2017 Sec 1 Green Book

TABLE 4 Management of Worsening or Lack of Improvement at 72 Hours Initial Management Worse in 72 Hours

Lack of Improvement in 72 Hours

Observation

Initiate amoxicillin with or without clavulanate

Additional observation or initiate antibiotic based on shared decision-making Additional observation or high-dose amoxicillin-clavulanate based on shared decision-making

Amoxicillin

High-dose amoxicillin-clavulanate

High-dose amoxicillin-clavulanate Clindamycin a and ce fi xime OR linezolid and ce fi xime OR levo fl oxacin Continued high-dose amoxicillin-clavulanate OR clindamycin a and ce fi xime OR linezolid and ce fi xime OR levo fl oxacin a Clindamycin is recommended to cover penicillin-resistant S pneumoniae . Some communities have high levels of clindamycin-resistant S pneumoniae . In these communities, linezolid is preferred.

S aureus or penicillin-resistant S pneumoniae ) and either ceftriaxone, ampicillin-sulbactam, or piperacillin- tazobactam. 103 Given the polymicrobial nature of sinogenic abscesses, cover- age for anaerobes (ie, metronidazole) should also be considered for intra- orbital complications and should be started in all cases of intracranial com- plications if ceftriaxone is prescribed. Patients with small orbital, subperi- osteal, or epidural abscesses and minimal ocular and neurologic abnor- malities may be managed with in- travenous antibiotic treatment for 24 to 48 hours while performing frequent visual and mental status checks. 104 In patients who develop progressive signs and symptoms, such as impaired visual acuity, ophthalmoplegia, elevated in- traocular pressure ( > 20 mm), severe proptosis ( > 5 mm), altered mental status, headache, or vomiting, as well as those who fail to improve within 24 to 48 hours while receiving antibiotics, prompt surgical intervention and drainage of the abscess should be un- dertaken. 104 Antibiotics can be tailored to the results of culture and sensitivity studies when they become available. AREAS FOR FUTURE RESEARCH Since the publication of the original guideline in 2001, only a small number of high-quality studies of the diagnosis and treatment of acute bacterial si- nusitis in children have been pub- lished. 5 Ironically, the number of published guidelines on the topic (5) exceeds the number of prospective,

have also been implicated in chronic sinusitis, and it is clear that there is an overlap between the 2 syn- dromes. 101,102 In some cases, there may be episodes of acute bacterial sinusitis superimposed on a chronic sinusitis, warranting antimicrobial therapy to hasten resolution of the acute infection. Complications of acute bacterial si- nusitis should be diagnosed when the patient develops signs or symptoms of orbital and/or central nervous system (intracranial) involvement. Rarely, complicated acute bacterial sinusitis can result in permanent blindness, other neurologic sequelae, or death if not treated promptly and appropriately. Orbital complications have been clas- si fi ed by Chandler et al. 32 Intracranial complications include epidural or subdural abscess, brain abscess, ve- nous thrombosis, and meningitis. Periorbital and intraorbital in fl am- mation and infection are the most common complications of acute si- nusitis and most often are secondary to acute ethmoiditis in otherwise healthy young children. These disorders are commonly classi fi ed in relation to the orbital septum; periorbital or preseptal in fl ammation involves only the eyelid, whereas postseptal (intraorbital) in- fl ammation involves structures of the orbit. Mild cases of preseptal cellulitis (eyelid < 50% closed) may be treated on an outpatient basis with appropriate Complications of Acute Bacterial Sinusitis

oral antibiotic therapy (high-dose amoxicillin-clavulanate for comprehen- sive coverage) for acute bacterial si- nusitis and daily follow-up until de fi nite improvement is noted. If the patient does not improve within 24 to 48 hours or if the infection is progressive, it is appropriate to admit the patient to the hospital for antimicrobial therapy. Similarly, if proptosis, impaired visual acuity, or impaired and/or painful extraocular mobility is present on ex- amination, the patient should be hos- pitalized, and a contrast-enhanced CT should be performed. Consultation with an otolaryngologist, an ophthalmolo- gist, and an infectious disease expert is appropriate for guidance regarding the need for surgical intervention and the selection of antimicrobial agents. Intracranial complications are most frequently encountered in previously healthy adolescent males with frontal sinusitis. 33,34 In patients with altered mental status, severe headache, or Pott ’ s puffy tumor (osteomyelitis of the frontal bone), neurosurgical con- sultation should be obtained. A contrast-enhanced CT scan (preferably coronal thin cut) of the head, orbits, and sinuses is essential to con fi rm intracranial or intraorbital suppurative complications; in such cases, in- travenous antibiotics should be started immediately. Alternatively, an MRI may also be desirable in some cases of intracranial abnormality. Appropriate antimicrobial therapy for intraorbital complications include vancomycin (to cover possible methicillin-resistant

FROM THE AMERICAN ACADEMY OF PEDIATRICS

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