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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.