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Peds ID Abx QOTW #6 Answer

f) Treat with Amox/Clav for 10 days

This is how others answered:

Q6 graph

Viral URI Typical Progression

  • Viral URI with fevers, myalgias, headaches in first 2-3 days
  • Secretions begin clear (1-2days), become mucopurulent (3-5 days), then again clear or dry up prior to resolving completely
  • Most resolve by ~10 days but not all

URI course

Acute Sinusitis

  • Symptoms show no improvement at >10 days
  • Less than 30 days (acute)
  • Others symptoms include:
    • Persistent secretions or worsening of secretions with fevers
    • Malodorous breath
    • Tooth or facial pain
    • Persistent fevers
    • Persistent cough day and night time
    • Sudden worsening of URI symptoms

Sinusitis Dx   Pediatr Rev. 2013 Oct;34(10):429-37

Sinus Development in Children

  • Sinus development in children should be considered in the diagnosis of sinusitis

sinus anatomy1sinusanatomy2

Imaging in Diagnosis of Acute Sinusitis

  • CT/MRI scans are the most useful test for imaging sinuses, although diagnosis is usually made clinically
    • Findings include complete sinus opacification, mucosal thickening of at least 4 mm, or an air-fluid level.
    • Imaging in presence of viral URI shows abnormalities in ~80% of viral infections
    • Negative imaging excludes the diagnosis, but a positive image does not make the diagnosis
  • Plain films are considered insensitive and should not be done

Microbiology of Acute Sinusitis

  • Mirrors the etiology of acute otitis media (AOM)
  • S. pneumoniae, H. influenzae, M. catarrhalis are the typical pathogens
  • S. aureus is not a common pathogen and should not be routinely consider outside of complications from sinusitis
  • Aspiration of sinuses or other testing of nasopharynx is not warranted based on available data (e.g. nasopharyngeal swabs or cultures from nares)
  • Treatment failures should be referred to otolaryngology for evaluation for possible aspiration

Treatment of Acute Sinusitis

  • Options for therapy include (typically 10 days for children, but short courses of 5 days for adolescents may be effective)
  • Amoxicillin alone (but increasing rates of H. influenzae resistance)
    • Can be considered, but probably second line
  • Amoxicillin/clavulanate (45mg/kg/day divided BID)
    • Preferred therapy
  • Cefidinir (14mg/kg/day qday or BID)
    • Second line
  • Cefuroxime (30mg/kg/day divided BID)
    • Second line
  • Levofloxacin (16mg/kg/day divided qday or BID based on age)
    • Should be reserved for cases in which no other options exist