Antibiotics

The goals of therapy in chronic pediatric rhinosinusitis are to eradicate the infection, provide reversal of sinus obstruction, and return effective mucociliary clearance.62 After all factors predisposing to this disease have been appropriately pursued, and the positive findings addressed, antibiotic therapy remains the cornerstone of treatment in children with rhinosinusitis. The choice of antibiotic is most often empirical, as representative cultures are difficult to routinely obtain in children. Selective cultures, however, are indicated for complicated cases (see Diagnosis).

Ideally, antimicrobial therapy is aimed at eradicating the most commonly found pathogens associated with a particular disease process. However, the microbiology of chronic sinusitis in children has received very limited study, and discrepancies exist in the bacterial results of several investigations.3 Some studies implicate respiratory anaerobic organisms as the predominant pathogens of chronic rhinosinusitis,63 whereas other investigators identify Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, a-hemolytic streptococci, and occasional staphylococcal species as the predominant organisms in chronic disease.7,64,65 Unfortunately, several of the bacteriologic studies were conducted after antibiotic therapy, making interpretation difficult. It is possible that the different groups of organisms identified may actually reflect both acute exacerbations and chronic inflammation. Despite the lack of microbiologic data, an important inference may be made from the findings that do exist—that chronic rhinosinusitis is often polymicrobial, with anaerobes and penicillin-resistant organisms potentially contributing to its chronicity; treatment may therefore require several different antibiotics before a satisfactory response is achieved.60

In the choice of antibiotics, the list of suitable agents for chronic rhinosinusitis is reportedly the same as that for acute disease3,17,27 (Table 69-1). However, because many children with chronic rhinosinusitis present to the otolaryngologist with protracted symptoms or after multiple failed antibiotic trials, several investigators suggest that the antibiotic agent chosen should provide activity against b-lactamase-producing bacteria.3,6,27,48 Examples of appropriate antimicrobials include amoxicillin/ clavulonic acid, clindamycin, or second- and third-generation cephalosporins.66,67 First-generation cephalosporins lack sufficient activity against H. influenzae and are therefore inappropriate for treatment of rhinosinusitis.

There are virtually no data indicating the optimum duration of antimicrobial therapy for chronic rhinosinusitis in children, although many clinicians recommend a minimum course of 3 to 6 weeks.2,3,27,68 In general, antibiotic therapy extended 1 week beyond the time that symptoms resolve provides an opportunity for eradication of all bacteria.68,69 If, however, there is no symptomatic response after 5 to 7 days of antimicrobial therapy, the antibiotic should be changed.

Prophylactic antibiotics have not gained uniform acceptance in pediatric rhinosinusitis in the absence of systemic disorders.27,70 Currently, there are no randomized controlled trials to support the efficacy of prophylaxis for chronic rhinosinusitis.

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