Post on 06-Jul-2020
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Carla M. Giannoni, MD Surgeon, Otolaryngology Texas Children's Hospital Professor, Surgery and Pediatrics, Baylor College of Medicine
Update on Rhinosinusitis 2013 AAP Guidelines Review
CDC: Acute Rhinosinusitis and URI • 90–98% of sinusitis cases are viral
– Antibiotics are not guaranteed to help even if the causative agent is bacterial
• At least 200 viruses can cause the common cold – Viral URIs are often characterized by nasal discharge and congestion or cough. Usually
nasal discharge begins as clear and changes throughout the course of the illness – Fever, if present, occurs early in the illness
• Management of the common cold, nonspecific URI, and acute cough illness should focus on symptomatic relief – Antibiotics should not be prescribed for these conditions – There is potential for harm and no proven benefit from over-the-counter cough and cold
medications in children younger than 6 years. These substances are among the top 20 substances leading to death in children <5 years old
– Low-dose inhaled corticosteroids and oral prednisolone do not improve outcomes in non-asthmatic children
http://www.cdc.gov/getsmart/community/for-hcp/outpatient-hcp/pediatric-treatment-rec.html
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Uncomplicated URI
PEDIATRICS Volume 132, Number 1, July 2013
0-3 days 3-5 days 5-7 days 7-10 days Fever (+) (-) (-) (-) Rhinorrhea Clear Yellow, mucoid Clear Improving Cough (-) (+) (+) (-)
Key Action Statement 1
Clinician should make a presumptive diagnosis of acute bacterial sinusitis in the following situations:
• Persistent illness (rhinorrhea and/or cough) > 10 days without improvement • Worsening course (rhinorrhea, cough +/- fever) AFTER initial improvement • Severe onset (fever > 102.2 and purulent rhinorrhea) for at LEAST 3 days
Why? – Other presentations are most likely viral illness
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Key Action Statement 2A
• Clinicians should NOT obtain imaging (plain X-ray, CT, MRI) • Strong recommendation
Why? – Imaging has a high likelihood of being abnormal and doesn’t help make a diagnosis
Key Action Statement 2B
• Clinicians should obtain a contrast-enhanced CT and/or an MRI with contrast whenever a child is suspected of having an orbital or CNS complications of acute bacterial sinusitis
Why? – You don’t want to miss an infection that may require IV antibiotics +/- surgery
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Key Action Statement 3 Recommendation Alternate treatment
Persistent illness (rhinorrhea and/or cough)
> 10 days without improvement
Antibiotic therapy* (*esp if complication, another infection like AOME or underlying conditions like RAD, CF, immunodef)
Observation for 3 additional days (decreases risk of developing antibiotic resistance and med side effects like diarrhea)
Worsening course (rhinorrhea, cough +/- fever)
AFTER initial improvement
Antibiotic therapy
Severe onset (fever > 102.2 and purulent rhinorrhea)
For at LEAST 3 days
Antibiotic therapy
Microbiology of Pediatric Sinusitis*
S. pneumoniae 10 - 50% PCN-R
H. Influenzae
50% β-lactamase
M. Catarrhalis 100% β-lactamase
GAS/Other Sterile/NG
20% 30%
30%
10%
*Current Sinusitis microbiology is extrapolated from AOME data
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Key Action Statement 4 > 2 yrs < 2 yrs or mod – severe illness
Mild to moderate symptoms No risk factors
Amoxicillin 45 mg/kg/day BID
Amoxicillin-clavulanate 80-90 mg/kg/day BID
Risk factors: daycare, recent abx (<4 wks)
Amoxicillin-clavulanate 80-90 mg/kg/day BID
Amoxicillin-clavulanate 80-90 mg/kg/day BID
High community prevalence of non-susceptible S. pneumo
Amoxicillin 80-90 mg/kg/day BID
Amoxicillin-clavulanate 80-90 mg/kg/day BID
Duration of therapy
Option 1: 10 - 28 days
Option 2: 7 days after symptom-free
Unable to take PO
Rocephin 50 mg/kg IM x 1* + PO antibiotics when taking PO *Additional IM doses if remain febrile > 24 hrs
PCN allergy Non-Type 1 (delayed allergy): Cefdinir, cefuroxime, or cefpodoxime
Type 1 PCN allergy: Clindamycin + cefixime or Linezolid + cefixime or Levofloxacin
Key Action Statements 5A and 5B • 5A: Reassess patient at 72 hours
– WHY? Majority of symptom improvement occurs in first 3 days of therapy • 5B: Consider changing therapy as indicated:
Initial Management Worse in 72 Hours Not Improved in 72 Hours
Observation Initiate antibiotic therapy Shared decision: antibiotic therapy vs. continued observation
Amoxicillin High dose amoxicillin-clavulanate
Shared decision: continue amoxicillin vs. high dose amoxicillin-clavulanate
High dose amoxicillin-clavulanate
Clindamycin + cefixime or Linezolid + cefixime or Levofloxacin
Shared decision: continue current therapy vs. alternate therapy (at left)
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Adjuvant Therapies Poor scientific evidence to support use of most adjuvant agents
Intranasal steroids Might help, confidence for benefit lacking, min risk
Saline irrigation Might help, confidence for benefit lacking, min risk
Antihistamines Do not use except to treat concurrent allergy
Decongestants Insufficient data to support use*
*There is potential for harm and no proven benefit from over-the-counter cough and cold medications in children younger than 6 years. These substances are among the top 20 substances leading to death in children <5 years old.