Acute Bacterial Sinusitis

Patient Population: Pediatric
Condition Major Pathogens  First-choice Therapy Alternative Therapy Comments

Acute bacterial sinusitis 

Diagnosed based on acute upper respiratory illness with: 

Persistent rhinorrhea or daytime cough lasting >=10 days and not improving  


Substantially worsening course after initial improvement 


Severe symptoms at onset:  

T >= 39C 


Purulent nasal discharge for at least 3 consecutive days 

Streptococcus pneumoniae 

Haemophilus influenzae 

Moraxella catarrhalis 


Recommend initial observation without antibiotic therapy if diagnosis is made only based on persistence of rhinorrhea or cough - many patients improve without antibiotic therapy 

Non-severe symptoms

45 mg/kg/dose (max 1000 mg/dose)* enterally bid  


Severe symptoms (see 1st  column)

Amoxicillin-clavulanate (Augmentin)
45 mg amoxicillin/kg/dose (max 2000 mg amoxicillin/dose)*  enterally bid  

Penicillin allergy with lower risk for allergic reaction

Oral cephalosporin (follow link for options) 


Penicillin allergy with higher risk for allergic reaction

Consult ID/ASP  

Azithromycin is not recommended for this indication. 

Duration: Typical treatment duration is 10 days 

*See guidance on maximum dosing of Amoxicillin and Amoxicillin-Clavulanate 

Refer to Intracranial Abscess section if intracranial complication or Orbital Cellulitis section if orbital extension 


Wald, ER, et al. Clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years. Pediatrics 2013;132:e262-e280. 

American Academy of Pediatrics. In: Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH, eds. Red Book: 2021 Report of the Committee on Infectious Diseases. 32nd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2021.  

American Academy of Family Physicians Choosing Wisely Recommendation (updated 2018).

American College of Emergency Physicians Choosing Wisely Recommendation (2014).


Pediatric Empiric Antimicrobial Therapy Guidelines

This is a subsection of the UCSF Benioff Children’s Hospitals Empiric Antimicrobial Therapy Guidelines, developed by the Pediatric Antimicrobial Stewardship Programs at each campus to inform initial selection of empiric antimicrobial therapy for children at the UCSF Benioff Children’s Hospitals and affiliated outpatient sites. 

These are guidelines only and not intended to replace clinical judgment. Modification of therapy may be indicated based on patient comorbidities, previous antibiotic therapy or infection history. Doses provided are usual doses but may require modification based on patient age or comorbid conditions. Refer to Pediatric Antimicrobial Dosing Guideline for further guidance on dosing in children, and Neonatal Dosing Guideline for infants < 1 month of age. Consult a pediatric pharmacist for individualized renal or hepatic dose adjustment. Durations provided are usual recommendations for patients who are responding appropriately to therapy. For additional guidance, please contact Pediatric Infectious Diseases (ID) or the Pediatric Antimicrobial Stewardship Program (ASP) at the campus where your patient is receiving care.  

For questions or feedback about these guidelines, please email primary content owners, Rachel Wattier, Pediatric ASP Medical Director at BCH SF and Prachi Singh, Pediatric ASP Medical Director at BCH OAK. 

The content of these guidelines was updated in July 2021. See Summary and Rationale for Changes (password login to Box needed) for detailed explanations of the content changes.