Elk Grove Village, Ill—In children and young adults, acute bacterial sinusitis can cause significant morbidity; in rare cases, it can lead to life-threatening complications. To reduce the toll that this condition takes on the nation’s health, the American Academy of Pediatrics (AAP) has released a new clinical practice guideline on the management of acute bacterial sinusitis in children and young adults ages 1 to 21 years.[1]

“The purpose of the guideline is to help practitioners make a proper diagnosis, use imaging resources appropriately, and reduce unnecessary antibiotic use,” Ellen R. Wald, MD, explained to RESPIRATORY REVIEWS. Dr. Wald, a Professor of Pediatrics and Otolaryngology at the University of Pittsburgh School of Medicine, chaired the AAP committee that developed the new guideline.

The committee made no recommendations for neonates or infants younger than 1 year for a simple reason: Bacterial sinusitis is rare and hard to assess in these patients. Furthermore, because the available data are limited and controversial, the committee opted not to offer recommendations about adjuvant therapies, antimicrobial prophylaxis, or complementary/alternative medicines for acute bacterial sinusitis.

RELEVANT DATA SCARCE

Creating the guideline was difficult, said Dr. Wald, due to the heterogeneity and paucity of relevant data. These included five randomized controlled trials and eight case series on antimicrobial therapy, three randomized controlled trials on ancillary therapies, and eight studies related to diagnosis. These data were obtained through MEDLINE and Excerpta Medica searches covering 1966 through March 1999 using the keyword “sinusitis.”

The draft guideline was extensively reviewed and revised by committees and sections within the AAP and by numerous outside organizations, including the American College of Emergency Physicians and the American Academy of Asthma, Allergy, and Immunology. The recommendations are therefore based on the best available data or, where evidence is lacking, on a combination of data and expert opinion. However, the AAP stresses that the guideline is not intended to be a clinician’s sole source of advice on acute bacterial sinusitis in children. Nor is it meant to replace clinical judgment or establish a universal protocol.

DIAGNOSTIC RECOMMENDATIONS

The diagnostic gold standard for acute bacterial sinusitis is sinus aspiration yielding at least 10 colony-forming units/mL. However, this procedure is invasive, time-consuming, and potentially painful and is therefore not recommended for the routine diagnosis of bacterial sinus infections in children, says the AAP guideline

A diagnosis of acute bacterial sinusitis can instead be based on clinical criteria in children with persistent or severe upper respiratory symptoms. Persistent symptoms are those lasting at least 10 to 14 days but less than 30 days; they may include nasal discharge of any quality, daytime cough that may worsen at night, or both. Severe symptoms are defined as a temperature of at least 102°F (39°C) and purulent nasal discharge for at least three to four days in a child who seems ill.

According to the guideline, imaging studies are not necessary to confirm a diagnosis of sinusitis in children 6 years or younger. In this group, reasonably good evidence exists that a positive history is a strong predictor of abnormal sinus radiographs. In addition, the value of confirmatory studies in older children remains uncertain. “In children over 6, there is no agreement as to whether imaging is necessary,” Dr. Wald acknowledged.

Computed tomography scans of the paranasal sinuses should be reserved for those patients who are being considered for operative management, the guideline states. The scans are essential in these cases to provide precise anatomic information to help guide surgery.

ANTIMICROBIAL TREATMENT

Antibiotics are recommended for acute bacterial sinusitis to achieve a more rapid clinical cure. Patients should get antibiotics, however, only if they have the persistent or severe symptoms that define the condition. This approach will minimize unnecessary antimicrobial treatment for uncomplicated viral upper respiratory tract infections, the guidelines note.

Because the most common pathogens found are Streptococcus pneumoniae, non-typeable Haemophilus influenzae, and Moraxella catarrhalis, the first-line regimen for acute bacterial sinusitis is 45 mg/kg/d amoxicillin in two divided doses because this narrow-spectrum agent is safe, tolerable, inexpensive, and generally effective. A regimen of 90 mg/kg/d in two divided doses is also appropriate for children younger than 2 years with mild to moderate uncomplicated acute bacterial sinusitis if they do not attend day care and have not recently received antimicrobial treatment.

Various alternative regimens are recommended for patients with amoxicillin allergy. These include cefdinir (14 mg/kg/d in one or two doses), cefuroxime (30 mg/kg/d in two divided doses), and cefpodoxime (10 mg/kg/d once daily). For children with more serious allergic reactions to amoxicillin, options include clarithromycin (15 mg/kg/d in two divided doses) and azithromycin (10 mg/kg/d on day 1, followed by 5 mg/kg/d once daily for four days). If a child is allergic to amoxicillin and infection with a penicillin-resistant strain of S pneumoniae is likely, clindamycin (30 to 40 mg/kg/d in three divided doses) should be given.

For children who are vomiting, a single dose of ceftriaxone (50 mg/kg/d) should be given intravenously or intramuscularly. Twenty-four hours later, once vomiting has stopped, oral therapy can be started.

High-dose amoxicillin-clavulanate (80 to 90 mg/kg/d of amoxicillin and 6.4 mg/kg/d of clavulanate in two divided doses) is advised for children who do not experience improvement within 48 to 72 hours after receiving the usual amoxicillin regimen, who have recently been given antimicrobial therapy, who are moderately to severely ill, or who attend day care. Alternatives in these cases include cefdinir, cefuroxime, and cefpodoxime.

When no improvement occurs after a second course of antibiotics or if the patient is acutely ill, two options are available:

• An otolaryngologist can be consulted about the possibility of maxillary sinus aspiration; the goal here is to obtain sinus secretions for culture and sensitivity analysis so that antibiotic therapy can be adjusted precisely.

• Alternatively, the physician may prescribe intravenous cefotaxime or ceftriaxone and refer to an otolaryngologist only if intravenous therapy fails.

The optimal duration of antibiotic therapy for acute bacterial sinusitis has not been systematically studied. Common recommendations for empiric treatment range from 10 to 28 days. An alternative strategy suggested by the guideline is to continue treatment for seven days after the patient is symptom-free. This strategy individualizes therapy and ensures at least a 10-day course but avoids prolonged treatment in patients who are asymptomatic and therefore unlikely to be compliant.

COPING WITH COMPLICATIONS

Complications of acute bacterial sinusitis usually involve the orbit, central nervous system, or both. Children with known or suspected complications of acute bacterial sinusitis should be treated promptly and aggressively, the guideline emphasizes.

Periorbital and intraorbital inflammation and infection are most common, and these and other orbit-related complications often require consultation with an otolaryngologist and ophthalmologist. Neurosurgical consultation is indicated for patients with altered mental status resulting from intracranial complications, such as cavernous sinus thrombosis, osteomyelitis of the frontal bone, meningitis, or subdural empyema.

Many aspects of acute bacterial sinusitis require further study, such as vaccination, adjuvant therapies, antimicrobial prophylaxis, the optimal duration of antibiotic therapy, and the impact of the antibiotic resistance. Research is also required to clarify the role of imaging studies in children older than 6 years—an issue Dr. Wald said will be under investigation soon.

—Timothy Begany