Acute Bacterial Rhinosinusitis ABRS

Similar to the CDC's recommendations for AOM, the guidelines issued by the Sinus and Allergy Health Partnership recommends empiric choices for treating ABRS (43). As in AOM, S. pneumoniae and H. influenzae are frequently implicated in ABRS. However, M. catarrhalis is less likely to be the infectious cause of this

TABLE 3 Criteria for Initial Antibacterial Treatment or Observation in Children with Acute Otitis Media

Age Certain diagnosis Uncertain diagnosis

TABLE 3 Criteria for Initial Antibacterial Treatment or Observation in Children with Acute Otitis Media

Age Certain diagnosis Uncertain diagnosis

< 6 mo

Antibacterial therapy

Antibacterial therapy

6 mo to 2 years

Antibacterial therapy

Antibacterial therapy if severe illness; observation option if non-severe illness when follow-up can be insured

> 2 years

Antibacterial therapy if severe illness; observation option if non-severe

Observation option

Source: Adapted from Ref. 42.

Source: Adapted from Ref. 42.

condition compared with its role in AOM (2% vs. 12%). The guidelines recognize that patients exposed to an antibiotic within 4 to 6 weeks of their current infection are likely to be infected with a resistant pathogen. In developing its antimicrobial guidelines, the panel employed the Poole Therapeutic Outcome Model to predict the therapeutic effectiveness of various antimicrobial agents. Recognizing that resistance rates may change over time and may vary from community to community, the Panel intends to revise the guidelines as resistance rates change and as new antibiotics are introduced. The model is available at the Sinus and Allergy website (76), where clinicians may input local resistance rates and develop their own optimal treatment recommendations.

Agents recommended for the treatment of ABRS are listed in Table 5. The antibiotic selections listed in the table are stratified by disease severity, age of the patient, and recent antibiotic exposure. The preferred agents are those that are active against the pathogens commonly implicated in acute sinusitis—S. pneumoniae, H. influenzae, and M. catarrhalis. Switching to a second agent is suggested if, after 72 hr, the patient's condition does not clinically improve or worsens. Selection of the appropriate antibiotic can help prevent the development of chronic sinusitis, decrease costs associated with multiple treatment failures, and curtail the development of resistance.

First-line therapy for adult patients with mild disease and no antibiotic therapy during the previous 4 to 6 weeks are limited to high-dose amoxicillin, amoxicillin-clavulanate, cefpodoxime proxetil, and cefuroxime axetil. The guidelines note that cefprozil may have a bacterial failure rate of up to 25%. Similarly, while clarithromycin, trimethoprim-sulfamethoxazole, doxycycline, azithromycin, or erythromycin may be considered for patients with beta-lactam allergies, they are generally less active for DRSP. The use of trimethoprim-sulfamethoxazole also has been associated with potentially fatal toxic epidermal necrolysis. For adults with mild disease who have had recent antibiotic therapy or for those with moderate disease with no recent antibiotic therapy, first-line treatment recommendations include amoxicillin-clavulanate, high-dose amoxicillin, cefpo-doxime proxetil, and cefuroxime axetil. Appropriate agents for beta-lactam-allergic or -intolerant patients include gatifloxacin, levofloxacin, and moxifloxacin. In adult patients with moderate disease and recent antibiotic use, the indicated agents are amoxicillin-clavulanate, gatifloxacin, levofloxacin, moxifloxacin, or combination therapy—amoxicillin or clindamycin for Gram-positive coverage plus cefixime or cefpodoxime proxetil for Gram-negative coverage.

31 CD

TABLE 4 Recommended Antibacterial Agents for Acute Otitis Media

CD 3

31 y

At diagnosis for patients treated initially with antibacterials

Clinically defined treatment failure at 48-72 hr after initial observation

Clinically defined treatment failure 48-72 hr after initial treatment with antibacterials

TABLE 4 Recommended Antibacterial Agents for Acute Otitis Media

At diagnosis for patients treated initially with antibacterials

Clinically defined treatment failure at 48-72 hr after initial observation

severe otalgia

Recommended

Alternative

Recommended

Alternative

Recommended

Alternative

No

Amoxicillin, 80-90 mg/kg/d

Non-type 1: cefnidir, cefuroxime, Cefpodoxime Type 1:

azithromycin, clarithromycin

Amoxicillin, 80-90 mg/kg/d

Non-type 1: cefnidir, cefuroxime, cefpodoxime;

Type 1: azithromycin, clarithromycin

Amoxicillin-clavulanate, 90 mg/k/d

Non-type 1:

ceftriaxone Type 1: clindamycin

Yes

Amoxicillin-clavulanate, 90 mg/k/d

Ceftriaxone

Amoxicillin-clavulanate, 90 mg / k/d

Ceftriaxone

Ceftriaxone

Tympanocentesis, clindamycin

CD 3

31 y

Source: Adapted from Ref. 42.

Source: Adapted from Ref. 42.

TABLE 5 Agents Recommended for Treatment of Acute Bacterial Sinusitis

Population

Mild disease

Moderate disease

Adults (if no antibiotics in

Amoxicillin (high dose)a

Amoxicillin (high dose)a

past 4-6 weeks)

Amoxicillin-clavulanate

Amoxicillin-clavulanate

Cefpodoxime proxetil

Cefpodoxime proxetil

Cefuroxime axetil

Cefuroxime axetil

Alternatives—limited effectiveness,

Alternatives

bacterial failure rates 20%-25%

Gatifloxacin

Cefprozil

Levofloxacin

Clarithromycinb

Moxifloxacin

TMP/SMXb

Doxycyclineb

Azithromycin11

Erythromycin11

Adults (if antibiotics in

Amoxicillin (high dose)a

Amoxicillin-clavulanate

past 4-6 weeks)

Amoxicillin-clavulanate

Gatifloxacin

Cefpodoxime proxetil

Levofloxacin

Cefuroxime axetil

Moxifloxacin

Alternatives:

Combination therapy: Gram-positive

Levofloxacin

coverage (amoxicillin or

Moxifloxacin

clindamycin) + Gram-negative

Gatifloxacin

coverage (cefixime or

cefpodoxime proxetil)

Children (if no antibiotics

Amoxicillin (high-dose)a

Amoxicillin (high-dose)a

in past 4-6 weeks)

Amoxicillin-clavulanate

Amoxicillin-clavulanate

Cefpodoxime proxetil

Cefpodoxime proxetil

Cefuroxime axetil

Cefuroxime axetil

Alternatives—limited effectiveness,

bacterial failure rates 20%-25%

TMP/SMX

Azithromycin

Clarithromycin

Erythromycin

Children (if antibiotics in

Amoxicillin (high dose)a

Amoxicillin-clavulanate

past 4-6 weeks)

Amoxicillin-clavulanate

Combination therapy: Gram-positive

Cefpodoxime proxetil

coverage (amoxicillin or

Cefuroxime axetil

clindamycin) + Gram-negative

coverage (cefixime or

cefpodoxime proxetil)

aHigh-dose amoxicillin (80-90 mg/kg/day). bFor penicillin allergy.

Abbreviations: ABRS, acute bacterial rhinosinusitis; TMP/SMX, trimethoprim-sulfamethoxazole. Source: Adapted from Ref. 42.

aHigh-dose amoxicillin (80-90 mg/kg/day). bFor penicillin allergy.

Abbreviations: ABRS, acute bacterial rhinosinusitis; TMP/SMX, trimethoprim-sulfamethoxazole. Source: Adapted from Ref. 42.

In pediatric patients with mild disease and no antibiotic use in the previous 4 to 6 weeks, first-line therapy includes amoxicillin-clavulanate, high-dose amox-icillin, cefpodoxime proxetil, or cefuroxime axetil. In patients with a history of immediate type I hypersensitivity to beta-lactams, the use of trimethoprim-sulfa-methoxazole, azithromycin, clarithromycin, or erythromycin is recommended, although bacterial failure rates of 20% to 25% are possible with these agents.

For children with moderate disease who have had no recent antibiotic therapy or for those with mild disease who have had recent antibiotic therapy, indicated treatment agents are high-dose amoxicillin, amoxicillin-clavulanate, cefpodoxime proxetil, and cefuroxime axetil. In children with moderate disease who have received recent antibiotic therapy, the recommended treatment is amoxicillin-clavulanate or combination therapy—amoxicillin or clindamycin for Gram-positive coverage plus cefixime or cefpodoxime proxetil for Gram-negative coverage.

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