Journal of Antimicrobial Chemotherapy (1996) 38, 547-550
Cefuroxime axetil in the treatment of acute sinusitis in childhood
N. Curses, A. G. Kalayci*, I. Islek and S. Uysal
Ondokuz Mayis University, School of Medicine, Departments of Pediatrics,
55139 Samsun, Turkey
A study of the efficacy of cefuroxime axetil was conducted for the treatment of acute
sinusitis in childhood. Thirty-nine patients aged 5-14 years were given cefuroxime
axetil 20 mg/kg/day divided into two doses for seven days. The diagnosis of acute
sinusitis was based on history, physical examination, and radiological findings. The
results of throat cultures before treatment were 17 patients with group A
/?-haemolytic streptococci, seven patients with pneumococci, and two patients with
Staphylococcus aureus; in the remainder of the patients only normal throat flora were
isolated. In 36 patients (92%) a satisfactory improvement was reported at the end
of the treatment. It was found that cefuroxime axetil was efficaceous for the treatment
of sinusitis in childhood.
Acute bacterial sinusitis is a common clinical problem in childhood (Wald, 1992). The
incidence of acute sinusitis remains to be denned and the criteria for diagnosis vary
widely. Between 5% and 10% of upper respiratory infections may be complicated by
acute sinusitis. Microbiologic evaluation of patients with acute sinusitis requires sinus
aspiration, but this method is a difficult procedure and so should be reserved for use
in cases of treatment failure. An empirical therapy for acute sinusitis should ideally be
effective against Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella
catarrhalis. Other bacterial species recovered much less frequently include Group A
streptococci, Group C streptococci, Streptococcus viridans, peptostreptococci, and other
Moraxella spp. (Wald et al., 1981, 1984). Antibiotics that penetrate well into the sinuses,
and are stable against bacterial /9-lactamases are preferred in the treatment of acute
sinusitis (Anderson, Maurer & Dajani, 1980; Jackson et al., 1984). Cefuroxime axetil
is a second-generation cephalosporin characterized by stability to /Mactamases of
Gram-positive and Gram-negative bacteria. Oral administration and its extended
half-life allow twice-daily dosing, a treatment regimen that facilitates patients'
compliance (Sommers et al., 1984; Knapp & Washington, 1988; James et al., 1991).
The purpose of this study was to evaluate the effectiveness of cefuroxime axetil in
the treatment of children with acute sinusitis.
•Corresponding author. Tel: +90 362 457 60 00; Fax: +90 362 457 60 41.
0305-7453/96/090547 + 04 $12.00/0 f) 1996 The British Society for Antimicrobial Chemotherapy
548 N. GQrses et al.
Patients and methods
Thirty-nine patients with clinical and radiographic evidence of acute sinusitis were
studied. The duration of symptoms in each case was less than 30 days. Clinical signs
and symptoms were recorded, and throat culture and radiography of the sinuses were
performed at patient enrollment. Cefuroxime axetil was administered orally twice daily
at a dose of 20 mg/kg per day for 7 days. On the last day of treatment all patients were
re-examined. Radiological findings, physical signs and symptoms were evaluated and
throat culture was repeated. The resolution of clinical symptoms with radiographic
evidence of improvement was defined as cure; improvement of clinical symptoms and
radiographic evidence of residual sinus congestion was defined as improvement; and no
improvement of clinical symptoms with persistence of radiographic findings was defined
as failure (Wald et al., 1984; Wald, Chiponis & Ledesma-Medina, 1986; Wald, 1992).
Patients were followed-up for three months.
Results and discussion
Of 39 patients (aged 5-14 years), 16 (41 %) were female and all had maxillary sinusitis.
Presenting symptoms and signs of acute sinusitis were cough (69%), nasal discharge
(54%), headache (49%), hypertrophied tonsils (44%), tenderness on percussion (31%),
and postnasal drip (26%). Radiographic findings were complete or incomplete
opacification in 33 patients (85%), mucosal thickening (31%), and air-fluid level in one
case. Clinical diagnosis of tonsillitis/pharyngitis (26 patients), otitis media (four
patients) and asthma (three patients) were made concurrently.
Bacterial isolates obtained from pre-treatment throat cultures included group A
/?-haemolytic streptococci in 17 patients (44%), pneumococci in seven patients (18%),
and S. aureus in two patients (5%). All 26 of these isolates were susceptible to
cefuroxime on disc testing.
At the end of treatment, 36 patients (92%) were cured or improved. Three patients
(8%) did not respond to the treatment. An air-fluid level persisted in one patient and
mucosal thickening in one patient of the three who did not respond to treatment.
Symptoms such as nasal discharge, fetid breath, hypertrophied tonsil, and postnasal
drip continued, and group A /?-haemolytic streptococcus, and S. aureus were isolated
in two of the three treatment failure patients. Cefuroxime axetil treatment was
administered in a dose of 20 mg/kg per day for an additional 7 days in three patients.
Two of the patients were cured with this treatment. The third patient did not respond,
and erythromycin (40 mg/kg/day) plus co-trimoxazole (8 mg trimethoprim -I- 40 mg
sulphamethoxazole/kg/day) therapy for 10 days resulted in symptom resolution. None
of the patients subsequently had relapse of symptoms in the three months after cessation
of antibiotic treatment. Diarrhoea was an adverse event in one patient.
The symptoms of our patients were in accordance with those of the previous
investigations (Wald et al., 1981, 1984).
Viral illness, anatomic obstruction, immunodeficiencies (especially Ig G3 and Ig A
deficiency), and immotile cilia syndrome are predisposing factors for sinusitis in the
paediatric age group. Recurrrent sinusitis is more prevalent in asthma patients and such
episodes may trigger flare-ups of reactive airway disease (Riding & Irvine, 1987; Shapiro
et al., 1991). We observed upper respiratory infections in most of the patients,
Cefuroxime axetil and acute sinusitis 549
hypertrophied tonsils in 44%, hypertrophied adenoids in 10%, and signs of asthma in
8% of cases.
Microbial pathogens in sinusitis are determined ideally by sinus aspiration, but this
is a difficult procedure particularly in children. Therefore, we performed only throat
culture to determine potential pathogens. In almost half of the study group group A
/?-haemolytic streptococci were isolated. We did not culture specifically for anaerobic
bacteria, but these are more prevalent in chronic as opposed to acute sinusitis.
Transillumination and ultrasonography may be helpful in the diagnosis of sinusitis.
CT and MRI are not necessary in children with uncomplicated acute sinusitis and
should be reserved for the evaluation of recurrent or chronic sinus infections (Wald,
1992; Druce, 1993). In children with signs and symptoms of acute sinus infection plain
radiography is sufficient to confirm or exclude the diagnosis. Radiologic findings in
acute sinusitis include diffuse opacification, mucosal thickening of at least 4 mm, or an
air-fluid level (Camacho el al., 1992; Wald, 1992). Radiographic findings of our patients
were in accordance with these descriptions.
Cefuroxime axetil has been compared with co-amoxiclav and cefaclor for the
treatment of upper respiratory tract infections such as tonsillitis, otitis, and sinusitis
(Griffiths et al., 1987; Hebblethwaite, Brown & Cox, 1987; Brodie, Knight &
Cunningham, 1989). Syndor et al. (1989) reported that in a randomized control trial,
treatment with cefuroxime axetil achieved a higher bacterial eradication rate (71% vs
95%) than cefaclor. In another clinical study cefuroxime axetil was reported to be as
effective as amoxiclav with fewer side effects (Camacho et al., 1992). In our
investigations the cure and improvement rate of patients was 92%. This relatively lower
cure rate in comparison with other studies can be attributed to the shorter treatment
period (7 vslO days). Diarrhoea, tremor and convulsions were reported by Camacho
el al. (1992) during treatment with cefuroxime axetil. In our study, only diarrhoea was
observed in one patient. We conclude that cefuroxime axetil 20 mg/kg divided into two
daily doses for seven days is effective for the treatment of acute bacterial sinusitis in
Anderson, K. C , Maurer, M. J. & Dajani, A. S. (1980). Pneumococci relatively resistant to
penicillin: a prevalence survey in children. Journal of Pediatrics 97, 939-41.
Brodie, D. P., Knight, S. & Cunningham, K. (1989). Comparative study of cefuroxime axetil and
amoxycilhn in the treatment of acute sinusitis in general practice. Journal of International
Medical Research 17, 547-51.
Camacho, A. E., Cobo, R., Otte, J., Spector, S. L., Lerner, C. J., Garrison, N. A. et al. (1992).
Clinical comparison of cefuroxime axetil and amoxicillin-clavulanate in the treatment of
patients with acute bacterial maxillary sinusitis. American Journal of Medicine 93, 271-6.
Druce, H. M. (1993). Sinusitis: agents, diagnostic strategies and techniques, treatments, and
problems. Immunology and Allergy Clinics of North America 13, 119-33.
Griffiths, G. K., VandenBurg, M. J., Wight, L. J. Gudgeon, A. C. & Kelsey, M. (1987). Efficacy
and tolerability of cefuroxime axetil in the patients with upper respiratory tract infections.
Current Medical Research and Opinion 10, 555-61.
Hebblethwaite, E. M., Brown, G. W. & Cox, D. M. (1987). A comparison of the efficacy and
safety of cefuroxime axetil and augmentin in the treatment of upper respiratory tract
infections. Drugs under Experimental and Clinical Research 13, 91—4.
Jackson, M. A., Shelton, S., Nelson. J. D. & McCracken, G. H. (1984). Relatively
penicillin-resistant pneumococcal infections in pediatric patients. Pediatric Infectious
Diseases 3, 129-32.
550 N. Curses et al.
James, N. C , Donn, K. H., Collins, J. J., Davis, I. M., Lloyd, T. L., Hart, R. W. et al. (1991).
Pharmacokinetics of cefuroxime axetil and cefaclor: relationship of concentrations in serum
to MICs for common respiratory pathogens. Antimicrobial Agents and Chemotherapy 35,
Knapp, C. C. & Washington, J. A. (1988). In vitro activities of LY163892, cefaclor, and
cefuroxime. Antimicrobial Agents and Chemotherapy 32, 131-3.
Riding, K. H. & Irvine, R. (1987). Sinusitis in children. Journal of Otolaryngology 16, 239-43.
Shapiro, G. G., Virant, F. S., Furukawa, C. T., Pierson, W. E. & Bierman, C. W. (1991).
Immunologic defects in patients with refractory sinusitis. Pediatrics 87, 311-6.
Sommers, D., Van Wyk, M., Williams, P. E. & Harding, S. M. (1984). Pharmacokinetics and
tolerance of cefuroxime axetil in volunteers during repeated dosing. Antimicrobial Agents and
Chemotherapy 25, 344-7.
Sydnor, A., Gwaltney, J. M., Cocchetto, D. M. & Scheld, W. M. (1989). Comparative evaluation
of cefuroxime axetil and cefaclor for treatment of acute bacterial maxillary sinusitis. Archives
Otolaryngologv—Head & Neck Surgery 115, 1430-3.
Wald, E. R. (1992). Sinusitis in children. New England Journal of Medicine 326, 319-23.
Wald, E. R., Chiponis, D. & Ladesma-Medina, J. (1986). Comparative effectiveness of amoxicillin
and amoxicillin-clavulanate potassium in acute paranasal sinus infections in children: a
double-blind, placebo-controlled trial. Pediatrics 77, 795-800.
Wald, E. R., Milmoe, G. J., Bowen, A., Ledesma-Medina, J., Salamon, N. & Bluestone, C. D.
(1981). Acute maxillary sinusitis in children. New England Journal of Medicine 304, 749-54.
Wald, E. R., Reilly, J. S., Casselbrant, M., Ledesma-Medina, J., Milmoe, G. J., Bluestone, C. D.
et al. (1984). Treatment of acute maxillary sinusitis in childhood: a comparative study of
amoxicillin and cefaclor. Journal of Pediatrics 104, 297-302.
(Received 18 October 1995; returned 19 February 1996; revised 9 April 1996;
accepted 10 June 1996)