Stewardship in the pediatrician's office: Antibiotic use for acute sinusitis - Healio

Posted: 25 Nov 2020 10:43 AM PST

November 25, 2020

6 min read

Disclosures: Kothari and Noor report no relevant financial disclosures.

Acute sinusitis is inflammation of mucosa lining of one or more paranasal sinuses. In children, most cases begin as a viral infection that extends from nasal mucosa (rhinitis) onto the mucosal lining of paranasal sinuses (sinusitis).

Acute viral rhinosinusitis resolves without treatment within 7 to 10 days. An estimated 5% to 10% of the acute upper respiratory viral infections are complicated by acute bacterial sinusitis. Acute bacterial sinusitis requires antibiotic treatment to quicken recovery and prevent complications, although many cases resolve without treatment.

Sinusitis is a common problem in the pediatrician's office. Distinguishing acute viral sinusitis from acute bacterial sinusitis is important to limit unnecessary antibiotic use. In this column, we discuss the clinical features, particularly the illness timeline, that can aid in separating acute viral from bacterial sinusitis.

1. Confronting the conundrum of appropriate antibiotic prescription

Sinus development and typical age of sinusitis:

Ulka Kothari

Asif Noor

The paranasal sinuses are paired air-filled extensions of the nasal cavity located in the facial bones. The timeline of paranasal sinus development is variable. For example, the ethmoid and maxillary sinuses are present at birth. The maxillary sinuses expand rapidly by 2 years of age. The sphenoid sinuses begin development by 2 years of age, and the frontal sinuses begin development by 6 to 8 years of age. Acute bacterial sinusitis is typically seen in children aged 4 to 7 years. Although uncommon in children aged younger than 2 years, cases in infancy are possible.

Pathophysiology:

An upper respiratory viral infection of nasal mucosa extends into the paranasal sinuses. In most instances, the inflammatory process resolves spontaneously. In some cases, infection of the mucosa results in obstruction of the sinus ostia (drainage sites of sinuses into the nasal mucosa), and there is impairment of mucociliary apparatus. The narrow caliber of ostia that drain maxillary and ethmoid sinuses predisposes to obstruction during an upper respiratory tract infection. This causes an increase in intrasinus pressure. In addition, absorption of oxygen by the metabolically active mucosa results in buildup of negative pressure within the sinus cavities. This leads to aspiration of mucus laden with bacteria from the nose and nasopharynx into the sinuses, leading to acute bacterial sinusitis.

Clinical presentation :

The timeline of upper respiratory tract symptoms can assist in separating uncomplicated viral infection from complicated bacterial sinusitis.

Most of the uncomplicated viral upper respiratory tract infections resolve in 5 to 10 days. Fever, if present, is typically seen during the initial 1 to 2 days. Nasal symptoms, such as rhinorrhea or nasal congestion, are predominant later. In regard to nasal discharge, it begins as watery in consistency, becomes purulent over the course of the illness and near resolution, becomes watery again.

In contrast, acute bacterial sinusitis has three peculiar presentations. The most common of these is persistent nasal symptoms without improvement for more than 10 days and less than 30 days. The persistent nasal discharge can be of any quality: thin/thick, watery/mucousy. About 6% to 7% of children with sinusitis are diagnosed with persistent symptoms. The second presentation is of severe symptoms, high fevers and purulent nasal discharge for 3 to 4 days. Nasal discharge is purulent from the beginning in this case. The third presentation is of biphasic illness with acute worsening on the 6th or 7th day in a child with upper respiratory tract signs and symptoms.

Subacute or chronic sinusitis is defined as the persistence of symptoms exceeding 30 days, including nasal symptoms of rhinorrhea/discharge/congestion, sore throat and facial pain.

Diagnostic accuracy :

Physical examination might reveal purulent nasal discharge. The nasal mucosa can be erythematous, and on occasion pale or boggy. The tympanic membranes might reveal evidence of acute otitis media or otitis media with effusion. Sometimes, there is tenderness over the paranasal sinuses. Neither tenderness of paranasal sinuses nor malodorous discharge are sensitive markers of sinusitis.

Imaging, such as X-ray, CT scan or MRI, is not helpful in cases of uncomplicated sinusitis in children. Normal imaging can exclude sinusitis, but abnormal imaging does not confirm sinusitis, and importantly, it does not differentiate viral from bacterial causes. However, imaging is useful in looking for complications of acute bacterial sinusitis, such as subperiosteal abscess, intracranial abscess, and so on.

Microbiology :

Important bacterial pathogens responsible for sinusitis include Streptococcus pneumoniae (30%), nontypeable Haemophilus influenzae (30%) and Moraxella catarrhalis (10%). The prevalence of these pathogens was determined nearly 30 years ago, and it was reevaluated more recently using middle ear fluid analysis. Since 2000, there has been an increase in non-Prevnar serotypes of S. pneumoniae and an emergence of beta-lactamase-producing H. influenzae and Moraxella species. Other uncommon organisms include group A streptococcus, viridans streptococci, Peptostreptococcus and Eikenella species. Staphylococcus aureus and oral anaerobes are infrequent causes of sinusitis.

Choice of antibiotic :

Antibiotic indications for acute bacterial sinusitis are listed in the Table, adapted from the clinical practice guidelines for the diagnosis and management of acute arterial sinusitis in children.

When the decision is made on antibiotic use, the two commonly encountered questions are a) whether to prescribe amoxicillin or amoxicillin-clavulanate, and b) whether to use low- vs. high-dose amoxicillin. The mechanism of resistance to penicillin in S. pneumoniae is alteration of penicillin-binding proteins. In strains with low susceptibility, the affinity of the antibiotic to penicillin-binding protein is reduced. S. pneumoniae susceptibility to penicillin differs from community to community. Nationally, it is estimated that 10% to 15 % of isolates are penicillin nonsusceptible. This susceptibility is not usually available. The prevalence of nonsusceptible S. pneumoniae is reported by the CDC's Active Bacterial Core surveillance program.

Amoxicillin has reliable absorption, is palatable and has a longer half-life compared with penicillin. The typical dose is 45 mg/kg per day in areas with low prevalence (< 10%) of nonsusceptible strains. In regions with higher penicillin resistance (> 10%), it is 90 mg/kg per day. At any dose, amoxicillin does not cover most H. influenzae or any Moraxella catarrhalis or beta-lactamase-producing strains of S. pneumoniae.

If amoxicillin was chosen as the initial antibiotic and there is no improvement or worsening of symptoms after 48 to 72 hours, broadening to amoxicillin-clavulanate should be considered. Other situations that necessitate the use of amoxicillin-clavulanate as the initial agent are risk factors for nonsusceptible S. pneumoniae, such as age younger than 2 years, day care attendance, use of antibiotics in the past 30 days, frontal sinusitis, sphenoid sinusitis, complicated ethmoidal sinusitis or protracted symptoms lasting longer than 30 days.

If the initial agent was amoxicillin-clavulanate and there is no improvement or worsening of symptoms after 48 to 72 hours, switch to oral cephalosporins (ie, cefuroxime, cefpodoxime or a combination of clindamycin/linezolid and cefixime).

If there is still no improvement, sinus aspiration and IV antibiotics should be considered. In children who appear clinically ill, hospitalization and treatment with a third-generation cephalosporin should be considered, such as ceftriaxone 100 mg/kg per day, and ampicillin sulbactam 200 mg/kg per day in four equally divided doses. If there is no improvement within 24 to 48 to hours, reevaluation, including imaging, should be attempted.

In children with nontype 1 hypersensitivity reaction (late, delayed > 7 days), physicians can consider oral cephalosporin such as cefuroxime, cefdinir and cefpodoxime. In children with type I hypersensitivity, levofloxacin can be used.

There are no systematic studies on appropriate duration of therapy. The AAP's approach is antibiotic treatment until resolution of symptoms plus 7 days.

2. Practice guidelines for outpatient settings

See the AAP's 2013 update to its clinical practice guideline on the diagnosis and management of acute bacterial sinusitis in children and adolescents.

3. Operationalizing an antimicrobial stewardship program in your office through quality improvement and electronic health records

Antibiotic stewardship efforts to improve appropriate treatment of acute bacterial sinusitis follow the same principles that we discussed in previous conditions. Start with provider education on evaluation and management guidelines for acute bacterial sinusitis. A standardized written protocol would aid providers in evaluation and management decisions after education. One could incorporate this protocol in an electronic clinical decision support tool in the form of standardized templates. Upon entering a sinusitis diagnosis, a best practice advisory, with links to guidelines, can serve as a reminder on appropriate management of acute bacterial sinusitis. Define, track and report process and outcome measures based on the protocol and include standards for the correct diagnosis, inappropriate imaging, shared decision-making, choice of antibiotics and so on.

Another focus for antibiotic stewardship could be an accurate diagnosis of penicillin allergy. Only 10% of children diagnosed with penicillin allergy are truly allergic. A thorough history that combines all subjective and objective information available is critical in the diagnostic evaluation of children with antibiotic allergy. Reconciling allergy information at every encounter, coupled with the further investigation for patients who may not have a true allergy to antibiotics, would aid in global antimicrobial stewardship efforts.

For more information:

Ulka Kothari, MD, is a general pediatrician, physician informaticist and director of pediatric ambulatory quality at NYU Winthrop Hospital. She can be reached at Ulka.Kothari@nyulangone.org.

Asif Noor, MD, FAAP, is an assistant professor of pediatrics at NYU Long Island School of Medicine. He can be reached at Asif.Noor@nyulangone.org.

References:

AAP. Antibiotic stewardship: Quality improvement resources & tools. htps://www.aap.org/en-us/professional-resources/quality-improvement/quality-improvement-resources-and-tools/Pages/antibiotic-stewardship.aspx. Accessed November 20, 2020.

Brook I, et al. Int J Pediatr Otorhinolaryngol. 2007;doi:10.1016/j.ijporl.2006.10.025.

CDC. Active Bacterial Core Surveillance (ABCs) Report. Emerging Infections Program Network, Streptococcus pneumoniae, 2017. https://www.cdc.gov/abcs/reports-findings/survreports/spneu17.pdf. Accessed November 20, 2020.

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