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.

Principles of Therapy

Symptomatic Therapy

  • Symptomatic treatment is the preferred initial management in patients w/ mild symptoms
  • Routine use of systemic decongestants & mucolytic agents is not recommended due to limited & 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, & prevent recurrences or complications 
  • Consider local pathogen distribution & 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 & 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 & 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

Antibiotic Therapy

Mild & 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 & 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, & 2nd & 3rd generation cephalosporins are no longer recommended as 1st line therapy due to variable rates of drug resistance among S pneumoniae &/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 & non-type I Penicillin allergy
  • Parenteral doses (eg Cefotaxime, Ceftriaxone) are recommended for hospitalized patients with severe infections, those with complications, & 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 & most highly resistant strains)
    • Clavulanic acid amount is sufficient to inhibit all beta-lactamase producing H influenzae & M catarrhalis

Levofloxacin

  • Recommended alternative therapeutic agent for patients unresponsive to Amoxicillin/clavulanic acid & 3rd generation cephalosporins & 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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