Acute Rhinosinusitis in Children Translated from the original French version published October 2009 This clinical guide is provided for information purposes and is not a substitute for the practitioner’s judgment. GENERAL VIRUS: most cases of rhinosinusitis and associated with a common cold • On an average children have 6 to 8 viral upper respiratory tract infections (VURI) per year, each episode lasting an average of 7 days. • 0.5%-5% of VURI progress into acute bacterial rhinosinusitis. Pathogens most often associated with bacterial rhinosinusitis are similar to those associated with acute otitis media •Streptococcus pneumoniae •Haemophilus influenzae •Moraxella catarrhalis •Streptococcus pyogenes Antimicrobial resistance: • Penicillin-resistant S. pneumoniae more likely in children who: - Are under 2 years - Attend day care - Received antibiotics in previous month DIAGNOSIS • Symptoms of bacterial rhinosinusitis and viral rhinosinusitis overlap. • Based on clinical criteria: - Persistent symptoms (≥10 days) or deterioration of symptoms after 5-7 days sPurulent rhinorrhea associated with: aNasal congestion aPersistent cough (often aggravated during nighttime) aIrritability aLess frequently: headache, facial pain, fever - Severe symptoms: sFever ≥39 °C sSignificant deterioration of general health, systemic toxicity, periorbital edema/redness: suspect underlying complications (urgent referral) • Radiography: - Not very useful in young children or in uncomplicated rhinosinusitis - Complete opacification or air-fluid level: only valid diagnostic criteria for acute rhinosinusitis - Thickening of nasal mucosa: not a criterion for acute rhinosinusitis www.cdm.gouv.qc.ca TREATMENT GUIDELINES •Most cases of rhinosinusitis are viral: no antibiotic treatment. •Most cases of acute rhinosinusitis resolve spontaneously without antibiotic treatment. • Reserve antibiotic treatment for acute bacterial rhinosinusitis. • Prevention: - Daily nasal hygiene increased during VURI episodes - Smoke-free home - Allergy investigation to identify the presence of allergens if allergic rhinitis is suspected • Adjuvant therapy for symptomatic relief: - Analgesic/antipyretic - Saline nasal solution - Topical decongestant (MAX 3 consecutive days): no clinical evidence to support its use in children • Children with complicated sinusitis (orbital or central nervous system impairment) must be assessed by a specialist. • Optimal duration of treatment has not been defined in pediatrics: 10-14 days of antibiotics including a minimum of 5 days after symptoms have ceased. There is no indication for the use of azithromycin in acute bacterial rhinosinusitis. Initial treatment of bacterial rhinosinusitis in children Antibiotic* Daily oral dosage† Maximum daily dosage First-line therapy Amoxicillin‡ 90 mg/kg/day ÷ BID 1 000 mg BID Second-line therapy Treatment if therapeutic failure after 48-72 hours Amoxicillin-clavulanate potassium (Clavulin®)§ 90 mg/kg/day ÷ BID 1 000 mg BID Treatment in case of allergy to penicillin Cefprozil (Cefzil®) 30 mg/kg/day ÷ BID 500 mg BID Cefuroxime axetil (Ceftin®) 30 mg/kg/day ÷ BID 500 mg BID Clarithromycin (Biaxin®) 15 mg/kg/day ÷ BID 500 mg BID Clindamycin (Dalacin C®) 20-30 mg/kg/day ÷ TID 450 mg TID Not a type I allergy to penicillin Type I allergy to penicillin * The antibiotics are listed in alphabetical order of their generic name. Only one brand name product is listed although several manufacturers may market other brand names. † Daily dosage must be divided as recommended. ‡ Amoxicillin 50 mg/kg/day may be used in children without risk factors for antibiotic resistance. § The 7:1 (BID) formulation amoxicillin-clavulanate potassium (Clavulin®) is preferred because of its better GI tolerance. For certain clinicians, adverse GI effects are lessened with a combination of amoxicillin (45 mg/kg/day) and amoxicillin-clavulanate potassium (45 mg/kg/day). REFERENCES American Academy of Pediatrics. Subcommittee on Management of Sinusitis and Committee on Quality Improvement. Clinical Pratice Guideline: Management of Sinusitis. Pediatrics. 2001;108:798-808. Fokkens WJ, Lund VJ, Mullol J et al. European position paper on nasal polyps 2007. Rhinology 45; Suppl 20, 1-139. Sinus and Allergy Health Partnership. Antimicrobial treatment guidelines for acute bacterial rhinosinusitis. Otolaryngol Head Neck Surgery. 2004;130 Suppl 1:1-45. Please note that other references have been consulted. Acute Rhinosinusitis in Children This guide was developed with the collaboration of the professional corporations (CMQ, OPQ), the federations (FMOQ, FMSQ) and Québec associations of pharmacists and physicians.