Management of Acute Bacterial Sinusitis in Children

2. Management of Acute Bacterial Sinusitis in Children Dr Mostafavi N Pediatric infectious disease departement Isfahan university of medical sciences

3. References • 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)

4. Case 1 • A 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?

5. Case 2 • A 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?

6. Case 3 • A 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?

7. Case 4 • A 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?

8. Case 5 • A 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 erythematouspharyngitis and clear nasal discharge. What's your diagnosis?

9. Case 6 • A 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. Case 7 • A 2 year old boy brought with history of high grade fever and coryza and cough for 5 days. On examination he has erythematouspharyngitis and clear nasal discharge. What's your diagnosis?

11. Case 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?

12. Features of an uncomplicated viral URI • Usually nasal symptoms (discharge and congestion/obstruction) or cough or both • Most often, discharge begins as clear and watery • Often, the quality of discharge changes during the course of the illness • Typically, discharge becomes thicker and more mucoid and may become purulent (thick, colored, and opaque) for several days.

13. Features of an uncomplicated viral URI • Then the purulent discharge becoming mucoid and then clear again or simply resolving. • Fever, when present, occur early in the illness, often with constitutional symptoms s • Typically, the fever disappear in the first 24 to 48 hours, and the respiratory symptoms become more prominent

14. Features of an uncomplicated viral URI • The 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 improve • Resolving symptoms and signs may persist in some patients after day 10

15. Course of viral upper respiratory infection

16. Diagnosis of acute bacterial sinusitis • Persistent illness: nasal discharge (of any quality) or daytime cough or both lasting more than 10 days without improvement • Worsening course: worsening or new onset of nasal discharge, daytime cough, or fever after initial improvement • Severe onset: concurrent fever (temperature ≥39°C) and purulent nasal discharge for at least 3 consecutive days

17. Persistent illness • Persistence symptoms without improvement suggests sinusitis • Symptoms include nasal discharge (of any quality: thick or thin, serous, mucoid, or purulent) or daytime cough (which may be worse at night) or both • Bad breath, fatigue, headache, and decreased appetite, although common, are not specific

18. Persistent illness • 6%–7% of children presenting with symptoms of URI will meet criteria for persistence • Before diagnosing bacterial sinusitis : • Differentiate sequential episodes of viral URI • Differentiate noninfectious rhinitis with personal/ family history of atopic conditions, prominent nasal crease, allergic shiners, cobblestoning of the conjunctiva or pharyngeal wall, or pale nasal mucosa • Establish clearly not improving symptoms

19. worsening course • Double sickening • Substantial 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

20. severe onset • Concurrent high fever (temperature >39°C) and purulent nasal discharge for 3-4 days in children • Acute onset of headache, fever, and facial pain in adults • Usually 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

21. Severe onset • Generally, in viral URTI fever resolve in the first 48 hours and then the respiratory symptoms become prominent • In 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 sinusitis

22. Case 8 • A 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?

23. Imaging studies • AAP: Clinicians should not obtain imaging studies ( x- ray, CT scan, MRI, or sonography) to distinguish bacterial sinusitis from viral URI • Bacterial sinusitis in children is a clinical diagnosis • Historically imaging was a diagnostic modality in children and is no longer recommended • Normal imaging can rule out bacterial sinusitis

24. Case 9 • A 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?

25. Management of persistent sinusitis • The clinician has two options: • Prescribe antibiotic • Offer additional outpatient observation for 3 days

26. Factors that influence the decision in persistent sinusitis • Symptom severity • Quality of life • Recent antibiotic • Concurrent 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 administration • Parents preferences

27. Case 4 • A 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?

28. Case 10 • A 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?

29. Management of severe onset or worsening course sinusitis • The clinician should prescribe antibiotic therapy.

30. Case 11 • An 8 month child has acute bacterial sinusitis, which antibiotics could be prescribed for the child?

31. Bacteriology of acute bacterial sinusitis

32. Bacteriology of acute bacterial sinusitis

33. Risk factors for the presence of resistant organisms • Attendance at child care • Receipt of Abs within the previous 30 days • Age younger than 2 years

34. Initial antimicrobial Regimens for acute sinusitis in children( AAP)

35. Antimicrobial Regimens for Acute Rhinosinusitisin children( IDSA)

36. Antimicrobial Regimens for Bacterial Rhinosinusitis in Adults( IDSA)

37. Case 12 • An 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?

38. Duration of treatment • Optimal 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 management

39. Case 13 • An 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?

40. Case 14 • An 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?

41. Management of Worsening or Lack of Improvement at 72 Hours

42. Case 15 • An 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?

43. Adjuvant Therapy for acute bacterial sinusitis