Clinical Review

Acute Bacterial Sinusitis in Children: Evaluation and Treatment

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Frequently encountered in primary care, acute bacterial sinusitis (ABS) occurs in about 6% to 7% of children with upper respiratory symptoms. Challenging to accurately diagnose and appropriately treat, this condition can be costly in terms of direct health care and patient comfort. Our expert provides an update on the management of ABS in children ages 1 year and older.




  • Complications of acute bacterial sinusitis
  • What are the medical options?
  • AAP 2013 recommendations for initial antimicrobial treatment

Acute bacterial sinusitis (ABS) is a common diagnosis in pediatric patients. Of children who are evaluated for respiratory complaints, 6% to 7% meet clinical criteria for ABS.1 In addition to being a frequent complication of upper respiratory infection (URI), ABS in children has a significant financial impact. Direct health care expenditures attributed to sinusitis in children ages 12 or younger is $1.8 billion annually.2

Differentiating between viral URI and ABS is a diagnostic challenge for health care providers. In recent years, the American Academy of Pediatrics (AAP) and the Infectious Diseases Society of America (IDSA) have released clinical practice guidelines on the clinical diagnosis and management of ABS in children.3,4

URIs manifest with a predictable pattern of symptoms. Children may experience one to two days of fever, accompanied by constitutional symptoms, such as fatigue, headache, decreased appetite, and myalgia. Nasal discharge typically begins clear and becomes mucopurulent over the next few days; subsequently, it either resolves or becomes serous again at the end of the URI. Cough, hoarseness, malodorous breath, and pharyngitis may be present.3,5 Symptoms typically resolve over five to 10 days, with respiratory symptoms peaking at days 3 to 5. Importantly, in viral URIs, nasal congestion and cough improve toward the end of the illness.1,3

Persistent illness. Patients with ABS may experience persistent illness with nasal discharge (of any quality) and/or daytime cough that persists more than 10 days without improvement.3,4 These patients are differentiated from those with a viral URI by a lack of improvement in congestion and/or cough after 10 days of symptoms.3 While some children with viral illnesses may have persistant upper respiratory symptoms, these should be gradually resolving. Clinicians must take a thorough history to identify children who may have multiple consecutive URIs rather than one persistent illness that is not resolving.

Other diagnoses, such as allergic rhinitis, nasal foreign body, pertussis, influenza, and bacterial pharyngitis, must also be excluded. Children who present with persistent nasal congestion, with or without cough, after 10 days of illness without signs of improvement meet the criteria for ABS.3

Severe symptom onset. Children with ABS may experience severe onset of symptoms.3,4 These children have purulent nasal discharge for at least three consecutive days at onset of illness and concurrent fever (temperature, ≥ 102.2°F). In contrast, a viral URI typically presents with fever for less than 48 hours and clear nasal discharge that becomes purulent after the first few days of symptoms.

“Double sickening.” Finally, children with ABS may have a worsening course of symptoms or a “double sickening.”3,4 These patients experience typical URI symptoms that initially begin to improve, then worsen on day 6 or 7 of illness with increasing or new onset of considerable nasal drainage, daytime cough, or fever.

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