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pediatric sinusitis summary PMD


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									                      Diagnosis and Management of                                                                                      2008 Update

                    Acute Bacterial Sinusitis: Children
                      Summary of the Alberta Clinical Practice Guideline, December 2000

Etiology      •     Most often viral. Most common bacterial pathogens: Streptococcus pneumoniae, Haemophilus influenzae,
                    Moraxella catarrhalis

Diagnosis     •     History of URTI symptoms >10 to 14 days with both: nasal congestion/purulent nasal discharge and
                    continued unwell state, +/- fever, cough, irritability, lethargy
              •     Physical findings of: swelling and/or erythema over symptomatic area, tenderness on palpation/
                    percussion of paranasal sinuses, periorbital swelling, erythema/swelling of nasal mucosa, post nasal drip
              •     Nasal/nasopharyngeal cultures NOT recommended. Transillumination has no diagnostic value

Antibiotic    •     Antibiotic therapy should be reserved for those with acute bacterial sinusitis as defined by history and
Therapy             physical examination
              •     Amoxicillin retains best coverage of oral beta-lactam agents against S. pneumoniae (including intermediate

                  1st-line agents
                  Amoxicillin                           Standard dose: 40 mg/kg/day PO div tid for 10 days, OR
                                                        High dose1: 90 mg/kg/day PO div bid - tid for 10 days
                  Beta-lactam allergy
                  TMP/SMX2                              6-12 mg/kg/day PO div bid (based on TMP) for 10 days
                  2nd-line agents
                  [Amoxicillin-clavulanate              (7:1 formulation) 45 mg/kg/day PO div bid - tid for 10 days
                   PLUS Amoxicillin]                    45 mg/kg/day PO div bid - tid for 10 days, OR
                  Cefuroxime axetil3                    30 mg/kg/day PO div bid for 10 days
                  Beta-lactam allergy4
                  Azithromycin                          10 mg/kg/day PO 1st day then 5mg/kg PO daily for 4 days, OR
                  Clarithromycin                        15 mg/kg/day PO div bid for 10 days
                  Cefuroxime                            100 - 150 mg/kg/d IV div q8h
                  Chronic bacterial sinusitis
                  Amoxicillin-clavulanate               (7:1 formulation) 45 mg/kg/day PO div bid for 3 weeks5, OR
                  Clindamycin                           30 mg/kg/day PO div tid or qid for 3 weeks7

              1. Higher dose should be considered in children who have attended daycare and recent (< 3 months) antibiotic exposure
              2. This higher dose should be used in high risk children:recent antibiotic exposure (<3 months) and/or daycare centre attendance
              3. Cefuroxime provides best coverage of all oral cephalosporins against penicillin intermediate strains of S. pneumoniae and
                 provides good coverage of Haemophilus/Moraxella/S. aureus
              4. Macrolide use should be restricted as resistance is increasing in Alberta and macrolides have been shown (in AOM) to be less
                 efficacious against H. influenzae and S. pneumoniae than amoxicillin-clavulanate
              5. Longer duration may be required in exceptional circumstances

Antibiotics NOT
Recommended •       Cephalexin, cefaclor, cefixime, ceftriaxone, clindamycin, erythromycin, quinolones

Follow-up     •     Non-responders: reassess at 72 hours
              •     Routine follow-up on completion of therapy in asymptomatic patients is NOT required

              For complete guideline refer to the TOP Web Site: www.topalbertadoctors.org
              Reviewed January 2006
              Reviewed January 2008                                                                                                 Administered by the
                                                                                                                                Alberta Medical Association
                                   Management of Sinusitis in Children
                     Viral rhinosinusitis occurs up to 200 times more commonly than bacterial sinusitis
                     Up to 60% of cases of acute sinusitis will resolve spontaneously without antibiotics

                    Does patient have persistent symptoms of URTI without improvement after 10 to 14 days?


History of both purulent nasal discharge and continued                         Physical findings of:
unwell state*                                                                  • swelling and/or erythema over the symptomatic area
+/-                                                                            • tenderness on palpation/percussion
• fever                                                                        • periorbital swelling
• cough                                                                        • mucopurulent secretions
• irritability                                                                 • anatomical anomalies, foreign bodies
• lethargy                                                                     • post nasal drip
• facial pain                                                                  • maxillary tooth tenderness
* Maintain a high degree of suspicion of intracranial suppurative              • concomitant otitis media
  complications in severely ill child with fever >39O and purulent nasal
  discharge associated with: cough, headache, facial swelling, sinus
                                                                               • lymphadenopathy

• Nasal/nasopharyngeal cultures NOT recommended
• Plain X-rays and CT scans not routinely recommended
• MRI not recommended
• Transillumination of the sinuses has no diagnostic value in children
                                                              Acute bacterial sinusitis?

                                 6                                                                       6
                                 NO                                                                      YES

                             6                                                                           6
• Antibiotic therapy NOT indicated                                             1st-line agents (6 weeks or more between episodes)
• Analgesics/antipyretics for control of pain/fever                            Amoxicillin (standard or high dose)
• Saline irrigation of the nasal cavities might be of                          Beta-lactam Allergy
   benefit                                                                     Erythromycin-sulfisoxazole OR
• Cool mist humidifier might be of benefit                                     TMP/SMX
                                                                               2nd-line agents (< 6 weeks between episodes)
• Short duration topical or systemic decongestants                             Amoxicillin-clavulanate +/- amoxicillin OR
   might be useful adjuncts
                                                                               Cefuroxime axetil
                                                                               Beta-lactam Allergy
                                                                               Erythromycin-sulfisoxazole OR
                                                                               Azithromycin OR

                                 6                                                                       6
• Routine follow-up on completion of therapy in asymptomatic patients is NOT required
• If patient shows no improvement at 72 hours of adjunctive therapy and 1st-line agents, use 2nd-line agents
• If patient deteriorates at any time reassess for acute complications, other diagnoses, adherence to treatments

                                                   Chronic bacterial sinusitis
                                  Sinusitis lasting 12 weeks or more with or without treatment
                      • Adjunctive therapy is as important as antibiotic therapy
                        Amoxicillin-clavulanate OR Clindamycin
                      • Consider allergy assessment

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