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Alternative ◊ : Amoxicillin 90 mg/kg per day orally divided in 2 doses Amoxicillin-clavulanate 90 mg/kg § per day orally divided in 2 doses (maximum 4 g/day) Severe disease or risk for antibiotic resistance •

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 Levofloxacin ¥ 10 to 20 mg/kg per day orally divided in 1 or 2 doses (maximum 500 mg/day) Ceftriaxone 50 mg/kg once per day (maximum 2g/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) Penicillin allergy (anaphylaxis) 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 (non-anaphylaxis) 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 One dose of ceftriaxone 50 mg/kg per day IV or IM (maximum 2 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 2 g/day), or Cefotaxime 100 to 200 mg/kg per day IV divided every 6 hours (maximum 8 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)

Cefotaxime 100 to 200 mg/kg per day IV divided every 6 hours (maximum 8 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) 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 to five days of initial therapy and in whom no pathogen is identified. If a pathogen is identified, antimicrobial therapy should be adjusted according to susceptibilities. • See text for definitions. ��������� Based on amoxicillin component; 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; use 600/5 mL suspension or 1000 mg/62.5 mg tablet for appropriate clavulanate ratio. ¥ Levofloxacin should be reserved for cases in which there is no other safe and effective alternative. 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. Bradley JS, Jackson MA, Committee on Infectious Diseases, American Academy of Pediatrics. The use of systemic and topical fluoroquinolones. Pediatrics 2011; 128:e1034.