The ART of medicine is much more difficult to learn than the science of medicine; however, it is through becoming comfortable with the “grey areas” that we often experience our greatest ability to help others. It is also what prevents robots from taking our jobs.
One “grey area” that we constantly explore is that of antibiotic administration. Now, this would seem like a very well defined area and not one of nuance – if there is a bacterial infection, give antibiotics; if there is not, do not. Unfortunately, we know that it is not that clear cut. The treatment of Acute Otitis Media, which can be complicated by Mastoiditis, is a good example of the need to do complex Pro-Con equations to determine the best plan for a specific patient. While there may be purulent material present, exposing the patient to antibiotics is not necessarily the best plan always (see Serum Sickness). Another excellent example of this is sinusitis in children.
Acute Bacterial Sinusitis “Diagnosis”
- In 2013, the clinical diagnosis of Acute Bacterial Sinusitis in children was revised.
- Admittedly, the research pertaining to Sinusitis in children was often undermined by varied definitions of sinusitis, so this is hopefully helpful.
- Acute Bacterial Sinusitis can be clinically diagnosed when a child who has an acute upper respiratory tract infection (URI) presents with:
- PERSISTENT illness – any nasal drainage, or DAYtime cough, or both lasting > 10 days WITHOUT IMPROVEMENT; or
- WORSENING course – worsening or new onset of nasal discharge, DAYtime cough, or new fever; or
- SEVERE onset AND PURULENT Nasal drainage – concurrent fever > 102.1F (>38.9C) AND purulent rhinorrhea for at least 3 consecutive days.
Key Words of Sinusitis
- Just to be clear… there are some keywords that cannot be overlooked when considering this diagnosis:
- PERSISTENT and NOT IMPROVING
- These are the only tools that we have to help us make this diagnosis. More importantly, these are the words that can help us not over-diagnose it!
- There is NO lab test.
- There is NO radiographic test.
- There is NO reliable physical exam finding.
Typical Time Course of an URI
I understand; there is nothing exciting about talking about a URI. It is common. It is simple. It can be accurately diagnosed by grandparents and managed effectively by them. So why do I torture you, an experienced clinician, with this? Because, it is what makes the above make some sense.
- A URI is typically characterized by nasal symptoms (congestion and/or discharge).
- Most often the nasal discharge starts as clear and watery.
- Over time, the discharge may become thicker and more mucoid or even purulent for several days.
- As the URI resolves, the nasal drainage usually becomes less mucoid and clears.
- Fever tends to occur early in the illness.
- Often fever occurs before respiratory symptoms are prominent.
- Usually resolves in the first 1-2 days.
- The total duration is often 5-7 days.
The Tricky Part
- Kids love to collect different URIs sequentially!
- Parents will not necessarily perceive that two separate viral illnesses have occurred… they just know that their child has been sick for “2 weeks straight.”
My General Approach
- Ok, take this for what it is…
- Start off with the knowledge that only ~6-7% of children will meet criteria for Sinusitis.
- Know that the benefit of antibiotic therapy in treating sinusitis only seems to be apparent in those more severe symptoms and when the more strict criteria are applied.
- Know that the benefit of antibiotic therapy in preventing suppurative complications (orbital cellulitis or intracranial abscess) is unproven.
- Focus on the history.
- Spend a little more effort in helping the family sort out if this “2 weeks” of illness is really two separate URIs.
- Consider the time course and the onset of fever. Fever that occurs after illness has started is not typical for an URI.
- Purulent rhinorrhea occurring during the onset of fever is also odd for an URI. 3 days of purulent snot and high fevers should make you think about sinusitis.
- Have the parents help you!
- Shared decision making can be very powerful… especially with these grey areas of medicine.
- Discuss the potential for sinusitis, but how there is no definitive way to diagnose it.
- Discuss how antibiotics may help some, kids, but can also cause harm (ex, diarrhea, allergy, toxic epidermal necrolysis, etc).
- A period of OBSERVATION for those with persistent symptoms can be very helpful in sorting out the ambiguous cases.
- Don’t just throw antibiotics at all kids with “persistent symptoms” please!! They all do not have sinusitis.
Treatment for Sinusitis
- Sinusitis defined by Persistent Symptoms – antibiotics OR Observation period for 3 days.
- Sinusitis defined by Worsening Symptoms or Severe and Acute symptoms – antibiotics.
- Antibiotic Options
- 1st line = Amoxicillin
- 45mg/kg/day divided BID is sufficient if you have low antimicrobial resistance.
- 90mg/kg/day divided BID (max of 2 grams per dose) in areas with abx resistance.
- Augmentin (80-90mg/kg/day of the amoxicillin component) can be used in those with moderate or severe illness or in those < 2 years of age.
- Ceftriaxone 50mg/kg IM dose x 1
- If clinical improvement is seen at 24 hours, then transition to Oral abx.
- If clinical improvement is not seen at 24 hours, then parental abx may be required.
- Penicillin allergic?
- Consider cefdinir, cefuroxime, or cefpodoxime.
- 1st line = Amoxicillin