1. 10/11/13921

2. Dr Mostafavi N Pediatric infectious disease departement Isfahan university of medical sciences 10/11/13922

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) 10/11/13923

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? 10/11/13924

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? 10/11/13925

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? 10/11/13926

7. Case 4 A 2 year old boy brought with recurrence of fever and cough on 6 th 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? 10/11/13927

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 erythematous pharyngitis and clear nasal discharge. What's your diagnosis? 10/11/13928

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? 10/11/13929

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 erythematous pharyngitis and clear nasal discharge. What's your diagnosis? 10/11/139210

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? 10/11/139211

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. 10/11/139212

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 10/11/139213

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 10/11/139214

15. Course of viral upper respiratory infection 10/11/139215

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 10/11/139216

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 10/11/139217

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 10/11/139218

19. worsening course Double sickening Substantial and acute worsening of nasal discharge/ nasal congestion/ daytime cough or new fever, often on the 6-7 th day of illness, after initial signs of recovery a viral URI 10/11/139219

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 10/11/139220

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 10/11/139221

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? 10/11/139222

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 10/11/139223

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? 10/11/139224

25. Management of persistent sinusitis The clinician has two options: Prescribe antibiotic Offer additional outpatient observation for 3 days 10/11/139225

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 10/11/139226

27. Case 4 A 2 year old boy brought with recurrence of fever and cough on 6 th 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? 10/11/139227

28. Case 10 A 3 years age child brought to clinic with history of fever and cough for 4 days. On examinations performed in 1 st and 4 th days she has purulent nasal discharge. The child appears ill. What's your decision? 10/11/139228

29. Management of severe onset or worsening course sinusitis The clinician should prescribe antibiotic therapy. 10/11/139229

30. Case 11 An 8 month child has acute bacterial sinusitis, which antibiotics could be prescribed for the child? 10/11/139230

31. Bacteriology of acute bacterial sinusitis BacteriaPrevalenc e Sensitive to low dose amoxicillin High dose amoxicilli n low dose coamoxicla v High dose coamoxiclav S, pneumonia30%85-90% ( 40-50%) 90-95% ( 65-70%) 85-90% ( 40-50%) 90-95% ( 65-70%) H. Influenza non typeable 30%60- 90% 100% M. catarrhalis10%5% 90%100% Sterile25%---------------------- S. aureusRarely---------------------- AnaerobesRarely---------------------- 10/11/139231

32. Bacteriology of acute bacterial sinusitis BacteriaSusceptible to cefixi me Cefuroxi me axetil Ceftria xone Azithr omyci n Levofl oxacin TMP /SM X Doxy cyclin e Clind amyci n S, pneumonia60%60-75%95-97%60- 70% 100%50- 70% 85%85- 88% H. Influenza non typeable 100%85- 100%100%90- 100% 100%73%0%---- M. catarrhalis----98%97%100% 99%0%----- 10/11/139232

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 10/11/139233

34. Initial antimicrobial Regimens for acute sinusitis in children( AAP) SituationDrug Low risk( age >2 yrs, uncomplicated mild to moderate sinusitis, not attend child care, no AB in the last 4 wks Nonsusceptible S pneumoniae < 10% Amoxicillin 45 mg/kg/day in 2 doses Low risk Nonsusceptible S pneumoniae > 10% Amoxicillin 80 to 90 mg/kg per day in 2 doses, max 2 g/dose High riskHigh-dose amoxicillin-clavulanate (80– 90 mg/kg/day of the amoxicillin with 6.4 mg/kg per day of clavulanate in 2 doses max 2 g per dose) Non–type 1 allergy to amoxicillinCefuroxime axetile Type 1 allergy to amoxicillinCefuroxime axetile or clindamycin (or linezolid) + cefixime or levofloxacin 10/11/139234

35. Antimicrobial Regimens for Acute Rhinosinusitis in children( IDSA) IndicationFirst-lineSecond-line Initial empirical therapyAmoxicillin- clavulanate (45 mg/kg/day PO bid) Amoxicillin-clavulanate (90 mg/kg/day PO bid) β-lactam allergy Type I hypersensitivity -------Levofloxacin (10–20 mg/ kg/day PO every 12–24 h) β-lactam allergy Non–type I hypersensitivity -------Clindamycin (30–40 mg/kg/day PO tid) plus cefixime (8 mg/kg/day PO bid) Risk for antibiotic resistance or failed initial therapy ------Amoxicillin-clavulanate (90 mg/kg/day PO bid) Clindamycin plus cefixime Levofloxacin 10/11/139235

36. Antimicrobial Regimens for Bacterial Rhinosinusitis in Adults( IDSA) IndicationFirst-lineSecond-line Initial empirical therapyAmoxicillin-clavulanate (500 mg/125 mg PO tid, or 875 mg/125 mg PO bid) Amoxicillin-clavulanate (2000 mg/125 mg PO bid) Doxycycline (100 mg PO bid or 200 mg PO qd) β-lactam allergy-------Doxycycline (100 mg PO bid or 200 mg PO qd) Levofloxacin (500 mg PO qd) Moxifloxacin (400 mg PO qd) Risk for antibiotic resistance or failed initial therapy ------Amoxicillin-clavulanate (2000 mg/125 mg PO bid) Levofloxacin (500 mg PO qd) Moxifloxacin (400 mg PO qd) 10/11/139236

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? 10/11/139237

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 10/11/139238

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? 10/11/139239

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? 10/11/139240

41. Management of Worsening or Lack of Improvement at 72 Hours Initial ManagementWorse in 72 HoursLack of Improvement in 72 Hours ObservationInitiate amoxicillin with or without clavulanate Additional observation or initiate antibiotic based on shared decision-making AmoxicillinHigh-dose amoxicillin- clavulanate Additional observation or high-dose amoxicillin- clavulanate based on shared decision-making High-dose amoxicillin- clavulanate Clindamycin and cefixime OR levofloxacin Continued high-dose amoxicillin-clavulanate OR clindamycin a and cefixime OR levofloxacin a 10/11/139241

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? 10/11/139242

43. Adjuvant Therapy for acute bacterial sinusitis DrugEfficacy Intranasal corticosteroids(budesonide, flunisolide, fluticasone, and mometasone) Significant in adolescents and adults, modest in children( poor designed studies) Saline nasal irrigation or lavage (not saline nasal spray) Effective in children( one study) Variable result in adults Oral or topical nasal decongestantsInsufficient data MucolyticsInsufficient data Oral or nasal spray antihistaminesInsufficient data Might be helpful in patients with atopy 10/11/139243

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