Acute Bacterial Rhinosinusitis in Children - Microbiology and Management - UpToDate

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Acute bacterial rhinosinusitis in children: Microbiology and management

Author: Ellen R Wald, MD
Section Editors: Sheldon L Kaplan, MD, Glenn C Isaacson, MD, FAAP, Robert A Wood, MD
Deputy Editor: Mary M Torchia, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Sep 2022. | This topic last updated: Oct 10, 2022.
INTRODUCTION
Acute rhinosinusitis is a disease that results from infection of one or more of the paranasal sinuses. A viral infection associated with the
common cold is the most frequent etiology of acute rhinosinusitis, more properly called viral rhinosinusitis. Acute bacterial rhinosinusitis
(ABRS) occurs when there is secondary bacterial infection of the sinuses. The clinical course (ie, duration, severity, and improvement or
worsening of symptoms ( table 1)) distinguishes uncomplicated viral rhinosinusitis from ABRS ( table 2), a distinction that is
necessary to prevent unnecessary use of antibiotics. (See "Acute bacterial rhinosinusitis in children: Clinical features and diagnosis",
section on 'Acute bacterial rhinosinusitis'.)
The microbiology and treatment of ABRS in children will be discussed here. The clinical features and diagnosis of ABRS in children and
acute sinusitis and rhinosinusitis in adults are discussed separately. (See "Acute bacterial rhinosinusitis in children: Clinical features and
diagnosis" and "Acute sinusitis and rhinosinusitis in adults: Clinical manifestations and diagnosis" and "Uncomplicated acute sinusitis
and rhinosinusitis in adults: Treatment".)
Our approach to the management of ABRS in children is generally consistent with recommendations of the American Academy of
Pediatrics and the Infectious Diseases Society of America. (See 'Society guideline links' below.)
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MICROBIOLOGY
Common pathogens
● Uncomplicated ABRS – Haemophilus influenzae (nontypeable), Streptococcus pneumoniae, and Moraxella catarrhalis are the
predominant causes of uncomplicated ABRS [1,2].
Cultures of middle ear fluid obtained by tympanocentesis from children with acute otitis media (AOM) are used as a surrogate for
cultures of the paranasal sinuses because AOM and ABRS have similar pathogenesis and microbiology [3,4]. Although culture of
material aspirated from the sinus yielding ≥104 colony-forming units/mL of bacteria is the standard for determining the etiology of
ABRS [5], sinus aspiration is an invasive procedure that is not routinely performed in children with uncomplicated ABRS. The use of
middle ear cultures as a surrogate for cultures of the paranasal sinuses has been validated by studies of sinus aspirates obtained
from children with uncomplicated ABRS that were performed before and after the widespread development of antibiotic-resistant
S. pneumoniae and the routine use of vaccines against S. pneumoniae [6,7].
Limited data detailing the microbiology of AOM in the post-13-valent pneumococcal conjugate vaccine (PCV13) era highlight the
prominence of nontypeable H. influenzae, including beta-lactamase positive isolates [8-12]. In 2017, it was estimated that H.
influenzae accounted for approximately 50 to 60 percent of middle ear isolates in AOM, S. pneumoniae for 15 to 25 percent, and M.
catarrhalis for 12 to 15 percent [11,13-16]. The presumption that isolates recovered from children with uncomplicated ABRS would
be similar was confirmed in a study of 31 children with severe symptoms of acute maxillary sinusitis who underwent sinus
aspiration [7]. The most common bacteria recovered were H. influenzae (45 percent), S. pneumoniae (32 percent), and M. catarrhalis
(16 percent). (See "Acute otitis media in children: Epidemiology, microbiology, and complications", section on 'Microbiology'.)
Several studies have reported isolation of Staphylococcus aureus from sinus aspirates (obtained endoscopically) or from cultures of
the middle meatus in children (most of whom had chronic sinusitis) [17-19]. However, these studies must be interpreted with
caution because of methodologic limitations (eg, unknown indication for obtaining culture, lack of quantification, possibility of
contamination from the nasal cavity) and because cultures of the middle meatus have not been established as a reliable surrogate
for maxillary sinus aspirates in children [20]. Nonetheless, S. aureus, including methicillin-resistant S. aureus, has been recovered
from cultures in patients with orbital cellulitis and epidural abscess, presumably complications of ABRS [21-23].
● Complications of ABRS – The microbiology of the complications of ABRS differs from that of uncomplicated ABRS. In retrospective
studies of the microbiology of complicated ABRS in children, polymicrobial infections were common and Streptococcus species (eg,
Streptococcus anginosus group), other anaerobes, and Staphylococcus species were more frequently isolated than H. influenzae, S.
pneumoniae, and M. catarrhalis [24-30].
Antimicrobial susceptibility
● S. pneumoniae – The proportion of isolates of S. pneumoniae that are nonsusceptible to penicillin varies from community to
community. Although the incidence of AOM caused by penicillin-resistant S. pneumoniae decreased for several years after PCV13
replaced the 7-valent pneumococcal conjugate vaccine in 2010 [13], cultures from tympanocenteses performed during 2015 to
2019 show an increase in serotypes not included in PCV13 (eg, 35B, 15B/C, and 23B) [12]. Children unimmunized or
underimmunized with PCV are more likely to have resistant strains [31]. (See "Impact of universal infant immunization with
pneumococcal conjugate vaccines in the United States", section on 'Antibiotic resistance'.)
● H. influenzae – Between 30 to 50 percent of H. influenzae [13] are likely to be beta-lactamase positive and nonsusceptible to
amoxicillin. In a single center longitudinal study of AOM pathogens between 2015 and 2019, nearly 49 percent of the H. influenzae
isolates were beta-lactamase producing [12].
● M. catarrhalis – Close to 100 percent of M. catarrhalis are likely to be beta-lactamase positive and nonsusceptible to amoxicillin.
Risk factors for antimicrobial resistance — Risks factors for resistant S. pneumoniae and H. influenzae include [31-37]:
● Living in an area with high endemic rates (ie, ≥10 percent) of invasive penicillin-nonsusceptible S. pneumoniae
● Age <2 years
● Daycare attendance
● Antibiotic therapy within the month before presentation
● Hospitalization within the past five days
● Unimmunized or underimmunized with PCV (see "Pneumococcal vaccination in children", section on 'Routine immunization for
children <5 years')
WHEN TO INITIATE ANTIBIOTICS
Prompt initiation of antibiotics is necessary for children with ABRS and complications or suspected complications ( table 3). (See "Acute
bacterial rhinosinusitis in children: Clinical features and diagnosis", section on 'Complications' and 'Complicated ABRS' below.)
There are three clinical presentations of acute bacterial sinusitis ( table 1). For children with ABRS and 10 days of symptoms that are
neither severe nor worsening, and none of the indications for immediate antimicrobial therapy listed below, we either provide
immediate antimicrobial therapy or a three-day period of observation, depending upon patient and caregiver preference. Additional
factors that are considered in this decision include severity of symptoms, quality of life, past history of ABRS, cost and ease of
administration of antibiotics, and concerns about adverse effects of antibiotics or development of complications. Immediate treatment
with antibiotics is preferred to observation because although ABRS may resolve without antibiotics, resolution of symptoms usually
occurs earlier and is more likely than without antibiotics.
We initiate antimicrobial therapy at the time of presentation to medical attention for children with ABRS and [38]:
● A clinical presentation of severe symptoms or worsening symptoms ( table 1)
● Receipt of antibiotic therapy in the previous four weeks
● Concurrent bacterial infection (eg, pneumonia, suppurative cervical adenitis, group A streptococcal pharyngitis, acute otitis media)
● Certain underlying conditions, including asthma, cystic fibrosis, immunodeficiency, previous sinus surgery, or anatomic
abnormalities of the upper respiratory tract
Randomized trials evaluating antibiotics versus placebo for the treatment of ABRS in children have conflicting results [39-41]. In a meta-
analysis of three trials including a total of 310 children [39-41], the rate of improvement or clinical cure was greater among children
treated with antibiotics than placebo (78.5 versus 59.7 percent, odds ratio 2.52, 95% CI 1.52-4.18) [32]. Although too few patients were
included to adequately evaluate the risk, intracranial and intraorbital complications were not observed in the randomized trials, even
among the placebo recipients [39,40]. In the only study that was performed after the development of widespread antibiotic-resistant S.
pneumoniae, treatment with amoxicillin-clavulanate was associated with increased rates of clinical cure (50 versus 14 percent) and
decreased rates of treatment failure (14 versus 68 percent) compared with placebo [40]. Treatment failure was defined by worsening at
any time, failure to improve within two to three days, or persistent symptoms at 14 days. Adverse events, predominantly self-limited
diarrhea, were more common in the treatment group (44 versus 14 percent), but only three patients in the treatment group
discontinued therapy because of adverse effects.
There have been no randomized, placebo-controlled trials of antibiotic treatment for ABRS that have used pre- and posttreatment
quantitative sinus aspirate culture as the standard for diagnosis and cure. Studies that use clinical and/or radiologic criteria for diagnosis
and outcome may underestimate the benefit of antibiotic therapy because they are likely to include at least some patients with self-
limited uncomplicated viral upper respiratory tract infection.
OUTPATIENT MANAGEMENT
We generally treat children with ABRS who are well-appearing and without complications or suspected complications ( table 3) as
outpatients ( algorithm 1A-B). Patients older than one year with mild preseptal cellulitis (characterized by slight swelling about the eye
such that the eye is open more than 50 percent) and no signs of toxicity may be treated as outpatients provided that follow-up the next
day is ensured. (See 'Indications for hospitalization' below and "Preseptal cellulitis", section on 'Treatment'.)
Indications for referral — Children with uncomplicated ABRS can usually be managed by their primary care provider. Indications for
consultation with a specialist (eg, infectious disease, otolaryngology, immunology) include [32,42,43]:
● Need for sinus aspiration (see "Acute bacterial rhinosinusitis in children: Clinical features and diagnosis", section on 'Microbiologic
evaluation')
● Isolation of resistant or rare pathogens from sinus aspirate (if performed)
● Diagnosed or suspected immunodeficiency
● Recurrent ABRS, particularly if it exacerbates underlying pulmonary conditions (eg, asthma)
Empiric antibiotics — Antibiotics that are used to treat ABRS must provide antibacterial activity against S. pneumoniae, H. influenzae, and
M. catarrhalis. (See 'Microbiology' above.)
Additional factors in the choice of therapy include the severity of illness, risk of complications, likelihood of infection with a resistant
organism, adverse drug reactions, acceptability, dosing convenience, and adverse effects ( algorithm 1A-B) [32].
Mild/moderate ABRS — Mild/moderate ABRS is characterized by a clinical severity score <8 ( table 4).
● No risk factors for antibiotic resistance – For children with uncomplicated mild/moderate ABRS who have no risks for antibiotic
resistance ( table 5), we suggest empiric antimicrobial therapy with standard dose amoxicillin-clavulanate rather than high-dose
amoxicillin-clavulanate or other oral antibiotics (eg, amoxicillin, fluoroquinolones, macrolides, or second- or third-generation
cephalosporins) ( algorithm 1A and table 6) (see 'Risk factors for antimicrobial resistance' above) [32]:
• Amoxicillin-clavulanate 45 mg/kg per day of the amoxicillin component orally in two divided doses (maximum daily dose 1.75 g)
for 10 days; in the United States, the 200 or 400 mg amoxicillin/5 mL suspension or the 200 or 400 mg chewable tablet can be
used for the appropriate clavulanate ratio.
● Risk factors for antibiotic resistance – For children with uncomplicated mild/moderate ABRS who have one or more risks for
antibiotic resistance or whose risk factors for antibiotic resistance are unknown ( table 5), we suggest treatment with high-dose
rather than standard-dose amoxicillin-clavulanate ( algorithm 1A and table 6) (see 'Risk factors for antimicrobial resistance'
above):
• Amoxicillin-clavulanate 90 mg/kg per day of the amoxicillin component orally in two divided doses (maximum daily dose 4 g) for
10 days; in the United States, the 600 mg amoxicillin/5 mL suspension or the 1000 mg extended-release tablet can be used for
the appropriate clavulanate ratio.
We prefer amoxicillin-clavulanate for the treatment of ABRS in children because of its spectrum of activity, effectiveness, and safety
[13,32,40,44]. The clavulanate component provides better activity than amoxicillin against ampicillin-resistant H. influenzae and M.
catarrhalis. Beta-lactamase producing nontypeable H. influenzae is an increasingly important cause of respiratory tract infection in the
post-13-valent pneumococcal conjugate vaccine (PCV13) era [13,32,45-49]. Other experts suggest amoxicillin for initial therapy of
mild/moderate disease [38]. They recommend amoxicillin 45 mg/kg per day orally divided in two doses for children without risk factors
for antimicrobial resistance and amoxicillin 90 mg/kg per day orally divided in two doses for children with risk factors for antimicrobial
resistance. (See 'Risk factors for antimicrobial resistance' above.)
High-dose amoxicillin-clavulanate provides better activity against penicillin-nonsusceptible S. pneumoniae and ampicillin-resistant
nonbeta-lactamase producing H. influenzae than standard-dose amoxicillin-clavulanate [32,46]. However, because of the slight increase
in cost and side effects and the stable proportion of penicillin-resistant S. pneumoniae in the post-pneumococcal conjugate vaccine era,
we suggest that high-dose amoxicillin-clavulanate be reserved for children with severe disease or increased or unknown risk of antibiotic
resistance (either penicillin-nonsusceptible S. pneumoniae or beta-lactamase producing ampicillin-resistant H. influenzae) [32]. (See 'Risk
factors for antimicrobial resistance' above.)
In a meta-analysis of randomized trials, fluoroquinolones provided no advantage over beta-lactam antibiotics in the treatment of ABRS
in adults [50].
Severe ABRS or risk for severe ABRS — Severe disease is characterized by a clinical severity score ≥8 ( table 4). Children with
immune-compromising conditions (eg, human immunodeficiency virus [HIV]) are at increased risk for severe disease [32].
For children with severe ABRS or risk for severe ABRS who are treated as outpatients, we suggest treatment with high-dose amoxicillin-
clavulanate rather than standard-dose amoxicillin-clavulanate or other oral antibiotics ( algorithm 1A and table 6) [32].
● Amoxicillin-clavulanate 90 mg/kg per day of the amoxicillin component orally in two divided doses (maximum daily dose 4 g) for 10
days; in the United States, use the 600 mg amoxicillin/5 mL suspension or the 1000 mg extended-release tablet for the appropriate
clavulanate ratio.
We suggest high-dose rather than standard-dose amoxicillin-clavulanate for children with severe ABRS or risk of severe ABRS to provide
better activity against penicillin-nonsusceptible S. pneumoniae and ampicillin-resistant nonbeta-lactamase producing H. influenzae
[32,46]. (See 'Microbiology' above.)
Alternative single-agent regimens, which have a slightly narrower spectrum of activity than amoxicillin-clavulanate, include a third
generation cephalosporin (eg, cefpodoxime, cefdinir) or levofloxacin ( algorithm 1B) [51]. Suggested doses are as follows:
● Cefpodoxime 10 mg/kg per day orally divided every 12 hours (maximum daily dose 400 mg) for 10 days
● Cefdinir 14 mg/kg per day orally divided every 12 or 24 hours (maximum daily dose 600 mg) for 10 days
● Levofloxacin 10 to 20 mg/kg per day orally divided every 12 to 24 hours (maximum daily dose 500 mg) for 10 days
Cefpodoxime has greater activity than cefdinir against H. influenzae and is preferred, especially if the patient can take a tablet [52,53]. For
the liquid formulation, some clinicians prefer cefdinir because it has a better taste. Although third-generation cephalosporins have been
considered inferior to high-dose amoxicillin-clavulanate for penicillin-resistant S. pneumoniae, this may be less of an issue if penicillin-
resistant S. pneumoniae remain less common as a cause of acute otitis media and ABRS following the introduction of PCV13. (See
'Microbiology' above.)
Levofloxacin should be reserved for cases in which there is no other safe and effective alternative (eg, in patients who have anaphylaxis
with or are intolerant of beta-lactams) [54-56]. In a meta-analysis of randomized trials, fluoroquinolones provided no advantage over
beta-lactam antibiotics in the treatment of ABRS in adults [50]. In addition, fluoroquinolones are associated with more severe side effects
than amoxicillin-clavulanate [55]. (See "Fluoroquinolones", section on 'Children'.)
Levofloxacin typically remains active against multidrug-resistant pneumococci with high-level resistance to penicillin or third-generation
cephalosporins and is an option for treatment when patients have failed initial therapy. (See 'Treatment failure in outpatients' below.)
Children with penicillin contraindications — Alternatives to amoxicillin-clavulanate for children with contraindications to penicillin
depend upon the type of adverse reaction ( table 6). (See "Penicillin allergy: Immediate reactions" and "Allergy evaluation for
immediate penicillin allergy: Skin test-based diagnostic strategies and cross-reactivity with other beta-lactam antibiotics".)
● For children with uncomplicated ABRS who have an immediate reaction (eg, anaphylaxis, bronchospasm) or serious delayed
reaction (eg, Stevens-Johnson syndrome, toxic epidermal necrolysis) to penicillin, or a contraindication to cephalosporins, we
suggest levofloxacin 10 to 20 mg/kg per day orally divided every 12 or 24 hours [32,56]. (See "Fluoroquinolones", section on
'Children'.)
● For children with uncomplicated ABRS who have a mild delayed hypersensitivity reaction to penicillin antibiotics, we suggest
therapy with a third-generation cephalosporin (eg, cefpodoxime or cefdinir):
• Cefpodoxime 10 mg/kg per day orally divided every 12 hours (maximum daily dose 400 mg), or
• Cefdinir 14 mg/kg per day orally divided every 12 or 24 hours (maximum daily dose 600 mg)
Cefpodoxime has greater activity than cefdinir against H. influenzae and is preferred, especially if the patient can take a tablet [52,53]. For
the liquid formulation, some clinicians prefer cefdinir because it has a better taste.
Children with vomiting — A single dose of ceftriaxone 50 mg/kg per day (maximum dose 1 g/day) intravenously (IV) or
intramuscularly (IM) can be used in children with uncomplicated ABRS and vomiting that precludes administration of oral antibiotics
[32,38]. Therapy with an oral antibiotic should be initiated 24 hours later, provided the vomiting has resolved.
Vomiting that persists for more than 24 hours and vomiting that is associated with periorbital/orbital swelling and/or persistent
headache should prompt consideration of orbital or intracranial complication. Additional evaluation is needed. (See "Acute bacterial
rhinosinusitis in children: Clinical features and diagnosis", section on 'Complications'.)
Treatment failure in outpatients — Treatment failure is defined by substantial worsening at any time after initiation of antibiotics or
failure to improve after three days [39,40]. Treatment failure in children with ABRS who have no evidence of complications ( table 3) is
often caused by a pathogen resistant to initial antimicrobial therapy [32,38]. (See 'Microbiology' above.)
● Consider other causes of symptoms – Other causes of treatment failure include a noninfectious cause for symptoms (eg, foreign
body, structural abnormality) or ABRS as the initial presentation of immune deficiency [32,38,57]. (See "Acute bacterial
rhinosinusitis in children: Clinical features and diagnosis", section on 'Differential diagnosis' and "Approach to the child with
recurrent infections".)
● Changes to antibiotic therapy – For children with uncomplicated ABRS who are initially treated as outpatients and whose
symptoms worsen substantially at any time or fail to improve after three days of initial antimicrobial treatment and in whom other
causes of symptoms have been excluded by history or examination, we suggest broadening antimicrobial activity or switching to a
different class of antibiotic ( algorithm 1A-B).
We continue antibiotic therapy for seven days after the child becomes symptom free (ie, a minimum of 10 days) [38,58].
Our choices for the new regimen depend upon which antibiotic was used initially:
• Initial treatment with standard-dose amoxicillin-clavulanate or amoxicillin (standard or high-dose) – We switch to one of the
following:
- Amoxicillin-clavulanate 90 mg/kg per day of the amoxicillin component orally in two divided doses (maximum daily dose 4
g); in the United States, the 600 mg amoxicillin/5 mL suspension or the 1000 mg extended-release tablet can be used for
the appropriate clavulanate ratio
- Ceftriaxone 50 mg/kg per day IV or IM (maximum 4 g/day) for one to three days, followed by amoxicillin-clavulanate 90
mg/kg per day of the amoxicillin component
• Initial treatment with high-dose amoxicillin-clavulanate – We switch to one of the following:
- Cefpodoxime 10 mg/kg per day orally divided every 12 hours (maximum daily dose 400 mg/day)
- Cefdinir 14 mg/kg per day orally divided every 12 or 24 hours (maximum daily dose 600 mg/day)
- Levofloxacin 10 to 20 mg/kg per day orally divided every 12 or 24 hours (maximum daily dose 500 mg/day); levofloxacin
should be reserved for cases in which there is no other safe and effective alternative [54-56] (see "Fluoroquinolones",
section on 'Children')
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• Initial treatment with cefpodoxime or cefdinir – We switch to either:
- Amoxicillin-clavulanate (depending on why a cephalosporin was started) 90 mg/kg per day of the amoxicillin component
orally in two divided doses (maximum daily dose 4 g), or
- Levofloxacin 10 to 20 mg/kg per day orally divided every 12 or 24 hours; levofloxacin should be reserved for cases in which
there is no other safe and effective alternative [54-56] (see "Fluoroquinolones", section on 'Children')
● Response to second therapy – Hospital admission for a trial of intravenous therapy and/or consultation with a specialist (eg,
infectious disease, otolaryngology) is warranted for children with ABRS who fail to improve after the second therapy
( algorithm 1A-B). (See 'Inpatient management' below and 'Indications for hospitalization' below.)
• For children with no contraindications to penicillins, we use:
- Ceftriaxone 50 mg/kg per day IV divided every 12 hours (maximum 4 g/day)
• For children with contraindications to penicillins, we use either:
- Levofloxacin 20 mg/kg per day IV divided every 12 to 24 hours (maximum 500 mg/day), or
- Meropenem 60 mg/kg per day divided every 8 hours (maximum 3 g/day)
For those who failed treatment with levofloxacin at 10 mg/kg per day orally, it is reasonable to try levofloxacin at 20 mg/kg per day
IV. For those who failed treatment with oral levofloxacin 20 mg/kg per day, meropenem is appropriate.
In addition, imaging and/or sinus aspiration may be indicated to confirm the diagnosis, evaluate complications, and tailor therapy,
particularly for children whose symptoms have not improved or have worsened after three days of initial antibiotics and another
three days of the second agent. (See "Acute bacterial rhinosinusitis in children: Clinical features and diagnosis", section on
'Complicated ABRS' and "Acute bacterial rhinosinusitis in children: Clinical features and diagnosis", section on 'Microbiologic
evaluation'.)
Symptomatic therapy
● Nasal obstruction/rhinorrhea in children without underlying allergic rhinitis – For symptomatic management of nasal
obstruction and rhinorrhea in children with ABRS who do not have underlying allergic rhinitis, we suggest topical saline rather than
decongestants, antihistamines, or intranasal glucocorticoids.
Although evidence of the efficacy of topical saline is limited [59-61], it is unlikely to be harmful or to impede recovery and is
inexpensive. Saline nose drops, saline nasal sprays, and/or saline nasal irrigation may help in preventing crust formation and
liquefying sinus secretions. In a small randomized trial, nasal saline irrigation improved symptoms, quality-of-life scores, and peak
expiratory flow rates in children with acute sinusitis [61]. Additional trials are need to better establish the benefits of topical saline.
Nasal irrigants should be prepared from sterile or bottled water; cases of amebic encephalitis associated with nasal irrigation
prepared from tap water have been reported [62]. (See "Free-living amebas and Prototheca", section on 'Epidemiology'.)
The benefits of decongestants and antihistamines are unproven [59,63] and they may have adverse effects (eg, impaired sinus
drainage, impaired delivery of antibiotics to the nasal mucosa). Although intranasal glucocorticoids theoretically may decrease
inflammation of the mucous membranes, which contributes to obstruction of the ostia and impaired mucociliary clearance [64], the
benefits demonstrated in randomized trials have been marginal and the trials have methodologic limitations (eg, varying inclusion
criteria, inclusion of patients with and without allergies, varying outcome criteria) [38,65-68].
● Nasal obstruction/rhinorrhea in children with underlying allergic rhinitis – Children with ABRS and allergic rhinitis may benefit
from antihistamines, decongestants, or intranasal glucocorticoids. The treatment of allergic rhinitis in children is discussed
separately. (See "Pharmacotherapy of allergic rhinitis", section on 'Approach to specific patient groups'.)
● Severe headache or facial pain — Therapeutic sinus aspiration ( figure 1) may be warranted for relief of severe headache or
facial pain [69]. Sinus aspiration should be performed by a specialist. Indications for diagnostic sinus aspiration are discussed
separately. (See "Acute bacterial rhinosinusitis in children: Clinical features and diagnosis", section on 'Microbiologic evaluation'.)
INPATIENT MANAGEMENT
Indications for hospitalization — Indications for hospitalization and parenteral antibiotics in children with ABRS ( table 1) include
(see 'Inpatient management' above):
● Toxic appearance (eg, lethargic, poorly perfused, cardiorespiratory compromise)
● Complications or suspected complications ( table 3), with the possible exception of preseptal cellulitis (patients older than one
year with mild preseptal cellulitis [characterized by slight swelling about the eye such that the eye is open more than 50 percent]
and no signs of toxicity may be treated as outpatients provided that follow-up the next day is ensured) (see "Acute bacterial
rhinosinusitis in children: Clinical features and diagnosis", section on 'Complications' and 'Complicated ABRS' below and "Preseptal
cellulitis", section on 'Treatment')
● Treatment failure with outpatient therapy (ie, high-dose amoxicillin-clavulanate, third-generation cephalosporin, or levofloxacin)
(see 'Treatment failure in outpatients' above)
Pretreatment evaluation — Consultation with an otolaryngologist for possible sinus aspiration (with Gram stain, aerobic and anaerobic
culture, and antimicrobial susceptibility testing) is warranted for children hospitalized with complications of ABRS or failure of outpatient
management [32,69]. Isolation of a pathogen and antimicrobial susceptibilities enable better targeting of antimicrobial therapy. (See
"Acute bacterial rhinosinusitis in children: Clinical features and diagnosis", section on 'Microbiologic evaluation'.)
For children who are hospitalized for toxic appearance without complications or suspected complications, sinus aspiration may be
deferred pending a trial of intravenous therapy [38].
Although there is literature suggesting that endoscopically obtained cultures of the middle meatus may be a surrogate for sinus
aspiration, endoscopically obtained cultures of the middle meatus may not reflect the true bacterial etiology in children suspected to
have ABRS because the meatus is frequently colonized with S. pneumoniae, H. influenzae, and M. catarrhalis, even when children are
asymptomatic [70].
Complicated ABRS — Sinus imaging with contrast-enhanced computed tomography (CT) should be performed in patients with
symptoms or signs of intracranial or orbital complications ( table 3). (See "Acute bacterial rhinosinusitis in children: Clinical features
and diagnosis", section on 'Complications'.)
The treatment of complicated sinusitis varies depending upon the complication and is discussed separately:
● Preseptal (periorbital) cellulitis (see "Preseptal cellulitis", section on 'Treatment')
● Postseptal complications of sinusitis (orbital cellulitis, orbital subperiosteal abscess, orbital abscess) are treated similarly; orbital
subperiosteal abscess and orbital abscess may require surgical drainage in addition to antibiotic therapy (see "Orbital cellulitis",
section on 'Treatment')
● Septic cavernous sinus thrombosis (see "Septic dural sinus thrombosis", section on 'Treatment')
● Meningitis (see "Bacterial meningitis in children older than one month: Treatment and prognosis")
● Osteomyelitis of the frontal bone associated with a subperiosteal abscess (Pott puffy tumor) (see "Hematogenous osteomyelitis in
children: Management")
● Intracranial epidural or subdural abscess (see "Spinal epidural abscess", section on 'Management')
● Brain abscess (see "Treatment and prognosis of bacterial brain abscess")
Uncomplicated ABRS — Empiric therapy for children hospitalized with uncomplicated ABRS should provide activity against highly
resistant S. pneumoniae, ampicillin-resistant H. influenzae, and ampicillin-resistant M. catarrhalis. The regimen should be adjusted based
upon clinical response and culture results. (See 'Microbiology' above.)
We suggest initial empiric antibiotic therapy with one of the following agents ( table 6) [32]:
● Ampicillin-sulbactam 200 to 400 mg/kg per day intravenously (IV) divided every six hours (maximum 8 g ampicillin component per
day), or
● Ceftriaxone 50 mg/kg per day IV divided every 12 hours (maximum 4 g per day), or
● Levofloxacin 10 to 20 mg/kg per day IV divided every 12 to 24 hours (maximum 500 mg per day); levofloxacin should be reserved
for cases in which there is no other safe and effective alternative [54,56] (see "Fluoroquinolones", section on 'Children')
These suggestions are based on in vitro susceptibilities. There are no studies comparing intravenous antibiotic regimens for the
treatment of ABRS in children.
We continue antimicrobial therapy for a total of 10 days in patients whose symptoms improve after three days of parenteral therapy. We
switch to oral antibiotics after the child shows definite signs of clinical improvement.
● Positive sinus aspirate culture – For children with a positive sinus aspirate culture, we choose an oral agent to which the isolate is
susceptible.
● Negative sinus aspirate culture or no sinus aspirate culture obtained – For children in whom sinus aspirate cultures were not
obtained or were negative, the choice of oral therapy varies with the reason for admission:
• For those who were admitted because of failure to respond to initial oral therapy with amoxicillin-clavulanate, we generally use
either:
- Cefpodoxime 10 m/kg per day orally divided in two doses (maximum 400 mg/day), or
- Cefdinir 14 mg/kg per day orally divided in one or two doses (maximum 600 mg/day).
- For children who improved with parenteral ampicillin-sulbactam, amoxicillin-clavulanate 90 mg/kg per day of the amoxicillin
component orally in two divided doses (maximum daily dose 4 g) for 10 days; in the United States, the 600 mg amoxicillin/5
mL suspension or the 1000 mg extended-release tablet can be used for the appropriate clavulanate ratio.
Levofloxacin is an alternative but should be reserved for cases in which there is no other safe and effective alternative (eg, in
patients who have anaphylaxis with or are intolerant of beta-lactams) [54-56].
• For those who were admitted because of toxic appearance, we usually switch to amoxicillin-clavulanate:
- For children with no risk factors for resistance ( table 5) – Amoxicillin-clavulanate 45 mg/kg per day of the amoxicillin
component orally in two divided doses (maximum daily dose 1.75 g) for a total of 10 days.
- For children with risk factors for resistance – Amoxicillin-clavulanate 90 mg/kg per day of the amoxicillin component orally
in two divided doses (maximum daily dose 4 g) for 10 days; in the United States, the 600 mg amoxicillin/5 mL suspension or
the 1000 mg extended-release tablet can be used for the appropriate clavulanate ratio.
Treatment failure in inpatients — Treatment failure is defined by substantial worsening at any time or failure to improve after three
days of antimicrobial therapy [39,40]. Causes of treatment failure in children with ABRS who are treated as inpatients include resistant
pathogens, development of complications ( table 3), noninfectious causes for symptoms, or ABRS as the initial presentation of
immune deficiency [32,38,57]. (See 'Microbiology' above and "Acute bacterial rhinosinusitis in children: Clinical features and diagnosis",
section on 'Differential diagnosis' and "Approach to the child with recurrent infections".)
● Additional evaluation – Failure to improve or worsening in hospitalized children who are receiving empiric antibiotic therapy
warrants additional evaluation, including [32]:
• Consideration of noninfectious causes (eg, foreign body, structural abnormality) or ABRS as the initial presentation of immune
deficiency [32,38,57] (see "Acute bacterial rhinosinusitis in children: Clinical features and diagnosis", section on 'Differential
diagnosis' and "Approach to the child with recurrent infections")
• Contrast-enhanced CT imaging or magnetic resonance imaging to exclude orbital and intracranial complications (if not
performed previously) ( table 3)
• Quantitative sinus aspirate cultures if they were not obtained at the time of admission (see "Acute bacterial rhinosinusitis in
children: Clinical features and diagnosis", section on 'Microbiologic evaluation')
● Changes to antibiotic therapy – For children with ABRS in whom other causes of symptoms have been excluded by history or
examination, we modify initial antimicrobial therapy:
• Pathogen isolated from sinus aspirate – Antimicrobial therapy should be modified according to results of sinus aspirate
culture as soon as the results are available.
• No pathogen isolated or cultures not performed – For children with ABRS who fail to improve despite parenteral therapy with
ampicillin-sulbactam, a third generation cephalosporin, or levofloxacin, and in whom no pathogen is isolated or sinus aspirate
cultures are unavailable or contraindicated, the addition of vancomycin with or without metronidazole may be warranted [71].
Vancomycin provides activity against highly resistant S. pneumoniae and S. aureus; metronidazole provides activity against
anaerobes.
- Vancomycin ( table 7)
- Metronidazole 30 mg/kg per day IV divided every six hours (maximum 4 g/day)
● Response to escalated therapy – For patients who improve after changes to initial antimicrobial therapy, we continue
antimicrobial therapy until they are free of symptoms for seven days (ie, a minimum of 10 days) [38,58].
For patients who fail to respond to changes to escalated antimicrobial therapy, consultation with an infectious disease specialist
and/or otolaryngologist is suggested.
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately.
(See "Society guideline links: Acute rhinosinusitis".)
INFORMATION FOR PATIENTS
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are
written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about
a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond
the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade
reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or email these topics to your patients.
(You can also locate patient education articles on a variety of subjects by searching on "patient education" and the keyword[s] of
interest.)
● Basics topic (see "Patient education: Sinusitis in children (The Basics)")
SUMMARY AND RECOMMENDATIONS
● Microbiology – Haemophilus influenzae (nontypeable), Streptococcus pneumoniae, and Moraxella catarrhalis are the predominant
causes of uncomplicated acute bacterial rhinosinusitis (ABRS) in otherwise healthy children. (See 'Microbiology' above.)
● Outpatient management – We generally treat children with ABRS who are well-appearing and without complications or suspected
complications ( table 3) as outpatients. (See 'Outpatient management' above.)
• Empiric antibiotics – For children with uncomplicated ABRS ( table 1), we suggest treatment with antimicrobial therapy
rather than observation (Grade 2B). Improvement and resolution of symptoms are more likely with antibiotic therapy. Although
we usually initiate antimicrobial therapy at the time of presentation, an alternative is to offer children with ABRS and 10 days of
symptoms that are neither severe nor worsening the option of a three-day period of observation. (See 'When to initiate
antibiotics' above.)
For initial treatment of uncomplicated ABRS in most children, we suggest amoxicillin-clavulanate rather than other oral
antibiotics ( algorithm 1A-B) (Grade 2B). We prefer amoxicillin-clavulanate because of its spectrum of activity, effectiveness,
and safety. (See 'Empiric antibiotics' above.)
For children whose symptoms worsen substantially at any time or who fail to improve after three days of oral antibiotics, we
broaden antimicrobial activity or switch to a different class ( algorithm 1A-B and table 6). (See 'Treatment failure in
outpatients' above.)
• Symptomatic management – For the management of nasal symptoms in children who do not have allergic rhinitis, we suggest
topical saline rather than decongestants, antihistamines, or intranasal glucocorticoids (Grade 2C). Although evidence of benefit
is limited, topical saline is inexpensive and unlikely to be harmful. (See 'Symptomatic therapy' above.)
The treatment of allergic rhinitis is discussed separately. (See "Pharmacotherapy of allergic rhinitis", section on 'Approach to
specific patient groups'.)
● Inpatient management
• Indications for hospitalization – Indications for hospitalization and parenteral therapy include (see 'Indications for
hospitalization' above):
- Toxic appearance (lethargic, poorly perfused, cardiorespiratory compromise)
- Complications or suspected complications ( table 3); children older than one year with mild preseptal cellulitis are a
possible exception
- Failure of outpatient therapy
• Complicated ABRS – For children hospitalized with complicated ABRS ( table 3), we perform sinus imaging with contrast-
enhanced CT in patients with symptoms or signs of intracranial or orbital complications if imaging was not previously
performed. Additional management varies depending upon the complication. It is discussed separately. (See 'Complicated
ABRS' above.)
• Uncomplicated ABRS – For children hospitalized with uncomplicated ABRS, we provide empiric therapy with activity against
highly resistant S. pneumoniae, ampicillin-resistant H. influenzae, and ampicillin-resistant M. catarrhalis ( table 6). We adjust the
regimen based upon culture results (if available) and clinical response. (See 'Uncomplicated ABRS' above.)
For children whose symptoms worsen substantially at any time or who fail to improve after three days of intravenous
antibiotics, additional evaluation is warranted, including evaluation for complications and quantitative sinus aspirate cultures if
these studies were not obtained at the time of admission. (See 'Treatment failure in inpatients' above.)
Use of UpToDate is subject to the Terms of Use.
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Topic 5999 Version 44.0
GRAPHICS
Clinical presentations of acute bacterial rhinosinusitis in children
Clinical presentation Description
Persistent symptoms Nasal discharge or cough or both for >10 days without improvement
Severe symptoms Onset with temperature of ≥39°C (102.2°F) and purulent nasal discharge for ≥3 consecutive days
Worsening symptoms Respiratory symptoms (nasal discharge or cough, or both) that worsen after initial improvement, or
Onset of new fever or severe headache
Graphic 103739 Version 1.0
Differential diagnosis of acute bacterial rhinosinusitis in children
Major consideration Clinical feature Viral rhinosinusitis Bacterial rhinosinusitis
Viral URI Fever Typically absent In severe presentation,

When present, fever occurs temperature may be ≥39°C
early (in first 24 hours), is low (102.2°F) for >3 days
grade, and resolves within the In worsening presentation,
first 2 days fever may develop or recur on
day 6 to 7 of illness after initial
improvement
Nasal discharge Peaks on days 3 to 6 then Fails to improve substantially or

steadily improves worsens over time
Cough Peaks on days 3 to 6 then Fails to improve substantially or

steadily improves worsens over time
Ill appearance Absent May occur (in severe

presentation)
Severe headache Absent May be a sign of severe illness

or complication
Clinical course Symptoms peak in severity on Symptoms are present for ≥10
days 3 to 6 and then improve days without improvement
Other considerations Associated clinical features
Allergic rhinitis May be associated with allergic facies:

Infraorbital edema
Accented lines or folds below the lower eyelids
Transverse nasal crease
May be associated with cobblestoning of posterior pharynx
Nasal foreign body Foul odor

Serosanguineous nasal drainage
May be directly observed
Infected adenoids Downward displacement of soft palate (adenoids usually not seen)
Mouth breathing
Halitosis
Snoring
Gastroesophageal reflux May be associated with persistent nasal discharge, wheezing, and cough
Pertussis (particularly catarrhal Nasal symptoms usually precede cough

stage) Cough is paroxysmal
Cough may be followed by inspiratory whoop
Cough may be associated with posttussive emesis
ABRS: acute bacterial rhinosinusitis; URI: upper respiratory infection.
Complications of acute bacterial rhinosinusitis in children
Complications involving the orbit Clinical manifestations
Preseptal complications
Preseptal cellulitis Swelling of eyelids/periorbital area

Erythema of eyelids/periorbital area
Absence of proptosis
Normal eye movements
Postseptal complications
Orbital cellulitis* Periorbital swelling
Orbital subperiosteal abscess* Erythema of eyelids

Pain with eye movement
Orbital abscess*
Conjunctival swelling (chemosis)
Proptosis
Limitation of eye movements
Double vision
Vision loss
Intracranial complications Clinical manifestations
Septic cavernous sinus thrombosis Ptosis

Proptosis
Limitation of eye movements
Bilateral periorbital edema
Headache
Change in mental status
Meningitis Fever
Headache
Nuchal rigidity
Osteomyelitis of the frontal bone with subperiosteal abscess (Pott puffy Fever
tumor) Forehead or scalp swelling and tenderness
Headache
Photophobia
Vomiting
Lethargy
Epidural abscess¶ Focal neurologic signs

Headache
Lethargy
Nausea
Vomiting
Papilledema
Subdural abscess¶ Fever

Severe headache
Meningeal irritation
Progressive neurologic deficits
Seizures
Vomiting
Papilledema
Brain abscess¶ Headache

Neck stiffness
Vomiting
Focal neurologic deficits
Papilledema
Third and sixth cranial nerve deficits
* Imaging is necessary to distinguish between orbital cellulitis, orbital subperiosteal abscess, and orbital abscess.
¶ Imaging is necessary to distinguish between epidural abscess, subdural abscess, and brain abscess.
Approach to empiric antimicrobial therapy for outpatient treatment of uncomplicated ABRS in

children with no contraindications to penicillin antibiotics
This algorithm is intended for use with UpToDate content on ABRS in children. Inpatient therapy is indicated for patients who have
toxic-appearance (eg, lethargy, poor perfusion, cardiorespiratory compromise) and complications or suspected complications, with the
possible exception of mild preseptal cellulitis in children older than 1 year. If a pathogen is identified, antimicrobial therapy should be
adjusted according to susceptibilities. Refer to relevant UpToDate content for additional information (eg, adverse reactions to penicillin
antibiotics, evaluation for complications, treatment of ABRS in children with contraindications to penicillin antibiotics).
ABRS: acute bacterial rhinosinusitis; CCS: clinical severity score; PNSP: penicillin nonsusceptible Streptococcus pneumoniae; IV:
intravenously; ID: infectious diseases; ORL: otorhinolaryngology; IM: intramuscular.
¶ If vomiting precludes administration of oral antibiotics, can administer ceftriaxone 50 mg/kg IM for one dose (maximum dose 1 g),
followed by amoxicillin-clavulanate 24 hours later.
Source:
1. Reproduced with permission from Pediatrics, Vol. 124, Pages 9-15, Copyright © 2009 by the AAP.
Approach to empiric antimicrobial therapy for

outpatient treatment of uncomplicated ABRS in
children with contraindications to penicillin antibiotics
This algorithm is intended for use with UpToDate content on ABRS in

children. Inpatient therapy is indicated for patients who have toxic-
appearance (eg, lethargy, poor perfusion, cardiorespiratory compromise)
and complications or suspected complications, with the possible
exception of mild preseptal cellulitis in children older than 1 year. If a
pathogen is identified, antimicrobial therapy should be adjusted
according to susceptibilities. Refer to relevant UpToDate content for
additional information (eg, adverse drug reactions to penicillins,
cephalosporin allergy, evaluation for complications, empiric treatment of
ABRS in children without contraindications to penicillin).
ABRS: acute bacterial rhinosinusitis; SJS, Stevens-Johnson syndrome;

TEN: toxic epidermal necrolysis; IV: intravenously; ID: infectious diseases;
ORL: otorhinolaryngology; IM: intramuscular.
* If vomiting precludes administration of oral antibiotics, admit for

parenteral therapy until vomiting resolves.
¶ If vomiting precludes administration of oral antibiotics, can administer

ceftriaxone 50 mg/kg IM for one dose (maximum dose 1 g), followed by
cefpodoxime or cefdinir 24 hours later.
Δ For those who failed treatment with levofloxacin at 10 mg/kg per day
orally, it is reasonable to try levofloxacin at 20 mg/kg per day IV. For
those who failed treatment with oral levofloxacin 20 mg/kg per day,
meropenem is appropriate.
Clinical severity score for acute bacterial rhinosinusitis in children and adolescents
Symptom or sign Points
Abnormal nasal or postnasal discharge
Minimal 1
Severe 2
Nasal congestion 1
Cough 2
Malodorous breath 1
Facial tenderness 3
Erythematous nasal mucosa 1
Fever*
<38.5°C 1
≥38.5°C 2
Headache (retro-orbital)/irritability
Severe 3
Mild 1
A total score <8 indicates mild/moderate disease. A total score ≥8 indicates severe disease.
* Within 24 hours of presentation, either observed or according to history and documented with thermometer.
Reproduced with permission from Pediatrics, Vol. 124, Pages 9-15, Copyright © 2009 by the AAP.
Risk factors for penicillin-nonsusceptible Streptococcus pneumoniae and ampicillin-resistant Haemophilus

influenzae in children with acute bacterial rhinosinusitis (ABRS)
Living in an area with high endemic rates (ie, ≥10%) of invasive penicillin nonsusceptible S. pneumoniae
Age <2 years
Daycare attendance
Antibiotic therapy within the month before presentation
Hospitalization within the past 5 days
Unimmunized or underimmunized with pneumococcal conjugate vaccine
Refer to UpToDate content on the management of ABRS in children and pneumococcal vaccination in children for additional information.
Antimicrobial regimens for acute bacterial rhinosinusitis in children[1,2]
Indication Initial therapy Second-line therapy*
Outpatient therapy
Mild/moderate disease¶ Preferred: Amoxicillin-clavulanate 45 mg/kgΔ per day Either:

orally divided in 2 doses (maximum 1.75 g/day) Amoxicillin-clavulanate 90 mg/kg§ per day orally
Alternative:◊ Amoxicillin 90 mg/kg per day orally divided in 2 doses (maximum 4 g/day), or
divided in 2 doses (maximum 4 g/day) Ceftriaxone 50 mg/kg once per day IV or IM
(maximum 4 g/day) for 1 to 3 days followed by
appropriate oral regimen
Severe disease or risk Preferred: Amoxicillin-clavulanate 90 mg/kg§ per day One of the following:
for antibiotic orally divided in 2 doses (maximum 4 g/day) Ceftriaxone 50 mg/kg once per day IV or IM
resistance¶ (maximum 4 g/day) for 1 to 3 days followed by
appropriate oral regimen, or
Cefpodoxime 10 mg/kg per day orally divided in 2
doses (maximum 400 mg/day), or
Cefdinir 14 mg/kg per day orally divided in 1 or 2
doses (maximum 600 mg/day), or
Levofloxacin¥ 10 to 20 mg/kg per day orally
divided in 1 or 2 doses (maximum 500 mg/day)
Alternatives:◊ Either:
Cefpodoxime 10 mg/kg per day orally divided in 2 Amoxicillin-clavulanate (depending upon the
doses (maximum 400 mg/day), or rationale for initial therapy with cefpodoxime or
Cefdinir 14 mg/kg per day orally divided in 1 or 2 cefdinir) 90 mg/kg§ per day orally divided in 2
doses (maximum 600 mg/day), or doses (maximum 4 g/day), or
Levofloxacin¥ 10 to 20 mg/kg per day orally
divided in 1 or 2 doses (maximum 500 mg/day)
Levofloxacin¥ 10 to 20 mg/kg per day orally divided in Inpatient therapy (see below)
1 or 2 doses (maximum 500 mg/day)
Penicillin allergy: Levofloxacin¥ 10 to 20 mg/kg per day orally divided in Inpatient therapy (see below)
Immediate (eg, 1 or 2 doses (maximum 500 mg/day)
anaphylaxis) or serious
delayed reaction (eg,
Stevens-Johnson
syndrome, toxic
epidermal necrolysis)
Penicillin allergy: Mild Cefpodoxime 10 mg/kg per day orally divided in 2 Levofloxacin¥ 10 to 20 mg/kg per day orally divided in
delayed reaction doses (maximum 400 mg/day), or 1 or 2 doses (maximum 500 mg/day)
Cefdinir 14 mg/kg per day orally divided in 1 or 2
doses (maximum 600 mg/day)
Vomiting Ceftriaxone 50 mg/kg per day IV or IM once

(maximum 1 g/day), followed 24 hours later by
appropriate oral therapy
Inpatient therapy
ABRS requiring Ampicillin-sulbactam 200 to 400 mg/kg per day IV Addition of vancomycin (60 mg/kg per day IV) divided
hospitalization¶ divided every 6 hours (maximum 8 g ampicillin every 6 hours (maximum 4 g/day)† and possibly,
component/day), or Metronidazole** (30 mg/kg per day IV) divided every 6
Ceftriaxone 50 mg/kg per day IV divided every 12 hours (maximum 4 g/day)
hours (maximum 4 g/day), or
Levofloxacin¥ 10 to 20 mg/kg per day IV divided every
12 or 24 hours (maximum 500 mg/day)
The doses above are intended for patients with normal renal function. The doses of many of these agents must be adjusted in the setting of renal
insufficiency; refer to the Lexicomp pediatric drug monograph for renal dose adjustments.
IV: intravenously; IM: intramuscularly; ABRS: acute bacterial rhinosinusitis.
* Second-line therapies are indicated for children who worsen within three days or fail to improve after three days of initial therapy and in whom
no pathogen is identified. If a pathogen is identified, antimicrobial therapy should be adjusted according to susceptibilities.
¶ Refer to UpToDate topic on treatment of acute bacterial rhinosinusitis in children for definitions.
Δ Based on amoxicillin component; in the United States, use 200 or 400 mg/5 mL suspension or 200 or 400 mg chewable tablet for appropriate
clavulanate ratio.
◊ Alternative regimens may not cover resistant pathogens as well as the suggested initial regimen.
§ Based on amoxicillin component; in the United States, use 600 mg/5 mL suspension or 1000 mg/62.5 mg extended-release tablet for
appropriate clavulanate ratio.
¥ Levofloxacin should be reserved for cases in which there is no other safe and effective alternative.
† Individualize vancomycin dose and interval based on serum concentration monitoring, when indicated.
** Metronidazole may be warranted for anaerobic coverage.
References:
1. Chow AW, Benninger MS, Brook I, et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Dis 2012; 54:e72.
2. Jackson MA, Schutze GE, Committee on Infectious Diseases. The use of systemic and topical fluoroquinolones. Pediatrics 2016; 138.
Sinusitis antral puncture
Illustration of antral puncture on coronal computed tomography image. A

trocar is passed beneath the inferior turbinate, through the lateral nasal wall
to reach the maxillary sinus antrum.
Reprinted by permission of Edizioni Minerva Medica from Minerva Pediatrica 2015;67:357-68.
Alternative approaches to vancomycin dosing for children and adolescents with normal kidney function
Subsequent dose and interval

Strategy Initial dose and interval
adjustments
Traditional approach for children >1 month and Typically 15 mg/kg per dose IV every 6 to 8 Either:
adolescents hours[1] : Continue initial dose (for most children,
Use the every-6-hour interval for serious particularly if duration of vancomycin is
infections* expected to be <3 days)¶
Maximum daily dose: 4 g/day Based on trough-guided serum
concentration monitoring for select
children (eg, those with renal
dysfunction, infective endocarditis, risk
factors for altered vancomycin kinetics
[eg, fluid overload, critical illness])
AUC-guided approachΔ[2] Generally requires consultation with a clinical Based on AUC-guided serum concentration
pharmacist monitoring (generally requires consultation
with a clinical pharmacist)
The approach to vancomycin dosing is generally determined at the institutional level. Refer to UpToDate content on invasive staphylococcal
infections in children for details of trough-guided and AUC-guided vancomycin dosing and traditional dosing of vancomycin for neonates.
IV: intravenous; AUC: area under the curve; MRSA: methicillin-resistant Staphylococcus aureus.
* Serious infections may include, but are not limited to, infective endocarditis, pneumonia requiring hospitalization, osteomyelitis, central
nervous system infection, and infection causing critical illness.
¶ The value of trough-monitoring before achieving steady state (usually on day 2 to 3 of treatment) is uncertain.
Δ Some experts suggest this approach for serious* MRSA infections in children of all ages.
References:
1. American Academy of Pediatrics. Tables of antibacterial drug dosages. In: Red Book: 2021-2024 Report of the Committee on Infectious Diseases, 32nd ed, Kimberlin DW,
Brady MT, Jackson MA, Long SS (Eds), American Academy of Pediatrics, Itasca, IL 2021. p.876.
2. Rybak MJ, Le J, Lodise TP, et al. Therapeutic monitoring of vancomycin for serious methicillin-resistant Staphylococcus aureus infections: A revised consensus guideline and
review by the American Society of Health-System Pharmacists, the Infectious Diseases Society of America, the Pediatric Infectious Diseases Society, and the Society of
Infectious Diseases Pharmacists. Am J Health Syst Pharm 2020; 77:835.
Contributor Disclosures
Ellen R Wald, MD No relevant financial relationship(s) with ineligible companies to disclose. Sheldon L Kaplan, MD Grant/Research/Clinical Trial
Support: MeMed Diagnostics [Bacterial and viral infections];Merck [Staphylococcus aureus];Pfizer [Streptococcus pneumoniae].
Consultant/Advisory
Boards: MeMed Advisory Board [Diagnostics bacterial and viral infections].
Other Financial Interest: Elsevier [Pediatric infectious diseases];Pfizer
[PCV13].
All of the relevant financial relationships listed have been mitigated. Glenn C Isaacson, MD, FAAP No relevant financial relationship(s) with
ineligible companies to disclose. Robert A Wood, MD Grant/Research/Clinical Trial Support: Aimmune [Food allergy]; Astellas [Food allergy]; DBV
Technologies [Food allergy]; HAL-Allergy [Food allergy]; NIAID [Food allergy]; Novartis [Food allergy]; Regeneron [Food allergy]; Sanofi [Food allergy].
Consultant/Advisory Boards: Aravax [Food allergy].
All of the relevant financial relationships listed have been mitigated. Mary M Torchia, MD No
relevant financial relationship(s) with ineligible companies to disclose.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level
review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all
authors and must conform to UpToDate standards of evidence.
Conflict of interest policy

Acute Bacterial Rhinosinusitis in Children - Microbiology and Management - UpToDate

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1/11/22, 6:55 Acute bacterial rhinosinusitis in children: Microbiology and management - UpToDate

Official reprint from UpToDate®

Acute bacterial rhinosinusitis in children: Microbiology and management

● Age <2 years

● Antibiotic therapy within the month before presentation

● Hospitalization within the past five days

WHEN TO INITIATE ANTIBIOTICS

● A clinical presentation of severe symptoms or worsening symptoms ( table 1)

● Receipt of antibiotic therapy in the previous four weeks

● Isolation of resistant or rare pathogens from sinus aspirate (if performed)

● Diagnosed or suspected immunodeficiency

● Recurrent ABRS, particularly if it exacerbates underlying pulmonary conditions (eg, asthma)

• Initial treatment with high-dose amoxicillin-clavulanate – We switch to one of the following:

• Initial treatment with cefpodoxime or cefdinir – We switch to either:

• For children with no contraindications to penicillins, we use:

- Ceftriaxone 50 mg/kg per day IV divided every 12 hours (maximum 4 g/day)

• For children with contraindications to penicillins, we use either:

- Meropenem 60 mg/kg per day divided every 8 hours (maximum 3 g/day)

● Toxic appearance (eg, lethargic, poorly perfused, cardiorespiratory compromise)

● Preseptal (periorbital) cellulitis (see "Preseptal cellulitis", section on 'Treatment')

● Brain abscess (see "Treatment and prognosis of bacterial brain abscess")

SOCIETY GUIDELINE LINKS

INFORMATION FOR PATIENTS

● Basics topic (see "Patient education: Sinusitis in children (The Basics)")

SUMMARY AND RECOMMENDATIONS

- Toxic appearance (lethargic, poorly perfused, cardiorespiratory compromise)

- Failure of outpatient therapy

Use of UpToDate is subject to the Terms of Use.

Clinical presentations of acute bacterial rhinosinusitis in children

Clinical presentation Description

Onset of new fever or severe headache

Graphic 103739 Version 1.0

Major consideration Clinical feature Viral rhinosinusitis Bacterial rhinosinusitis

Viral URI Fever Typically absent In severe presentation,

Nasal discharge Peaks on days 3 to 6 then Fails to improve substantially or

Cough Peaks on days 3 to 6 then Fails to improve substantially or

Ill appearance Absent May occur (in severe

Severe headache Absent May be a sign of severe illness

Other considerations Associated clinical features

Allergic rhinitis May be associated with allergic facies:

Nasal foreign body Foul odor

Pertussis (particularly catarrhal Nasal symptoms usually precede cough

ABRS: acute bacterial rhinosinusitis; URI: upper respiratory infection.

Graphic 83921 Version 4.0

Complications of acute bacterial rhinosinusitis in children

Complications involving the orbit Clinical manifestations

Preseptal cellulitis Swelling of eyelids/periorbital area

Orbital cellulitis* Periorbital swelling

Orbital subperiosteal abscess* Erythema of eyelids

Intracranial complications Clinical manifestations

Septic cavernous sinus thrombosis Ptosis

Epidural abscess¶ Focal neurologic signs

Subdural abscess¶ Fever

Brain abscess¶ Headache

Third and sixth cranial nerve deficits

Graphic 83408 Version 5.0

Approach to empiric antimicrobial therapy for outpatient treatment of uncomplicated ABRS in

Graphic 135260 Version 2.0

Approach to empiric antimicrobial therapy for

This algorithm is intended for use with UpToDate content on ABRS in

ABRS: acute bacterial rhinosinusitis; SJS, Stevens-Johnson syndrome;

* If vomiting precludes administration of oral antibiotics, admit for

¶ If vomiting precludes administration of oral antibiotics, can administer