Management of Acute Bacterial Sinusitis in Children

10/11/13921Management of Acute Bacterial Sinusitis in Children Dr Mostafavi NPediatric infectious disease departementIsfahan university of medical sciences 10/11/13922References 1. American Academy of Pediatrics. Clinical Practice Guideline for the Diagnosis and Management of Acute Bacterial Sinusitis in Children Aged 1 to 18 Years . Pediatrics Vol. 132 No. 1 July 1, 2013 2. IDSA Clinical Practice Guideline for Acute Bacterial Rhinosinusitis in Children and Adults. Clin Infect Dis. (2012)

10/11/13923Case 1A 16 months old girl brought to clinic with fever and coryza for 2 days. The parent advised to take the child high dose amoxicillin- clavulonate if the child developed purulent nasal discharge. What's your judgment about the prescription?10/11/13924Case 2A 2 year old boy brought with history of cough for 8 days. On examination he has purulent nasal and postnasal discharge. What's your diagnosis?

10/11/13925Case 3A 3 years age child brought to clinic with history of fever and cough for 2 days. On examination she has purulent nasal discharge. She received amoxicillin from 2 days ago but had no improvement. What's your decision?10/11/13926Case 4A 2 year old boy brought with recurrence of fever and cough on 6th days of an improving viral URTI. The child received azithromycin for 5 days in the course of the disease. On examination he has purulent nasal and postnasal discharge. What's your diagnosis? 10/11/13927Case 5A 2 year old boy brought with recurrence of fever and cough 8 days after improving a course of coryza and cough. The child received azithromycin for 5 days in the course of the disease. On examination he has erythematous pharyngitis and clear nasal discharge. What's your diagnosis?

10/11/13928Case 6A 2 years old boy brought with history of nasal discharge and cough for 10 days. The parents say that his cough was decreasing in previous 2 days. On examination he has purulent nasal discharge. What's your diagnosis?

10/11/13929Case 7A 2 year old boy brought with history of high grade fever and coryza and cough for 5 days. On examination he has erythematous pharyngitis and clear nasal discharge. What's your diagnosis?

10/11/139210Case 8 A 3 years age child brought to clinic with history of high fever and cough for 7 days. On examination she has purulent nasal discharge and appears ill. What's your diagnosis?

10/11/139211Features of an uncomplicated viral URIUsually nasal symptoms (discharge and congestion/obstruction) or cough or bothMost often, discharge begins as clear and wateryOften, the quality of discharge changes during the course of the illnessTypically, discharge becomes thicker and more mucoid and may become purulent (thick, colored, and opaque) for several days. 10/11/139212Features of an uncomplicated viral URIThen the purulent discharge becoming mucoid and then clear again or simply resolving.Fever, when present, occur early in the illness, often with constitutional symptoms sTypically, the fever disappear in the first 24 to 48 hours, and the respiratory symptoms become more prominent10/11/139213Features of an uncomplicated viral URIThe course of most uncomplicated viral URIs is 5 to 7 days. Respiratory symptoms usually peak in severity by days 3 to 6 and then begin to improveResolving symptoms and signs may persist in some patients after day 1010/11/139214Course of viral upper respiratory infection

10/11/139215Diagnosis of acute bacterial sinusitisPersistent illness: nasal discharge (of any quality) or daytime cough or both lasting more than 10 days without improvementWorsening course: worsening or new onset of nasal discharge, daytime cough, or fever after initial improvementSevere onset: concurrent fever (temperature 39C) and purulent nasal discharge for at least 3 consecutive days

10/11/139216Persistent illnessPersistence symptoms without improvement suggests sinusitisSymptoms include nasal discharge (of any quality: thick or thin, serous, mucoid, or purulent) or daytime cough (which may be worse at night) or bothBad breath, fatigue, headache, and decreased appetite, although common, are not specific

10/11/139217Persistent illness6%7% of children presenting with symptoms of URI will meet criteria for persistenceBefore diagnosing bacterial sinusitis :Differentiate sequential episodes of viral URIDifferentiate noninfectious rhinitis with personal/ family history of atopic conditions, prominent nasal crease, allergic shiners, cobblestoning of the conjunctiva or pharyngeal wall, or pale nasal mucosaEstablish clearly not improving symptoms 10/11/139218worsening course Double sickeningSubstantial and acute worsening of nasal discharge/ nasal congestion/ daytime cough or new fever, often on the 6-7th day of illness, after initial signs of recovery a viral URI

10/11/139219severe onsetConcurrent high fever (temperature >39C) and purulent nasal discharge for 3-4 days in childrenAcute onset of headache, fever, and facial pain in adultsUsually ill appearing and need to be distinguished from unusually severe viral infections Fever is in viral URIs tends to be present early in the illness

10/11/139220Severe onsetGenerally, in viral URTI fever resolve in the first 48 hours and then the respiratory symptoms become prominentIn most viral infections, purulent nasal discharge does not appear for several days Accordingly, concurrent presentation of high fever and purulent nasal discharge for the first 3 to 4 days helps to define the severe onset of acute bacterial sinusitis10/11/139221Case 8A 2 year old boy brought with history of cough for 8 days. X- ray shows complete opacification of both maxillary sinuses. On examination he has purulent nasal and postnasal discharge. What's your diagnosis?

10/11/139222Imaging studiesAAP: Clinicians should not obtain imaging studies ( x- ray, CT scan, MRI, or sonography) to distinguish bacterial sinusitis from viral URIBacterial sinusitis in children is a clinical diagnosisHistorically imaging was a diagnostic modality in children and is no longer recommendedNormal imaging can rule out bacterial sinusitis10/11/139223Case 9A 2 years old boy brought with history of nasal discharge and cough for 10 days. The parents say that his cough was not decreasing. On examination he has purulent nasal discharge. What's your decision?

10/11/139224Management of persistent sinusitisThe clinician has two options:Prescribe antibiotic Offer additional outpatient observation for 3 days 10/11/139225Factors that influence the decision in persistent sinusitisSymptom severityQuality of lifeRecent antibioticConcurrent bacterial infection ( pneumonia, adenitis, GAS pharyngitis, or AOM) Underlying conditions (asthma, CF, immunodeficiency, sinus surgery, or anatomic abnormalities ) Complications Previous experience of sinusitis Cost of antibiotics Ease of administrationParents preferences

10/11/139226Case 4A 2 year old boy brought with recurrence of fever and cough on 6th days of an improving viral URTI. The child received azithromycin for 5 days in the course of the disease. On examination he has purulent nasal and postnasal discharge. What's your decision?

10/11/139227Case 10A 3 years age child brought to clinic with history of fever and cough for 4 days. On examinations performed in 1st and 4th days she has purulent nasal discharge. The child appears ill. What's your decision?

10/11/139228Management of severe onset or worsening course sinusitisThe clinician should prescribe antibiotic therapy.10/11/139229Case 11An 8 month child has acute bacterial sinusitis, which antibiotics could be prescribed for the child?10/11/139230Bacteriology of acute bacterial sinusitisBacteria Prevalence Sensitive tolow dose amoxicillin High dose amoxicillinlow dose coamoxiclav

High dose coamoxiclav S, pneumonia30%85-90% ( 40-50%)90-95% ( 65-70%)85-90% ( 40-50%)90-95% ( 65-70%)H. Influenza non typeable30%60- 90%60-90%

100%100%M. catarrhalis10%5%5%90%100%Sterile 25%----------------------S. aureusRarely----------------------Anaerobes Rarely ----------------------10/11/139231Bacteriology of acute bacterial sinusitisBacteria Susceptible tocefiximeCefuroxime axetilCeftriaxoneAzithromycinLevofloxacinTMP/SMXDoxycyclineClindamycinS, pneumonia60%60-75%95-97% 60-70%100%50-70%85% 85-88%H. Influenza non typeable100%85- 100%100%90-100%100%73%0%----M. catarrhalis----98%97%100%100%99%0%-----10/11/139232Risk factors for the presence of resistant organismsAttendance at child careReceipt of Abs within the previous 30 daysAge younger than 2 years10/11/139233Initial antimicrobial Regimens for acute sinusitis in children( AAP)Situation Drug Low risk( age >2 yrs, uncomplicated mild to moderate sinusitis, not attend child care, no AB in the last 4 wksNonsusceptible S pneumoniae < 10%Amoxicillin 45 mg/kg/day in 2 dosesLow riskNonsusceptible S pneumoniae > 10%Amoxicillin 80 to 90 mg/kg per day in 2 doses, max 2 g/doseHigh riskHigh-dose amoxicillin-clavulanate (8090 mg/kg/day of the amoxicillin with 6.4 mg/kg per day of clavulanate in 2 doses max 2 g per dose)Nontype 1 allergy to amoxicillinCefuroxime axetileType 1 allergy to amoxicillinCefuroxime axetile or clindamycin (or linezolid) + cefixime or levofloxacin10/11/139234Antimicrobial Regimens for Acute Rhinosinusitis in children( IDSA)Indication First-line Second-line Initial empirical therapyAmoxicillin-clavulanate (45 mg/kg/day PO bid)Amoxicillin-clavulanate (90 mg/kg/day PO bid)-lactam allergy Type I hypersensitivity-------Levofloxacin (1020 mg/ kg/day PO every 1224 h)-lactam allergyNontype I hypersensitivity-------Clindamycin (3040 mg/kg/day PO tid) plus cefixime (8 mg/kg/day PO bid) Risk for antibiotic resistance or failed initial therapy------Amoxicillin-clavulanate (90 mg/kg/day PO bid)Clindamycin plus cefixime Levofloxacin 10/11/139235Antimicrobial Regimens for Bacterial Rhinosinusitis in Adults( IDSA)Indication First-line Second-line Initial empirical therapyAmoxicillin-clavulanate (500 mg/125 mg PO tid, or 875 mg/125 mg PO bid)Amoxicillin-clavulanate (2000 mg/125 mg PO bid)Doxycycline (100 mg PO bid or 200 mg PO qd)-lactam allergy-------Doxycycline (100 mg PO bid or 200 mg PO qd)Levofloxacin (500 mg PO qd)Moxifloxacin (400 mg PO qd)Risk for antibiotic resistance or failed initial therapy------Amoxicillin-clavulanate (2000 mg/125 mg PO bid)Levofloxacin (500 mg PO qd)Moxifloxacin (400 mg PO qd)10/11/139236Case 12An 8 month child ( Wt= 10 kg) has acute bacterial sinusitis. You decide to treat the patient with coamoxiclav. Which supply and for what duration would you prescribe for he/she? When reassess the child for response to therapy?

10/11/139237Duration of treatmentOptimal duration of antimicrobial therapy : 10 to 28 days (7 d after freeness of signs and symptoms)Clinicians should reassess initial if worsening (progression of initial signs/symptoms or appearance of new signs/symptoms) OR failure to improve (lack of reduction in all presenting signs/symptoms) within 72 hours of initial management10/11/139238Case 13An 8 month child ( Wt= 10 kg) has acute bacterial sinusitis. You decide to treat the patient with coamoxiclav. After 72 hrs of treatment the child developed high fever and cough. What's your recommendation?10/11/139239Case 14An 8 month child ( Wt= 10 kg) has acute bacterial sinusitis. You decide to treat the patient with coamoxiclav. After 72 hrs of treatment the child had no improve in her/his signs and symptoms. What's your recommendation?

10/11/139240Management of Worsening or Lack of Improvement at 72 HoursInitial ManagementWorse in 72 HoursLack of Improvement in 72 HoursObservationInitiate amoxicillin with or without clavulanateAdditional observation or initiate antibiotic based on shared decision-makingAmoxicillinHigh-dose amoxicillin-clavulanateAdditional observation or high-dose amoxicillin-clavulanate based on shared decision-makingHigh-dose amoxicillin-clavulanateClindamycin and cefixime OR levofloxacin Continued high-dose amoxicillin-clavulanate OR clindamycinaand cefixime OR levofloxacin10/11/139241Case 15An 8 month child ( Wt= 10 kg) has acute bacterial sinusitis. You decide to treat the patient with coamoxiclav. If any other drug prescribe for him/her?10/11/139242Adjuvant Therapy for acute bacterial sinusitisDrug Efficacy Intranasal corticosteroids(budesonide, flunisolide, fluticasone, and mometasone)Significant in adolescents and adults, modest in children( poor designed studies)Saline nasal irrigation or lavage (not saline nasal spray)Effective in children( one study)Variable result in adultsOral or topical nasal decongestantsInsufficient dataMucolyticsInsufficient dataOral or nasal spray antihistaminesInsufficient dataMight be helpful in patients with atopy 10/11/139243

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