Family Medicine Residency Clinic (Dr. Hughes) and Family Health Clinic (Dr. Hungerford), Mike O’Callaghan Military Medical Center, Las Vegas, NV; Ear Nose and Throat Specialists of Alaska, Wasilla (Dr. Jensen) pamela.r.hughes4.mil@mail.mil
The authors reported no potential conflict of interest relevant to this article.
The opinions and assertions contained herein are those of the authors and are not to be construed as official or as reflecting the views of the US Air Force Medical Department, the US Air Force at large, or the US Department of Defense.
Diagnosis of ABRS in children is defined as an acute upper respiratory infection (URI) accompanied by persistent nasal discharge, daytime cough for ≥ 10 days without improvement, an episode of “double sickening,” or severe onset with a temperature ≥ 102°F and purulent nasal discharge for 3 days.15
Weigh the decision to treat acute bacterial rhinosinusitis with antibiotics against the risk for potential adverse reactions and within the context of antibiotic stewardship.
Initial presentations of viral URIs and ABRS are almost identical; thus, persistence of symptoms is key to diagnosis.6 Nasal discharge tends to appear several days after initial symptoms manifest for viral infections including influenza. In children < 5 years of age, the most common complication involves the orbit.15 Orbital complications generally manifest with eye pain and/or periorbital swelling and may be accompanied by proptosis or decreased functioning of extraocular musculature. The differential diagnosis for orbital complications includes cavernous sinus thrombosis, orbital cellulitis/abscess, subperiosteal abscess, and inflammatory edema.27,28 Intracranial complications are also possible with severe ABRS.12
Radiology studies are not recommended for the initial diagnosis of ABRS in children, as again, imaging does not differentiate between viral and bacterial etiologies. However, in children with complications such as orbital or cerebral involvement, a contrast-enhanced CT scan of the paranasal sinuses is indicated.15
Antibiotic therapy is indicated in children with a diagnosis of severe ABRS or in cases of “double sickening.” Clinicians may consider watchful waiting for 3 additional days before initiating antibiotics in patients meeting criteria for ABRS.Amoxicillin with or without clavulanate is the antibiotic of choice.15
For penicillin-allergic children without a history of anaphylactoid reaction, treatment with cefpodoxime, cefdinir, or cefuroxime is appropriate. For children with a history of anaphylaxis, treatment with a combination of clindamycin (or linezolid) and cefixime is indicated. Alternatively, a fluoroquinolone such as levofloxacin may be used, but adverse effects and emerging resistance limit its use.15
