|ANTIMICROBIALS AND SINUSITIS|
Dr. Suparna Banavar
M D(Peds),D C H
Consultant Pediatrician Kalawati Saran Hospital, Powai
Nine out of ten patients with a cold develop viral sinusitis, thus making sinusitis a major cause of illness in most parts of the world. Accurate diagnosis depends on clinical assessment with purulent nasal discharge, pain in the head/face, fever and cough being strong predictors of sinusitis. Plain film radiography (PFR) has proven to be inadequate in disease detection or subsequent disease assessment. In contrast CT/MRI provide good visualization of sinus anatomy and pathology but are not used routinely.
Rhino, influenzae and parainfluenzae viruses are the commonest causes of sinusitis. Bacteria can be isolated in 2/3 of patients with sinusitis. Streptococcus pneumoniae, Moraxella catarrhalis and Hemophilus influenzae are the commonest bacteria causing acute purulent sinusitis in children. Infection is polymicrobial in about one third of the cases. Prevotella, Fusobacterium and Peptostreptococcus amongst the anaerobic group and S.aureus, M. catarrhalis and Hemophilus spp from the aerobic group were the chief causative agents in chronic sinusitis. Beta lactamase producing strains of these bacteria (BPLB) have been isolated from both acute and chronic sinusitis aspirates. Prior antibiotic exposure, day care attendance, age <2years, recent hospitalization and recurrent infection, all contribute to development of antimicrobial resistance.
Amoxycillin (with and without clavulanic acid), oral and parenteral cephalosporins, macrolides and trimethoprim/sulfamethoxazole (TMP/SMX) are commonly used to treat acute sinusitis. Amoxycillin continues to be the drug of choice for intermediate penicillin susceptible S.pneumoniae. The increasing resistance of S.pneumoniae to penicillin calls for an increase in the amoxycillin dose upto 90mg/kg/day in children. Second generation cephalosporins like cefuroxime axetil and cefprozil are effective against penicillin resistant Hemophilus and Moraxella spp. and intermediate penicillin resistant S.pneumoniae. Parenteral third generation cephalosporins are the most effective against the aforementioned resistant organisms. TMP/SMX are ineffective against most bacteria including S.pneumoniae and H.influenzae. Erythromycin is inactive against H.influenzae and some GABHS while azithromycin and clarithromycin have limitations. The recommended length of therapy in acute sinusitis is atleast 14 days.
Resistant bacteria in unresolving cases are revealed through culture of sinus puncture aspirates. Amoxycillin (with or without clavulanic acid), clindamycin, chloramphenicol, a combination of metronidazole and a macrolide are effective against aerobic and anaerobic BPLB of chronic sinusitis. The recommended length of therapy is at least 21 days and may be extended upto 10 weeks. Surgical drainage is considered in all cases not responding to medical therapy. There are a host of other therapies like decongestants, steroids, mucolytic agents, antihistamines, nasal lavage and humidification whose effectiveness is still to be adequately researched.
Keywords: Sinusitis; Bacterial resistance; Cure; Diagnosis
Author's Name: Itzhak Brook
Title: Sinusitis- overcoming bacterial resistance
Name of Journal: Int. J. of Ped. Otorhinolaryngology
Vol. No: 58 PP: 27-36 Issue No.: 1
Last updated on 26-06-2001
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