Acute Bacterial Rhinosinusitis Clinical Pathway, Primary Care, Emergency Department and Inpatient – Antibiotic Recommendations

Acute Bacterial Rhinosinusitis Clinical Pathway – Primary Care, Emergency Department and Inpatient

Antibiotic Recommendations

Antibiotic Therapy for Acute Bacterial Rhinosinusitis (ABRS)

General Principles

  • Most sinusitis, particularly in young children, is caused by viral infections and does not require antibiotic treatment.
  • For Acute Bacterial Rhinosinusitis (ABRS), antibiotics may lead to faster resolution, but in placebo-controlled trials, up to 80% of children who did not receive antibiotics also improved.
  • Amoxicillin is recommended over amoxicillin-clavulanate for most children with non-severe ABRS who haven’t received recent antibiotics. Studies show no difference in treatment failure between children treated with amoxicillin or amoxicillin-clavulanate. The incidence of antibiotic-associated diarrhea is higher in those treated with amoxicillin-clavulanate.
  • Oral cephalosporins (including cefdinir) are inferior to high-dose amoxicillin for S. pneumoniae, the most common cause of acute bacterial rhinosinusitis that requires antibiotic treatment. Oral cephalosporins can be used for true amoxicillin allergy but are unlikely to provide additional benefit in the case of amoxicillin or amoxicillin-clavulanate treatment failure.
  • Azithromycin has poor activity against Streptococcus pneumoniae and Haemophilus influenzae and is not recommended for acute bacterial rhinosinusitis.
  • Consider ENT consult for children with prolonged symptoms greater than 30 days, recurrence, or treatment failure with amoxicillin/clavulanate or levofloxacin.

Definitions

Antibiotic treatment failure: no clinical improvement, e.g. improvement in fever, cough, and nasal drainage, in 72 hrs.

Common Pathogens

  • S. pneumoniae (pneumococcus)
  • Nontypeable Haemophilus influenzae
  • Moraxella catarrhalis
Indications First-Line Therapy Allergy to First-Line β-Lactam
Assess Need for Alternative		 Duration/Comments
Non-Severe ABRS
Worsening or persistent
  • Amoxicillin, PO
    • 90 mg/kg/day of amoxicillin component in
      2 divided doses
    • Max: 2,000 mg/dose
  • Cefdinir, PO
    • ≥ 6 months: 7 mg/kg/dose twice daily
    • Max: 600 mg/day
  • Cefpodoxime, PO
    • ≥ 2 months: 10 mg/kg/day in 2 divided doses
    • Max: 200 mg/dose
 5 days
Non-Severe ABRS with First-Line Treatment Failure or Recent Amoxicillin (Last 30 Days)
  • Amoxicillin-Clavulanate, PO
    • 90 mg/kg/day of amoxicillin component in
      2 divided doses
    • Max: 2,000 mg/dose
    • For oral suspension, use ES formulation and for tablet use ER formulation
  • Levofloxacin, PO
    • ≥ 6 months and < 5 years: 10 mg/kg/dose twice daily
    • Max: 375 mg/dose
    • ≥ 5 years: 10 mg/kg/dose daily
    • Max: 750 mg/dose
 5 days
Severe ABRS
  • Amoxicillin-Clavulanate, PO
    • 90 mg/kg/day of amoxicillin component in
      2 divided doses
    • Max: 2,000 mg/dose
    • For oral suspension, use ES formulation and for tablet use ER formulation
  • Levofloxacin, PO
    • ≥ 6 months and < 5 years: 10 mg/kg/dose twice daily
    • Max: 375 mg/dose
    • ≥ 5 years: 10 mg/kg/dose daily
    • Max: 750 mg/dose
 7 days
  • CHOP Formulary for complete drug information.
  • Penicillin allergy: Assess the nature of the penicillin allergy per the Clinical Pathway for the Assessment of Children with a Penicillin Drug Allergy. Severe penicillin allergy includes any of the following: anaphylaxis, angioedema, cardiac arrest, respiratory distress, severe cutaneous reaction (e.g., Stevens-Johnson syndrome, erythema multiforme, DRESS and TEN). All other reactions are considered non-severe. Children who experience hives or mild allergic reaction with penicillin/amoxicillin can still receive cephalosporins.

Reference

Treatment Failure and Adverse Events After Amoxicillin-Clavulanate vs Amoxicillin for Pediatric Acute Sinusitis