Antimicrobial Issues

There have been no recent clinical trials pitting one antibiotic versus another for pediatric sinusitis. The major reason has to do with the perceived need to obtain bacteriologic data by means of maxillary antral taps. Still, the lack of direct comparative evidence does not diminish the compelling evidence from other sources about the relative efficacy of available antimicrobials against the pathogens of interest. Young children with persistent bacterial rhinosinusitis often harbor multiple relatively resistant pathogens, making empirical therapy with a single agent problematic. Even the more potent agents (e.g., amoxicillin-clavulanate, cefuroxime axetil, cefpodoxime proxetil) will fail against some of strains of S. pneumoniae and H. influenzae. Resistance to sulfa drugs and the macrolides (including azithromycin and clarithromycin) is relatively common among those same organisms. Even pneumococcal resistance to clindamycin is increasing. However, if a given strain is isolated and susceptibility testing is performed, an astute clinician can usually find at least one oral agent that is active against that organism. Ceftriaxone, when given for more than 3 to 5 doses is currently active (in the respiratory tract) against virtually all strains of pneumococci, Haemophilus, and Moraxella. In an important recent study, 90% of surgical candidates were cured by potent antimicrobial therapy.17 If a patient still has suspected bacterial rhinosinusitis, and a culture has not been obtained or is not helpful, empirical therapy with 5 to 10 days of ceftriaxone can be expected be effective in well over 90% of cases (in older children, the addition of anti-staphylococcal and anaerobe coverage should be considered, e.g., clindamycin). Other potent empirical combinations include high-dose amoxicillin-clavulanate (approximately 90 mg/kg/day of the amoxicillin component, maintaining a 14:1 ratio of amoxicillin to clavulanate), clindamycin plus a third-generation cephalosporin (e.g., ceftibuten), or one or more shots of ceftriaxone followed by high-dose amoxicillin. Recently available conjugated pneumococcal vaccines may reduce the likelihood of colonization or infection with drug-resistant strains of pneumococci, making third generation cephalosporins (e.g., cefpodoxime proxetil or cefdinir) relatively more attractive. The interested reader is directed elsewhere or to papers related to antimicrobial therapy for otitis media.

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