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Treatment of sinusitis in children: an Italian intersociety consensus (SIPPS-SIP-SITIP-FIMP-SIAIP-SIMRI-SIM-FIMMG)

Italian paediatric intersociety (SIPPS, SIP, SITIP, FIMP, SIAIP, SIMRI, SIM, FIMMG) · 2025 · Italy

Source and licence

Authors
Elisabetta Venturini, Margherita Del Bene, Lara Fusani et al.
Title
Treatment of sinusitis in children: an Italian intersociety consensus (SIPPS-SIP-SITIP-FIMP-SIAIP-SIMRI-SIM-FIMMG)
Journal
Italian Journal of Pediatrics, 2025
DOI
10.1186/s13052-025-01868-1
Licence
CC BY 4.0
Changes
Verbatim excerpts; formatting adapted

Full text retrieved 2026-10-27 from Europe PMC · PMC11948864

Licence statement of the original publication

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This page reproduces excerpts of the original publication; the original is authoritative. It has not been reviewed by a physician, does not state a recommendation of Medelix and does not replace medical advice. The guideline may have been updated since.

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Recommendations

Verbatim, with grade of recommendation or strength of consensus where given.

Question 1: is antibiotic treatment indicated in a child with uncomplicated acute sinusitis?

  • Recommendation 1In children with a diagnosis of uncomplicated acute bacterial sinusitis, made according to strict clinical criteria [represented by: (1) sudden onset of ≥ 2 symptoms among nasal obstruction/congestion, nasal discharge (regardless of its characteristics), daytime or night-time cough lasting at least 10 days without improvement (excluding allergic subjects); or (2) persistent malaise, worsening or new onset of nasal discharge, daytime cough, or fever after initial improvement; or (3) severe onset with fever (temperature ≥ 39 °C) and purulent nasal discharge for at least 3 consecutive days], empiric antibiotic therapy is indicated to achieve rapid symptom improvement (moderate quality of evidence) and reduce the risk of developing potential complications.Low quality of evidence. Weak recommendation in favour of the intervention
  • Recommendation 2In children with subacute sinusitis, it is suggested to prescribe antibiotic therapy if it has not already been administered.Very low quality of evidence. Expert opinion. Weak recommendation in favour of the intervention
  • Recommendation 3According to the principles of “good clinical practice”, in children with subacute sinusitis, if there is no response to antibiotic therapy, it is suggested to seek specialist consultation (paediatrician with expertise in infectious diseases, or otolaryngologist).Very low quality of evidence. Expert opinion. Weak recommendation in favour of the intervention

Question 2: which first-line topical antibiotic is indicated for uncomplicated acute sinusitis in children?

  • Recommendation 4In uncomplicated acute sinusitis in children, topical antibiotic therapy should not be prescribed.Very low quality of evidence. Expert opinion. Strong recommendation against the intervention

Question 3: which first-line systemic antibiotic is indicated for uncomplicated acute sinusitis in children?

  • Recommendation 5In children with uncomplicated acute sinusitis, is suggested an empirical antibiotic therapy with amoxicillin in patients falling under category 1 of the definition (sudden onset of ≥ 2 symptoms among nasal obstruction/congestion, nasal discharge regardless of characteristics, daytime or night-time cough lasting at least 10 days without improvement for a total duration of < 12 weeks/90 days, excluding allergic subjects), and with amoxicillin-clavulanic acid in those falling under category 2 (persistent discomfort, worsening or new onset of nasal discharge, daytime cough, or fever after initial improvement) and 3 of the definition (severe onset with fever (temperature ≥ 39 °C) and purulent nasal discharge for at least 3 consecutive days).Expert opinion. Weak recommendation in favour of intervention
  • Recommendation 6Macrolides and trimethoprim-sulfamethoxazole should not be used in empiric treatment due to high resistance rates of pathogens responsible for acute sinusitis.Low-quality evidence. Strong recommendation against intervention
  • Recommendation 7In children with subacute sinusitis, empirical oral antibiotic therapy with amoxicillin-clavulanic acid is suggested, or tailor antibiotic therapy based on microbiological isolates where available.Very low-quality evidence. Expert opinion. Weak recommendation in favour of intervention

Question 4: what dosage of first-line systemic antibiotic therapy is recommended for children with uncomplicated acute sinusitis?

  • Recommendation 8For the treatment of uncomplicated acute sinusitis, considering the resistance rate of S. pneumoniae strains in Italy, which is consistently ≥ 10%, amoxicillin or amoxicillin-clavulanic acid should be prescribed at a high dose (90 mg/kg/day, calculated based on amoxicillin, preferably in 3 daily doses).Very low-quality evidence. Expert opinion. Weak recommendation in favour of the intervention

Question 5: which is the duration of oral antibiotic therapy in children with uncomplicated acute sinusitis?

  • Recommendation 9In children with uncomplicated acute sinusitis, oral antibiotic therapy should be continued for at least 10 days.Low quality of evidence. Expert opinion. Strong recommendation in favour of the intervention

Question 6: which is the recommended second-line systemic antibiotic therapy for children with acute sinusitis?

  • Recommendation 10In children with acute sinusitis who are on first-line empirical antibiotic therapy, if there is clinical worsening (or no improvement after 48–72 h), a switch to second-line antibiotic therapy should be considered.Low quality of evidence. Strong recommendation in favour of the intervention
  • Recommendation 11In children who not respond to first-line therapy with amoxicillin, a second-line antibiotic therapy with amoxicillin-clavulanic acid is suggested. For children with a poor response to first-line therapy with amoxicillin-clavulanic acid, a second-line therapy with a combination of a second or third-generation cephalosporin (e.g., cefixime, cefpodoxime, cefuroxime) and clindamycin is suggested.Low quality of evidence. Weak recommendation in favour of the intervention

Question 7: is systemic antibiotic treatment indicated in children with chronic sinusitis?

  • Recommendation 12In children with chronic sinusitis, systemic antibiotic treatment is not recommended.Quality of evidence very low. Weak recommendation against the intervention
  • Recommendation 13Before perform invasive diagnostic interventions, including radiological procedures, it is suggested to prescribe a course of antibiotic therapy if not previously administered.Quality of evidence very low. Expert opinion. Weak recommendation in favour of the intervention
  • Recommendation 14In cases of chronic sinusitis, before undertaking invasive diagnostic interventions, including radiological procedures, according to the principles of good clinical practice, a specialist consultation (paediatric infectious disease specialist, otolaryngologist) is recommended.Quality of evidence very low. Expert opinion. Weak recommendation in favour of the intervention

Question 8: which is the first-line systemic antibiotic therapy indicated in children with chronic sinusitis?

  • Recommendation 15In children with chronic sinusitis, it is not possible to make any specific recommendation regarding antibiotic agents due to the scarcity of scientific evidence supporting treatment.Quality of evidence very low. Expert opinion. Weak recommendation in favour of the intervention
  • Recommendation 16In children for whom antibiotic treatment has been decided based on the reasons described in recommendation 24, it is suggested to prescribe systemic antibiotic therapy with amoxicillin-clavulanate, if not previously administered.Quality of evidence very low. Expert opinion. Weak recommendation in favour of the intervention

Question 9: what is the duration of systemic antibiotic therapy in children with chronic sinusitis?

  • Recommendation 17In the absence of scientific evidence, it is not possible to formulate any specific recommendation. In children with chronic sinusitis, the duration of any systemic antibiotic therapy should be evaluated in consultation with a specialist (paediatric infectious disease specialist, otolaryngologist), taking into account previous antibiotic therapies, resistance patterns, and host-related risk factors.Low-quality evidence. Expert opinion. Weak recommendation in favour of the intervention

Question 10: which is the recommended treatment for a patient with uncomplicated sinusitis and penicillin allergy?

  • Recommendation 18In patients diagnosed with sinusitis suspected of amoxicillin allergy and with low risk of severe allergic reaction, it is recommended to consider a third-generation cephalosporin (e.g., cefixime, cefpodoxime, ceftibuten) as an alternative therapy for at least 10 days. Macrolides should be avoided due to their limited activity against the likely pathogens involved. The prescription of a quinolone should be limited to patients classified under category 3 of the acute sinusitis definition and with a concurrent high risk of allergic reaction. This prescription should be discussed with a paediatric infectious disease specialist.Quality of evidence very low, Expert opinion. Weak recommendation in favour of the intervention

Question 11: which antibiotic therapy is recommended for a child with a recurrence of uncomplicated acute sinusitis?

  • Recommendation 19In case of recurrence of uncomplicated acute sinusitis without risk factors, it is suggested to use antibiotic therapy with amoxicillin-clavulanate if the previous episode was treated with amoxicillin. If the previous therapy with amoxicillin-clavulanate had poor compliance, it is recommended to repeat the therapeutic cycle with the same antibiotic while ensuring adherence to treatment. For patients who have already been treated with amoxicillin-clavulanate with good compliance, switching to second-line antibiotic therapy is suggested. The panel also recommends, in accordance with good clinical practice principles, seeking specialist consultation (paediatric infectious diseases specialist, otolaryngology).Quality of evidence very low. Expert opinion. Weak recommendation in favour of the intervention

Question 12: is antibiotic prophylaxis recommended in children with recurrent sinusitis?

  • Recommendation 20The available literature is not sufficient to formulate a specific recommendation on antibiotic prophylaxis in children with recurrent sinusitis.Low-quality evidence. Expert opinion. Weak recommendation in favour of the intervention

Abstract

Sinusitis is an inflammation of the mucous membrane of the paranasal sinuses. Bacterial sinusitis usually occurs as a complication of viral infections of the upper respiratory tract and is a frequent cause of medical consultation. The clinical presentation of acute bacterial sinusitis can vary. It most commonly manifests as an upper respiratory tract infection (nasal congestion, postnasal drip, cough) that persists for more than 10 days without clinical improvement. Unfortunately, updated guidelines in paediatric age are not currently available. The purpose of this consensus is to provide guidelines for the therapeutic management of previous healthy paediatric patients with sinusitis. A systematic review was conducted to identify the most recent and relevant evidence. Embase, Scopus, PubMed, and Cochrane databases were systematically screened, combining the terms “children” and “sinusitis” and “antibiotics” and “rhinosinusitis” with a date restriction from 2012 to April 2024, but without language limitations. The certainty of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methods. The final recommendations were obtained through a Delphi consensus of an expert panel. In children with a diagnosis of uncomplicated acute bacterial sinusitis, made according to strict clinical criteria, systemic empiric antibiotic therapy with amoxicillin or amoxicillin-clavulanic acid is indicated at a high dose (90 mg/kg/day, calculated based on amoxicillin, preferably in 3 daily doses) and for at least 10 days. In children with chronic sinusitis, systemic antibiotic treatment is not recommended, and it is not possible to make any specific recommendation regarding antibiotic agents due to the scarcity of scientific evidence supporting treatment. In conclusion, the diagnosis of sinusitis is primarily clinical, and despite acute sinusitis generally having a favourable course, some cases can present orbital and intracranial complications. The misuse of antibiotics in managing upper respiratory tract infections, including acute sinusitis, and the challenges posed by antibiotic resistance are a current issue in paediatric care. Due to the scarcity, heterogeneity, and poor quality of available evidence either supporting or opposing the use of systemic antibiotic therapy in children with sinusitis prospective studies on larger and more homogeneous cohort are needed.

Supplementary Information: The online version contains supplementary material available at 10.1186/s13052-025-01868-1.

Contents of the original publication

The section headings of the original.

  • Background
  • Methods
  • Results and recommendations
  • Question 1: is antibiotic treatment indicated in a child with uncomplicated acute sinusitis?
  • Question 2: which first-line topical antibiotic is indicated for uncomplicated acute sinusitis in children?
  • Question 3: which first-line systemic antibiotic is indicated for uncomplicated acute sinusitis in children?
  • Question 4: what dosage of first-line systemic antibiotic therapy is recommended for children with uncomplicated acute sinusitis?
  • Question 5: which is the duration of oral antibiotic therapy in children with uncomplicated acute sinusitis?
  • Question 6: which is the recommended second-line systemic antibiotic therapy for children with acute sinusitis?
  • Question 7: is systemic antibiotic treatment indicated in children with chronic sinusitis?
  • Question 8: which is the first-line systemic antibiotic therapy indicated in children with chronic sinusitis?
  • Question 9: what is the duration of systemic antibiotic therapy in children with chronic sinusitis?
  • Question 10: which is the recommended treatment for a patient with uncomplicated sinusitis and penicillin allergy?
  • Question 11: which antibiotic therapy is recommended for a child with a recurrence of uncomplicated acute sinusitis?
  • Question 12: is antibiotic prophylaxis recommended in children with recurrent sinusitis?
  • Conclusion

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