Update on Rhinosinusitis 2013 AAP Guidelines Review

Transcription

1 Update on Rhinosinusitis 2013 AAP Guidelines Review Carla M. Giannoni, MD Surgeon, Otolaryngology Texas Children's Hospital Professor, Surgery and Pediatrics, Baylor College of Medicine CDC: Acute Rhinosinusitis and URI 90 98% of sinusitis cases are viral Antibiotics are not guaranteed to help even if the causative agent is bacterial At least 200 viruses can cause the common cold Viral URIs are often characterized by nasal discharge and congestion or cough. Usually nasal discharge begins as clear and changes throughout the course of the illness Fever, if present, occurs early in the illness Management of the common cold, nonspecific URI, and acute cough illness should focus on symptomatic relief Antibiotics should not be prescribed for these conditions There is potential for harm and no proven benefit from over-the-counter cough and cold medications in children younger than 6 years. These substances are among the top 20 substances leading to death in children <5 years old Low-dose inhaled corticosteroids and oral prednisolone do not improve outcomes in non-asthmatic children 1

2 Uncomplicated URI 0-3 days 3-5 days 5-7 days 7-10 days Fever (+) (-) (-) (-) Rhinorrhea Clear Yellow, mucoid Clear Improving Cough (-) (+) (+) (-) PEDIATRICS Volume 132, Number 1, July 2013 Key Action Statement 1 Clinician should make a presumptive diagnosis of acute bacterial sinusitis in the following situations: Persistent illness (rhinorrhea and/or cough) > 10 days without improvement Worsening course (rhinorrhea, cough +/- fever) AFTER initial improvement Severe onset (fever > and purulent rhinorrhea) for at LEAST 3 days Why? Other presentations are most likely viral illness 2

3 Key Action Statement 2A Clinicians should NOT obtain imaging (plain X-ray, CT, MRI) Strong recommendation Why? Imaging has a high likelihood of being abnormal and doesn t help make a diagnosis Key Action Statement 2B Clinicians should obtain a contrast-enhanced CT and/or an MRI with contrast whenever a child is suspected of having an orbital or CNS complications of acute bacterial sinusitis Why? You don t want to miss an infection that may require IV antibiotics +/- surgery 3

4 Key Action Statement 3 Persistent illness (rhinorrhea and/or cough) > 10 days without improvement Recommendation Antibiotic therapy* (*esp if complication, another infection like AOME or underlying conditions like RAD, CF, immunodef) Alternate treatment Observation for 3 additional days (decreases risk of developing antibiotic resistance and med side effects like diarrhea) Worsening course (rhinorrhea, cough +/- fever) Severe onset (fever > and purulent rhinorrhea) AFTER initial improvement For at LEAST 3 days Antibiotic therapy Antibiotic therapy Microbiology of Pediatric Sinusitis* Sterile/NG 20% GAS/Other 10% M. Catarrhalis 100% β-lactamase 30% 30% S. pneumoniae 10-50% PCN-R H. Influenzae 50% β-lactamase *Current Sinusitis microbiology is extrapolated from AOME data 4

5 Key Action Statement 4 Mild to moderate symptoms No risk factors > 2 yrs < 2 yrs or mod severe illness Amoxicillin 45 mg/kg/day BID Risk factors: daycare, recent abx (<4 wks) High community prevalence of nonsusceptible S. pneumo Amoxicillin Unable to take PO PCN allergy Rocephin 50 mg/kg IM x 1* + PO antibiotics when taking PO *Additional IM doses if remain febrile > 24 hrs Non-Type 1 (delayed allergy): Cefdinir, cefuroxime, or cefpodoxime Type 1 PCN allergy: Clindamycin + cefixime or Linezolid + cefixime or Levofloxacin Duration of therapy Option 1: days Option 2: 7 days after symptom-free Key Action Statements 5A and 5B 5A: Reassess patient at 72 hours WHY? Majority of symptom improvement occurs in first 3 days of therapy 5B: Consider changing therapy as indicated: Initial Management Worse in 72 Hours Not Improved in 72 Hours Observation Initiate antibiotic therapy Shared decision: antibiotic therapy vs. continued observation Amoxicillin High dose amoxicillinclavulanate High dose amoxicillinclavulanate Clindamycin + cefixime or Linezolid + cefixime or Levofloxacin Shared decision: continue amoxicillin vs. high dose amoxicillin-clavulanate Shared decision: continue current therapy vs. alternate therapy (at left) 5

6 Adjuvant Therapies Poor scientific evidence to support use of most adjuvant agents Intranasal steroids Saline irrigation Antihistamines Decongestants Might help, confidence for benefit lacking, min risk Might help, confidence for benefit lacking, min risk Do not use except to treat concurrent allergy Insufficient data to support use* *There is potential for harm and no proven benefit from over-the-counter cough and cold medications in children younger than 6 years. These substances are among the top 20 substances leading to death in children <5 years old. 6