, is the drug of choice for most cases of uncomplicated ABS in children in whom antibacterial resistance is not suspected 3.
• Alternatively, oral amoxicillin 90 mg/kg/day can be administered 3.
• For those with severe ABS or uncomplicated acute sinusitis who are at risk for severe disease or antibiotic resistance, oral high-dose amoxicillin-clavulanate (90 mg/kg/day) is the drug of choice 3.
• Other alternatives include cefuroxime, cefpodoxime, or cefdinir 4.
• In cases of serious drug allergy, clarithromycin or azithromycin may be prescribed 4, 5.

Antibiotic Therapy Duration

• The optimal duration of therapy is unknown, but some recommend treatment until the patient becomes free of symptoms and then for an additional 7 days 4.
• Typical length of antibiotic therapy for providers is 10 days (70%) and 14 days (17%) 6.
• ENT providers (21%) prescribe 7 days past any symptom compared to PCP (6%) and UC (5%) 6.