Medical Therapy

Acute Sinusitis

Treatment guidelines have recently been developed by expert panels for both children and adults with acute sinusitis. These consensus statements emphasize that antibiotics are the primary form of treatment for acute sinusitis. For patients with uncomplicated acute bacterial sinusitis that is mild to moderate in severity (Table 4) who have not recently been treated with an antimicrobial, amoxicillinis recommended at a dose of 45 mg/kg/d in two divided doses. If the patient has had a history of a late-onset rash to amoxicillin (non-type-1 hypersensitivity reaction), either cefdinir (14mg/kg/d in one or two doses), cefuroxime (30 mg/kg/d in two divided doses), or cefpodoxime (10 mg/kg/d once daily) can be used. In cases of type 1 systemic reactions (including immediate-onset urticaria), clarithromycin (15 mg/kg/d in two divided doses) or azithromycin (10 mg/kg/d on day 1, with 5 mg/kg/ d 4 d as a single daily dose) can be used. Alternative therapy in the penicillin-allergic patient who is known to be infected with a penicillin-resistant S. pneumoniae is clindamycin at 30-40 mg/kg/d in three divided doses.

Most patients with acute bacterial sinusitis who are treated with an appropriate antimicrobial agent respond promptly (within 48-72 h) with a reduction of nasal discharge and cough and an improvement in general well-being. If a patient fails to improve, either the antimicrobial is ineffective or the diagnosis of sinusitis is not correct.

If patients have an illness that is more severe or do not improve while receiving the above dose of amoxicillin, have recently been treated with an antimicrobial, or attend day care, therapy should be initiated with high-dose amoxicillin-clavulanate (80-90 mg/kg/d of amoxicillin component, with 6.4 mg/kg/d of clavulanate in two divided doses). This dose of amoxicillin will yield sinus fluid levels that exceed the minimum inhibitory concentration of all S. pneumoniae that are intermediate in resistance to penicillin and most, but not all, highly resistantS. pneumoniae. There is sufficient potassium clavulanate to inhibit all p-lactamase producing H. influenzae and M. catarrhalis. Alternative therapies include cefdinir, cefuroxime, or cefpodoxime. A singledose of ceftriaxone (at 50 mg/kg/d), given either intravenously or intramuscularly, can be used in patients with vomiting who do not tolerate oral antibiotics. Twenty-four hours later an oral antibiotic is added to complete the therapy. Although trimethoprim-sulfamethoxazole and erythromycin-sulfisoxazole have traditionally been useful in the past as first- and second-line therapy for patients with acute bacterial sinusitis, recent pneumococcal surveillance studies indicate that resistance to these two combination agents is substantial. Therefore, when patients fail to improve while receiving amoxicillin, neither trimethoprim-sulfamethoxazole nor erythromycin-sulfisoxazole is an appropriate choice for antimicrobial therapy. For patients who do not improve with a second course of antibiotics or who are acutely ill, an otolaryn-gologist should be consulted for consideration of maxillary sinus aspiration.

There are emerging data that shorter courses (e.g., 3 d) of antibiotic treatment may be adequate in treating acute sinusitis. However, we recommend that antibiotics be given for a minimum of 10 d and that the course of treatment should be extended for 7 d beyond the day of significant improvement. There are no data demonstrating that longer courses (e.g., 21 d) are associated with better outcomes. Symptoms recurring soon after a course of antibiotics are usually a reaction to the original organism and should be treated with an alternative p-lactamase-resistant agent for 21 d.

Topical and oral decongestants reduce nasal congestion associated with acute sinusitis and may reduce ostial edema, allowing for improved sinus drainage. Older antihistamines with strong anticholinergic effects such as diphenhydramine and hydroxyzine may cause mucous inspissation and make it more difficult to clear secretions. However, the newer second- and third-generation antihistamines such as loratadine, cetirizine, and fexofenadine have virtually no anticholinergic effects and can be continued in patients who require these agents for concomitant allergic rhinitis.

Chronic Sinusitis

In patients with chronic sinusitis and evidence of purulent discharge, a trial of antibacterial therapy is warranted (Table 5). In patients who have not been previously treated with antibiotics, amoxicillin is a cost-effective choice for first-line therapy. Although there are few published data regarding antimicrobial therapy for chronic sinusitis, anecdotal evidence suggests that patients should be treated for a minimum of 21 d. In patients who are allergic to penicillin, clarithromycin provides good coverage against most relevant pathogens. If the patient has demonstrated no response to these drugs within 10 d, a p -lactamase-resistant antibiotic (per acute sinusitis) should be given for 21 d. For adult patients who do not improve with this treatment, agents with increased anaerobic coverage such as clindamycin or metronidazole may be effective.

In addition to antibiotics, topical nasal corticosteroids should be started to reduce chronic mucosal edema and inflammation. If severe turbinate swelling or nasal polyps are

Table 5

Treatment of Chronic Sinusitis

• Medical therapy

Antibiotic for 3-6 wk Nasal corticosteroid Nasal irrigation with saline Allergen avoidance (if indicated)

Indicated for moderate-severe, medically refractory cases Long-term variable present, a 5- to -7 d course of prednisone (0.5 mg/kg/d given in two to three divided doses) may be beneficial. Both topical and oral corticosteroids appear to be safe in chronic sinusitis, and there is no evidence that they increase the risk of intracranial extension or fulminant infection when given to patients with normal immune function. In allergic patients and patients with nasal polyposis, long-term use of nasal corticosteroids may be helpful in preventing recurrences of sinusitis.

Nasal irrigations, performed two to three times a day with a bulb syringe and saline, can be very helpful in removing dried secretions. Other methods to increase nasal humidification (hot showers, room humidifiers, and steam inhalers) are easy to use and may provide symptomatic relief for short periods.

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