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A report published in March 2012 by a multidisciplinary panel from the Infectious Diseases Society of America (IDSA) recommends changes to the diagnosis and treatment of rhinosinusitis in children and adults.
Existing criteria for differentiating viral versus bacterial sinusitis have resulted in inappropriate use of antibiotics. In addition, changing microbiologic profiles in patients with sinusitis due in part by the emergence of pneumococcal species not covered by PCV-13 vaccine have been identified. These issues, along with several other factors, have motivated a new investigation into a common infectious disease.
Most children with bacterial sinusitis will present with cough (80%), nasal discharge (76%) and fever (63%). Often there are subjective reports of halitosis, while headache, facial pain and swelling are uncommon complaints.
Patients who meet the following predictive factors for acute bacterial rhinosinusitis warrant empiric treatment with antibiotics for 10 to 14 days:
· Persistent symptoms of cough with nasal discharge lasting at least 10 days
· Abrupt onset of severe symptoms with fever and purulent rhinorrhea or facial pain lasting 3 to 4 days
· Any patient whose upper respiratory symptoms began to improve, and then worsened with fever and cough.
Augmentin (not amoxicillin) should be used as first-line therapy for suspected bacterial rhinosinusitis (45 mg/kg/day divided in 2 daily doses).
High-dose Augmentin (90 mg/kg/day divided in 2 daily doses, up to 2 grams twice daily) should be given to the following patients:
· Patients living in regions of the USA
· Fever 102 F or higher
· Daycare attendance
· Recent hospitalization
· Antibiotic use in the past month
· Immunocompromised children
· Age < 2 years
· Failed treatment with Augmentin 45 mg/kg/day
Trimethoprim-sulfamethoxazole (TMP/SMX), monotherapy with Cephalosporins and Macrolides (Azithromycin) are all ineffective against more than 30% of pneumococcal strains and should not be used in treating bacterial sinusitis.
In Penicillin-allergic patients, Doxycycline (children over age 8) or Levofloxacin (10–20 mg/kg/day PO every 12–24 h) may be used. Alternatively, a third generation cephalosporin such as Cefdinir, in combination with clindamycin may be used in penicillin-allergic patients. Patients who fail to improve clinically after 3 to 5 days of antibiotics, should be switched to broader spectrum coverage.
The report also recommends saline irrigation as an adjunctive therapy, and intranasal steroids (Fluticasone) for patients who have a history of allergic rhinitis.
For patients with suspected suppurative complications such as orbital or intracranial involvement, CT scan is the imaging modality of choice.
Reasons to refer to an ENT specialist for possible sinus aspiration and culture:
· Worsening symptoms in the first 2 to 3 days of antibiotic therapy
· Failure to respond to 2nd line therapy of antibiotics
· Patients who are clinically toxic, immunocompromised, and/or have recurrent sinus infections
Commentary by Tara Greenhow, MD and John Belko, MD, Pediatric ID Specialists:
The Pediatric ID Chiefs would like to emphasize a few important points about the guidelines:
1. Antibiotics are NOT recommended for healthy children with rhinosinusitis unless symptoms are severe, persistent or worsening. Overall, 6 children would need to be treated with antibiotics before 1 additional patient would benefit. 60% of children in placebo groups improve.
2. Amoxicillin-Clavulanate is now recommended as first-line therapy for sinusitis in children. This is due to the increasing prevalence of beta-lactamase producing Hemophilus influenzae and Moraxella catarrhalis in sinus isolates.
3. Macrolides and TMP-SMX are NOT RECOMMENDED for empiric therapy due to high rates of resistance among S. pneumoniae.
4. Second and third generation oral cephalosporins are NOT RECOMMENDED for empiric monotherapy due to variable resistance among S. pneumoniae. This includes cefdinir, a commonly used 3rd generation cephalosporin, with resistance rates of 23-30%.
5. Please contact your local pediatric ID colleagues for children with suspected or confirmed suppurative complications to assist in management.
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