Medication

Medication Summary

Antibiotic therapy is the mainstay of medical treatment for pediatric rhinosinusitis. [21] Because of increasing prevalence of beta-lactam–resistant bacteria in the community, administer antibiotics only for suspected infection as based on a careful history and physical examination. Direct the therapeutic regimen against the prevalent pathogens in the community and carefully consider suspicion for highly resistant bacteria. Typically, uncomplicated cases of acute sinusitis are responsive to amoxicillin. Most patients respond to this initial regimen. For children allergic to penicillin, a second- or third-generation cephalosporin can be used (only if the allergic reaction is not a type 1 hypersensitivity reaction). In cases of serious allergic reaction, a macrolide or clindamycin can be used.

Second-line antibiotics should account for bacterial resistance and should be safe in the pediatric population. For chronic sinusitis, a 4-week course of a broad-spectrum beta-lactam–stable antibiotic should be administered. This should allow treatment for more than a week beyond symptom resolution and ensure restoration of mucociliary function and resolution of mucosal edema. Antibiotic prophylaxis as a strategy to prevent infection in patients who experience recurrent episodes of acute bacterial rhinosinusitis has not been systemically evaluated and is controversial. There is little enthusiasm for this approach in light of the current concern with antibiotic resistance. Antibiotics for treatment of chronic sinusitis are best chosen based on culture results and sensitivities. Listed below are excellent choices for second-line antibiotics.

Antibiotics

Class Summary

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.

Amoxicillin (Trimox, Biomox)

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First-line therapy; may be administered at mealtime; has a pleasant taste. Interferes with synthesis of cell wall mucopeptides during active multiplication, resulting in bactericidal activity against susceptible bacteria.

Amoxicillin-clavulanate (Augmentin)

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First-line choice for chronic sinusitis; clavulanate gives beta-lactamase resistance (H influenzae, M catarrhalis, S aureus, anaerobes); may be administered at mealtime; IV form available.

Cefuroxime (Ceftin, Kefurox)

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Highly active against all common sinusitis-causing pathogens; useful with resistance to amoxicillin; good coverage of Haemophilus and Moraxella species; IV form available; good CSF penetration makes it appropriate in cases of suspected orbital or intracranial extension.

Administer with meals; follow with yogurt.

Cefpodoxime (Vantin)

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Highly active against all common sinusitis-causing pathogens; useful with resistance to amoxicillin.

Administer with meals; follow with yogurt.

Cefdinir (Omnicef)

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Used to treat acute maxillary sinusitis. Classified as a third-generation cephalosporin and inhibits mucopeptide synthesis in the bacterial cell wall. Typically bactericidal, depending on organism susceptibility, dose, and serum or tissue concentrations.

Azithromycin (Zithromax)

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Has better coverage against Haemophilus species than erythromycin.

Vancomycin (Vancocin, Lyphocin)

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Provides good coverage for resistant S pneumoniae.

Clindamycin (Cleocin)

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Good for polymicrobial infections and in cases of S pneumoniae resistance shown to be sensitive by culture; poor activity against Haemophilus species.

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Preseptal cellulitis of the left eye. Courtesy of Dwight Jones, MD.

Axial CT scan of subperiosteal abscess of the left eye.

Coronal CT scan of subperiosteal abscess of the left eye.

Coronal CT scan of superior subperiosteal abscess of the left eye.

Axial CT scan of orbital cellulitis of the right eye.

Author

Hassan H Ramadan, MD, MSc, FACS, FARS Stephen and Patricia Wetmore Professor and Chairman, Director, Sinus and Allergy Center, Department of Otolaryngology-Head and Neck Surgery, Professor, Department of Pediatrics, West Virginia University School of Medicine

Hassan H Ramadan, MD, MSc, FACS, FARS is a member of the following medical societies: American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Rhinologic Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Arlen D Meyers, MD, MBA Emeritus Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan; Neosoma; MI10;Invitrocaptal,Medtechsyndicates<br/>Received income in an amount equal to or greater than $250 from: Neosoma; Cyberionix (CYBX);MI10;Invitrocaptal;MTS<br/>Received ownership interest from Cerescan for consulting for: Neosoma, MI10 advisor.

Additional Contributors

Acknowledgements

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors Karla R Brown, MD, and Lincoln Lippincott, MD, to the development and writing of this article.

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