Wise Use of Antibiotics: Acute Bacterial Rhinosinusitis – Updates and Pearls for the Pediatric Practitioner
Column Author: Joshua Saucedo, MD|Pediatric Emergency Medicine Fellow
Column Editor: Rana El Feghaly, MD, MSCI | Director, Infectious Diseases Clinical Services; Director, Outpatient Antibiotic Stewardship Program; Medical Director, Vaccines for Children (VFC) Program
Acute bacterial rhinosinusitis (ABRS) has been traditionally treated with prolonged courses of antibiotics of 10 days or greater. Although the 2012 Infectious Diseases Society of America guidelines recommended shortening antibiotic durations for adults with ABRS to five to seven days based on robust data, longer durations continue to be recommended to children due to historical practice and the lack of evidence from pediatric studies.1 More recent national and international guidelines with a focus on adult and pediatric patients recommend shorter duration of antibiotics.
The Diagnosis of ABRS Continues to Be Clinical.
We continue to rely on clinical criteria to attempt to differentiate ABRS from viral rhinosinusitis. There are currently three criteria: (1) Persistent illness – Patients with history of persistent nasal discharge, daytime cough, or both lasting 10 or more days without improvement; (2) Worsening illness – Patients who experience worsening nasal discharge, daytime cough, or fever after initial improvement in these symptoms; (3) Severe illness – Patients presenting with severe onset of symptoms with fevers 39°C or greater and purulent nasal discharge for at least three days.1 The color of the secretions has not been shown to differentiate bacterial from viral infections.2
Complications of ABRS Are Rare but May Be Severe.
Complications of ABRS are estimated to occur in only 5% of hospitalized patients with ABRS. Those include pre-septal (~70% complications), post-septal (~25% complications), intracranial (only 5%-10% complications), and frontal bone osteomyelitis (very rare). Complications should be considered when patients present with periorbital edema/erythema, displaced globe, double vision, ophthalmoplegia, reduced visual acuity, severe headache, frontal swelling, signs of sepsis or meningitis, or neurological signs. If these alarm signs and symptoms are noted, immediate evaluation is warranted.
Are Antibiotics Necessary for All Patients with ABRS?
Although many studies suggest that placebo results in similar outcomes to antibiotics for adults with ABRS, a recent metanalysis of six pediatric studies showed that antibiotics reduced the rate of treatment failure by 41%, although resulted in higher rates of side effects.3 Until more studies are available, antibiotics continue to be recommended for children with ABRS. That said, it is important to be diligent with diagnosis so that antibiotics are not prescribed to children with viral infections.
What Is the Best Antibiotic to Use for ABRS?
In children with risk factors of resistance, i.e., age <2 years, children who attend child care, those with antibiotic exposure within the past month, or those who have been hospitalized within the past five days, we recommend high-dose amoxicillin-clavulanate. For children without risk factors of antibiotic resistance, high-dose amoxicillin continues to provide excellent coverage with fewer side effects.4
Are 5-7 Days of Antibiotics Sufficient for Treating Children with ABRS?
Since ABRS is an uncommon pediatric diagnosis, studies are hard to come by and often need to be supplemented by adult studies to establish significant findings. Multiple international guidelines support shorter durations citing comparable efficacy and safety. In addition, shorter durations minimize risk of resistance, favor fewer adverse events, and may result in higher medication adherence rates.
The National Institute for Health and Care Excellence (NICE) in the United Kingdom made updates to their clinical practice guidelines in 2017 for adults and children based on high-quality evidence from one systematic review that recommended a five-day treatment course. This review took into consideration the overall efficacy and safety of antibiotics while minimizing the risk of resistance.5
Orlandi et al. (2021), through a meta-analysis of randomized control trials, set out to review new evidence regarding the progress and understanding of treatment in rhinologic diseases. They provided updates to the first international consensus statement on rhinosinusitis treatment to limit treatment to no more than 10 days, favoring shorter courses due to fewer adverse events and higher medication adherence.6
Similarly, Fokkens et al. (2020) reviewed two pediatric randomized control trials when updating the European Position Paper. They noted that there was no significant difference between placebo and antibiotic treatment, though found again that pediatric data was limited. Ultimately, they recommended a short course of antibiotics of less than 10 days if an antibiotic prescription was given.7
The World Health Organization (WHO) recommends a five-day treatment course through the WHO AWaRe Antibiotic Book (2022) based on their review of three position papers.8
Most recently, the American Academy of Pediatrics Committee on Infectious Diseases updated the Red Book (2024) to recommend five to seven days of treatment for ABRS, although this recommendation was based primarily on adult data and data for acute otitis media.9
Practical Considerations
Following the diagnosis of ABRS, several considerations should be made regarding the severity of symptoms and antibiotic resistance risk factors. Patients presenting with severe symptoms (such as facial pain and elevated temperatures greater than 39°C) may benefit from longer courses of up to 10 days. Most patients otherwise could be treated with five to seven days.
Shortening antibiotic duration goes a long way in improving the value of antibiotics by reducing unnecessary antibiotic exposure and, subsequently, reducing a primary driver of antimicrobial resistance. Decreasing antibiotic durations also decreases the risk of adverse effects and improves cost-effectiveness for families and the health care system. The Children’s Mercy Department of Evidence Based Practice recently reviewed the most up-to-date literature and created our new ABRS Clinical Pathway to include recommendations for shorter antibiotic durations.
Where Can I Find More Information on ABRS?
ABRS Clinical Pathway: https://www.childrensmercy.org/health-care-providers/evidence-based-practice/cpgs-cpms-and-eras-pathways/acute-bacterial-rhinosinusitis/
Outpatient Antibiotic Handbook: https://www.childrensmercy.org/siteassets/media-documents-for-depts-section/documents-for-health-care-providers/evidence-based-practice/clinical-practice-guidelines--care-process-models/outpatient-antibiotic-handbook.pdf
References:
- Chow AW, Benninger MS, Brook I, et al; Infectious Diseases Society of America. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Dis. 2012;54(8):e72-e112. PMID: 22438350. doi:10.1093/cid/cir1043
- Shaikh N, Hoberman A, Shope TR, et al. Identifying children likely to benefit from antibiotics for acute sinusitis: a randomized clinical trial. JAMA. 2023;330(4):349-358. doi:10.1001/jama.2023.10854. Erratum in: JAMA. 2024;332(2):173. PMID: 37490085. PMCID: PMC10370259. doi:10.1001/jama.2024.11869
- Conway SJ, Mueller GD, Shaikh N. Antibiotics for acute sinusitis in children: a meta-analysis. Pediatrics. 2024;153(5):e2023064244. PMID: 38646685. PMCID: PMC11035158. doi:10.1542/peds.2023-064244
- Wald ER, Applegate KE, Bordley C, et al; American Academy of Pediatrics. Clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years. Pediatrics. 2013;132(1):e262-80. PMID: 23796742. doi:10.1542/peds.2013-1071
- National Institute for Health and Care Excellence. Sinusitis (acute): antimicrobial prescribing. NICE guideline NG79. October 27, 2017. https://www.nice.org.uk/guidance/ng79
- Orlandi RR, Kingdom TT, Smith TL, et al. International consensus statement on allergy and rhinology: rhinosinusitis 2021. Int Forum Allergy Rhinol. 2021;11(3):213-739. doi:10.1002/alr.22741
- Fokkens WJ, Lund V J, Hopkins C, et al. European position paper on rhinosinusitis and nasal polyps. 2020;58(Suppl S29):1-464. doi:10.4193/Rhin20.600
- The WHO AWaRe (Access, Watch, Reserve) antibiotic book. World Health Organization; 2022. https://www.who.int/publications/i/item/9789240062382
- Kimberlin DW, Banerjee R, Barnett ED, Lynfield R, Sawyer MH, eds; Committee on Infectious Diseases, American Academy of Pediatrics. Red Book: 2024–2027 Report of the Committee on Infectious Diseases. 33rd ed. American Academy of Pediatrics; 2024. https://doi.org/10.1542/9781610027373