rhinosinusitis%20-%20acute,%20bacterial%20(pediatric)
RHINOSINUSITIS - ACUTE, BACTERIAL (PEDIATRIC)
Rhinosinusitis is the mucosal inflammation of the nose and paranasal sinuses caused by bacteria lasting >10 days for up to 4 weeks, symptoms resolve completely and may either be persistent or severe.
It is often preceded by a viral upper respiratory tract infection.
Signs & symptoms are nonspecific and it is typically difficult to differentiate from viral upper respiratory tract infection.
Streptococcus pneumoniae is the most common cause followed by nontypeable Haemophilus influenzae.

Rhinosinusitis%20-%20acute,%20bacterial%20(pediatric) Treatment

Principles of Therapy

Symptomatic Therapy

  • Symptomatic treatment is the preferred initial management in patients with mild symptoms
  • Routine use of systemic decongestants and mucolytic agents is not recommended due to limited and controversial data

Antibiotic Therapy 

  • Goals of therapy:
    • Rapid recovery
    • Prevent severe complications (eg meningitis, brain abscess)
    • Avoid chronic sinus disease
  • Antibiotic therapy should be initiated as soon as diagnosis has been established
    • This may help decrease illness duration, relieve symptoms earlier, and prevent recurrences or complications 
  • Consider local pathogen distribution and rates of antibacterial resistance in treatment selection
  • Recommended duration of antimicrobial treatment is 10-14 days to minimize development of bacterial resistance
    • Alternative is to continue treatment 7 days after resolution of symptoms
    • Should consider shifting antibiotics or altering the treatment strategy if patient worsens after 48-72 hours of initial therapy, or no improvement 3-5 days after initiation of antibiotic therapy
  • Routine administration of initial empiric therapy against S aureus or MRSA is not recommended

Pharmacotherapy

Symptomatic Therapy

Analgesics and Antipyretics

  • Analgesics are useful in controlling pain
  • Antipyretics may be used to relieve fever
  • Avoid Aspirin in patients ≤16 years of age because of the risk of Reye’s Syndrome

Intranasal Corticosteroids

  • Several studies show that intranasal corticosteroids may be an effective add-on to antimicrobials in patients with allergic rhinitis especially if given in the early course of the disease
  • Reduce cough and nasal discharge
  • Reduce the swelling around the sinus ostia that may hasten the resolution of symptoms

Topical Decongestants

  • May relieve nasal congestion in appropriate concentrations
  • Should be limited to <10 days to avoid rhinitis medicamentosa

Bacterial Immunostimulants

  • Studies showed that bacterial lysate OM-85 BV may be beneficial for shortening the duration of acute post-viral rhinosinusitis and may reduce risk for disease recurrence especially in children at high risk for respiratory tract infections

Antibiotic Therapy

Mild and No Antibiotic of <90 Days

Amoxicillin/clavulanic acid

  • 1st-line drug of choice in uncomplicated mild to moderate ABRS
  • High-dose Amoxicillin/clavulanic acid is recommended for children with ARBS located in areas with high incidence rates, attending daycare, age <2 years, recent hospitalization, recently treated with antibiotics
  • Recommended in patients who have failed high-dose Amoxicillin or in suspected cases of beta-lactamase producing strains of H influenzae and M catarrhalis

Levofloxacin

  • Recommended therapeutic agent in patients who have type 1 allergy to Penicillin

Clindamycin plus 3rd Generation Oral Cephalosporins (eg Cefixime, Cefpodoxime)

  • 2nd-line therapy for ABRS patients with non-type 1 allergy to Penicillin or those located in areas with high incidence rates of S pneumoniae

Ceftriaxone

  • Initial therapy for patients experiencing vomiting, to be given 24 hours prior to initiation of antibiotic therapy

Others

  • High-dose Amoxicillin, macrolides, Trimethoprim-sulfamethoxazole, and 2nd and 3rd generation cephalosporins are no longer recommended as 1st line therapy due to variable rates of drug resistance among S pneumoniae and/or H influenzae

Moderate to Severe Acute Bacterial Rhinosinusitis (ABRS) or Antibiotic Use of <90 Days

3rd Generation Cephalosporins

  • Eg Cefdinir, Cefpodoxime, Ceftriaxone 
  • Alternative treatment to Amoxicillin/clavulanic acid for patients with severe ARBS and non-type I Penicillin allergy
  • Parenteral doses (eg Cefotaxime, Ceftriaxone) are recommended for hospitalized patients with severe infections, those with complications, and treatment failure after outpatient therapy 
  • A single dose of Ceftriaxone (50 mg/kg/day) can be administered through intramuscular (IM)/intravenous (IV) in patients with symptoms of vomiting precluding intake of oral antibiotics, then shifted to oral antibiotics after 24 hours of improvement to complete the treatment

Amoxicillin/sulbactam

  • Alternative agent for hospitalized ARBS patients with severe disease

High-Dose Amoxicillin/clavulanic acid

  • 1st-line agent for patients with severe ARBS, at risk for severe ARBS previously treated as outpatient, immunocompromised, or in those with risk of resistant organisms
  • Therapy should be initiated with high-dose Amoxicillin/Clavulanic acid (80-90 mg/kg/day based on Amoxicillin,with 6.4 mg/kg/day of Clavulanic acid in 2 divided doses)
    • High-dose Amoxicillin will increase the coverage against S pneumoniae (all intermediate resistant and most highly resistant strains)
    • Clavulanic acid amount is sufficient to inhibit all beta-lactamase producing H influenzae and M catarrhalis

Levofloxacin

  • Recommended alternative therapeutic agent for patients unresponsive to Amoxicillin/clavulanic acid and 3rd generation cephalosporins and those with type I Penicillin allergy

Vancomycin with or without Metronidazole

  • Vancomycin (60 mg/kg/day IV divided 6 hrly) with or without Metronidazole (30 mg/kg/day IV divided 6 hrly) may be added to cephalosporin regimen if no improvement is seen even with negative culture results
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