Current issues in the management of acute bacterial sinusitis in children

Gas Monitoring in Human Frontal Sinuses-Stability Considerations and Gas Exchange Studies

Acute rhinosinusitis is a common infectious disease, which, in more than 90% of cases, is caused by viruses rather than by bacteria. Even so, antibiotics are often unnecessarily prescribed, and in the long run this contributes to the alarming level of antibiotics resistance. The reason is that there are no good guiding tools for defining the background reason of the infection. One main factor for the clearance of the infection is if there is non-obstructed ventilation from the sinus to the nasal cavity. Gas in Scattering Media Absorption Spectroscopy (GASMAS) has potential for diagnosing this. We have performed a study of frontal sinuses of volunteers with a focus on signal stability and reproducibility over time, accurate oxygen concentration determination, and assessment of gas transport through passages, naturally and after decongestant spray administration. Different from earlier studies on frontal sinuses, water vapor, serving the purpose of oxygen signal normalization, was measured at 818 nm rather than earlier at 937 nm, now closer to the 760 nm oxygen absorption band and thus resulting in more reliable results. In addition, the action of decongestants was objectively demonstrated for the first time. Evaluated oxygen concentration values for left- and right-hand side sinus cavities were found to agree within 0.3%, and a left-right geometrical asymmetry parameter related to anatomical differences was stable within 10%.

Acute bacterial sinusitis in children: an updated review

Background

In the pediatric age group, approximately 7.5% of upper respiratory tract infections (URIs) are complicated by acute bacterial sinusitis (ABS). Despite its prevalence, ABS is often overlooked in young children. The diagnosis and management present unique challenges in primary care. This is an updated narrative review on the evaluation, diagnosis, and management of ABS.

Methods

A PubMed search was performed using the key term ‘acute sinusitis’. The search strategy included clinical trials, meta-analyses, randomized controlled trials, observational studies, and reviews. The search was restricted to the English literature and children.

Results

Haemophilus influenzae (non-typeable), Streptococcus pneumoniae, and Moraxella catarrhalis are the major pathogens in uncomplicated ABS in otherwise healthy children. In complicated ABS, polymicrobial infections are common. The diagnosis of acute sinusitis is mainly clinical and based on stringent criteria, including persistent symptoms and signs of a URI beyond 10 days, without appreciable improvement; a URI with high fever and purulent nasal discharge at onset lasting for at least 3 consecutive days; and biphasic or worsening symptoms.

Conclusion

Data from high-quality studies on the management of ABS are limited. The present consensus is that amoxicillin-clavulanate, at a standard dose of 45 mg/kg/day orally, is the drug of choice for most cases of uncomplicated ABS in children in whom antibacterial resistance is not suspected. Alternatively, oral amoxicillin 90 mg/kg/day can be administered. For those with severe ABS or uncomplicated acute sinusitis who are at risk for severe disease or antibiotic resistance, oral high-dose amoxicillin-clavulanate (90 mg/kg/day) is the drug of choice.

The DNABII family of proteins is comprised of the only nucleoid associated proteins required for nontypeable Haemophilus influenzae biofilm structure

Biofilms play a central role in the pathobiology of otitis media (OM), bronchitis, sinusitis, conjunctivitis, and pneumonia caused by nontypeable Haemophilus influenzae (NTHI). Our previous studies show that extracellular DNA (eDNA) and DNABII proteins are essential components of biofilms formed by NTHI. The DNABII protein family includes integration host factor (IHF) and the histone‐like protein HU and plays a central role in NTHI biofilm structural integrity. We demonstrated that immunological targeting of these proteins during NTHI‐induced experimental OM in a chinchilla model caused rapid clearance of biofilms from the middle ear. Given the essential role of DNABII proteins in maintaining the structure of an NTHI biofilm, we investigated whether any of the other nucleoid associated proteins (NAPs) expressed by NTHI might play a similar role, thereby serving as additional target(s) for intervention. We demonstrated that although several NAPs including H‐NS, CbpA, HfQ and Dps are present within the biofilm extracellular matrix, only the DNABII family of proteins is critical for the structural integrity of the biofilms formed by NTHI. We have also demonstrated that IHF and HU are located at distinct regions within the extracellular matrix of NTHI biofilms formed in vitro, indicative of independent functions of these two proteins.

Developing a vaccine to prevent otitis media caused by nontypeable Haemophilus influenzae

Nontypeable Haemophilus influenzae (NTHi) is a predominant organism of the upper respiratory nasopharyngeal microbiota. Its disease spectrum includes otitis media, sinusitis, non-bacteremic pneumonia and invasive infections. Protein-based vaccines to prevent NTHi infections are needed to alleviate these infections in children and vulnerable populations such as the elderly and those with chronic obstructive pulmonary disease (COPD). One NTHi protein is included in a pneumococcal conjugate vaccine and has been shown to provide efficacy. Our lab has been interested in understanding the immunogenicity of NTHi vaccine candidates P6, protein D and OMP26 for preventing acute otitis media in young children. We expect that continued investigation and progress in the development of an efficacious protein based vaccine against NTHi infections is achievable in the near future.

Nasal saline irrigation with or without systemic antibiotics in treatment of children with acute rhinosinusitis

OBJECTIVES

Acute rhinosinusitis (ARS) is a common pediatric problem. Our aim was to determine the efficacy of normal nasal saline irrigation (NSI) with or without amoxicillin in treatment of acute rhinosinusitis (ARS) in children.

METHODS

It is a prospective randomized, blind placebo-controlled trial. Children with uncomplicated ARS were recruited. One group received (amoxacillin 100mg/kg/day) and 0.9% NSI. The second group received placebo and 0.9% NSI. The primary outcome was the effect of treatment on clinical response. Secondary outcomes included: Rating of Pediatric Rhinoconjunctivitis Quality of Life Questionnaire (PRQLQ), middle meatus (MM) bacteriological and cytological cellular responses and adverse effects.

RESULTS

Sixty two patients with ARS were eligible for the study. In amoxicillin group (31 patients); clinical cure was observed in 26 (83.9%) in comparison to 22 (71%) patients in NSI without antibiotics group (31 patients) (p=0.22). No differences between both groups in the reported nasal symptom scores and total symptoms scores improvements at day 7 (p=0.09 and 0.65) and day 14 (p=0.29 and 0.14), respectively. The mean total PRQLQ values had no differences between both groups after the 2 weeks of treatment (p=0.06). At day 7, MM neutrophils reduced significantly in amoxicillin group in comparison to placebo group (p=0.004). At day 14, the MM cytological content had no differences between both groups (p=0.07). Normal NSI with placebo has less reported adverse effects than amoxicillin and nasal saline irrigations (p=0.005).

CONCLUSIONS

NSI can be used alone with the same clinical, bacteriological and cytological cellular changes efficacy and with higher safety profile than amoxicillin after 14 days of treatment in uncomplicated clinically diagnosed ARS in children.

Non-typeable Haemophilus influenzae, an under-recognised pathogen

Non-typeable Haemophilus influenzae (NTHi) is a major cause of mucosal infections such as otitis media, sinusitis, conjunctivitis, and exacerbations of chronic obstructive pulmonary disease. In some regions, a strong causal relation links this pathogen with infections of the lower respiratory tract. In the past 20 years, a steady but constant increase has occurred in invasive NTHi worldwide, with perinatal infants, young children, and elderly people most at risk. Individuals with underlying comorbidities are most susceptible and infection is associated with high mortality. β-lactamase production is the predominant mechanism of resistance. However, the emergence and spread of β-lactamase-negative ampicillin-resistant strains in many regions of the world is of substantial concern, potentially necessitating changes to antibiotic treatment guidelines for community-acquired infections of the upper and lower respiratory tract and potentially increasing morbidity associated with invasive NTHi infections. Standardised surveillance protocols and typing methodologies to monitor this emerging pathogen should be implemented. International scientific organisations need to raise the profile of NTHi and to document the pathobiology of this microbe.

Pathogen Genomics and the Potential for Understanding Diseases in the Developing World

Approximately 46% and 32% of deaths among children under five globally occur in sub-Saharan Africa and South Asia, respectively. Over 80% of the 4.2 million child deaths in Africa are caused by infectious diseases, sharply contrasted to Europe where 39% of the 0.15 million child deaths are attributable to infectious diseases (Fig. 5.1) (Black et al. 2010). Hence, despite the remarkable public health advancements in hygiene, sanitation, antimicrobial drugs and vaccine strategies of the twenty-first century, the burden of infectious diseases remains unacceptably high in the developing world.

Common childhood bacterial infections

Children with infectious diseases are commonly encountered in primary care settings. Identification of the subset of patients with bacterial infections is key in guiding the best possible management. Clinicians frequently care for children with infections of the upper respiratory tract, including acute otitis media, otitis externa, sinusitis, and pharyngitis. Conjunctivitis is not an uncommon reason for office visits. Bacterial pneumonia, urinary tract infections, and gastroenteritis are regularly seen. Over the last decade, a growing number of children have had infections of the skin and soft tissue, driven by the increased prevalence of infections caused by methicillin-resistant Staphylococcus aureus. The following review addresses the epidemiology and risk factors for specific infections and examines the clinical presentation and selection of appropriate diagnostic methods in such conditions. Methods to prevent these bacterial infections and recommendations for follow-up are suggested. Management of these infections requires that antimicrobial agents be used in a judicious manner in the outpatient setting. Such antibiotic therapy is recommended using both available clinical evidence and review of disease-specific treatment guidelines.

Do general practitioners' consultation rates influence their prescribing patterns of antibiotics for acute respiratory tract infections?

OBJECTIVES

To examine general practitioners' (GPs') antibiotic prescribing patterns for acute respiratory tract infections (ARTIs) as compared with national guidelines. We also wanted to explore possible predictors of antibiotic prescription patterns.

METHODS

Observational study based on prescription data from 440 Norwegian GPs in December 2004 through to November 2005. Outcome measures were the type and frequency of antibiotic prescriptions for various ARTI diagnoses, with patients' and GPs' characteristics as explanatory variables.

RESULTS

In the study period, the 440 GPs treated a total of 142 900 ARTI episodes. In 33.5% [95% confidence interval (CI): 31.9%-35.1%] of these episodes an antibiotic was issued, of which penicillin V (pcV) accounted for 41.2% (95% CI: 37.4%-44.9%). GPs with a high number of total annual encounters had higher antibiotic prescription rates for ARTIs and used more non-pcV antibiotics compared with GPs with fewer annual patient encounters. GPs in the highest quintile with respect to the total annual encounter rate had 1.6 times the odds of prescribing antibiotics compared with GPs in the lowest quintile. Correspondingly, the odds of choosing a non-pcV antibiotic were 2.8 times higher in the top quintile of GPs compared with GPs in the bottom quintile with respect to antibiotic prescription rates.

CONCLUSIONS

ARTIs are frequently treated with antibiotics and often with broader spectrum agents than pcV, which is the recommended first-line antibiotic in the Norwegian guidelines. GPs with a high practice activity are, in general, more liberal with respect to the prescription of antibiotics for ARTIs, and the higher the antibiotic prescription rate, the larger the share of non-pcV agents.

National trends in visit rates and antibiotic prescribing for children with acute sinusitis

OBJECTIVE

The heptavalent pneumococcal conjugate vaccine contributed to a substantial decrease in the number of ambulatory visits attributable to acute otitis media (AOM) and amoxicillin use for AOM increased after publication of American Academy of Pediatrics guidelines regarding AOM. Our objective was to determine whether similar trends occurred for children with acute sinusitis.

METHODS

We analyzed data from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey (1998-2007), which are nationally representative surveys of office and emergency department visits. For children younger than 18 years with diagnosed acute sinusitis (N = 538), we examined time trends in visit rates and antibiotic prescribing. Multivariate logistic regression analyses were used to identify factors associated with narrow-spectrum antibiotic prescribing.

RESULTS

Between 1998 and 2007, the annual visit rate for acute sinusitis remained stable, ranging from 11 to 14 visits per 1000 children (P = .67). No change occurred in the proportion of visits with receipt of an antibiotic (82%; P = .71); however, the proportion with receipt of amoxicillin increased from 19% to 58% during the study period (P < .01). Prescriptions for broader-spectrum agents, especially macrolides (18% overall), remained common.

CONCLUSIONS

Unlike the visit rate for AOM, the visit rate for acute sinusitis among children did not decrease after introduction of the pneumococcal conjugate vaccine. Although prescriptions for amoxicillin increased in accordance with the guidelines, reducing unnecessary prescriptions for macrolides remains an important target for campaigns promoting judicious antibiotic use.

A comparison of conventional and molecular microbiology in detecting differences in pneumococcal colonization in healthy children and children with upper respiratory illness

Conventional microbiology (CM) and real-time polymerase chain reaction (PCR) were used to determine rate and serotype of pneumococcal nasopharyngeal colonization in healthy children and children with upper respiratory illnesses (URI). One hundred and thirty-six healthy children and 79 children with URI were evaluated. Pneumococcal colonization was detected more often by real-time PCR than CM in healthy children (50% vs. 24%, p <or= 0.001), while detection rates were comparable by CM and real-time PCR in children with URI (61% vs. 65%, NS). Pneumococcal serotypes were identified 2.3 times more often in healthy children by real-time PCR than CM, p <or= 0.001 and 1.5 times more often in children with URI by PCR than CM, p = 0.01. Real-time PCR was also more sensitive in detecting multiple strains rather than CM in both healthy (p = 0.001) and children with URI (p <or= 0.001). Overall real-time PCR proved superior to CM in detection and serotyping of Streptococcus pneumoniae. Future studies should incorporate real-time PCR technology along with CM to fully understand the epidemiology of colonization in health and illness.