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/kg^Δ per day orally divided in 2 doses (maximum 1.75 g/day) Alternative:^◊ Amoxicillin 90 mg/kg per day orally divided in 2 doses (maximum 4 g/day)	Either: Amoxicillin-clavulanate 90 mg/kg^§ per day orally divided in 2 doses (maximum 4 g/day), or 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 for antibiotic resistance^¶	Preferred: Amoxicillin-clavulanate 90 mg/kg^§ per day orally divided in 2 doses (maximum 4 g/day)	One of the following: Ceftriaxone 50 mg/kg once per day IV or IM (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:^◊ 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	Either: Amoxicillin-clavulanate (depending upon the rationale for initial therapy with cefpodoxime or cefdinir) 90 mg/kg^§ per day orally divided in 2 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 1 or 2 doses (maximum 500 mg/day)	Inpatient therapy (see below)
Penicillin allergy: Immediate (eg, anaphylaxis) or serious delayed reaction (eg, Stevens-Johnson syndrome, toxic epidermal necrolysis)	Levofloxacin^¥ 10 to 20 mg/kg per day orally divided in 1 or 2 doses (maximum 500 mg/day)	Inpatient therapy (see below)
Penicillin allergy: Mild delayed reaction	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)	Levofloxacin^¥ 10 to 20 mg/kg per day orally divided in 1 or 2 doses (maximum 500 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 hospitalization^¶	Ampicillin-sulbactam 200 to 400 mg/kg per day IV divided every 6 hours (maximum 8 g ampicillin component/day), or Ceftriaxone 50 mg/kg per day IV divided every 12 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)	Addition of vancomycin (60 mg/kg per day IV) divided every 6 hours (maximum 4 g/day)^† and possibly, Metronidazole** (30 mg/kg per day IV) divided every 6 hours (maximum 4 g/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:

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.
Jackson MA, Schutze GE, Committee on Infectious Diseases. The use of systemic and topical fluoroquinolones. Pediatrics 2016; 138.

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Antimicrobial regimens for acute bacterial rhinosinusitis in children[1,2]

Antimicrobial regimens for acute bacterial rhinosinusitis in children^[1,2]