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Supportive medications that target symptoms of viral URIs are used widely in patients with rhinosinusitis, particularly in the early stage of infection. There is a lack of evidence supporting their use in ABRS, but they may provide temporary relief in cer-

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tain patients. ' Analgesics can be used to treat fever and pain from sinus pressure. Oral decongestants relieve congested nasal passages but should be avoided in children younger than 4 years of age and patients with ischemic heart disease or uncontrolled hypertension. Intranasal decongestants can be used for severe congestion in most patients 6 years of age or older, but use should be limited to 3 days or less to avoid rebound nasal congestion. Guaifenesin is often used as a mucolytic with no evidence to support its use in rhinosinusitis. Antihistamines should be avoided because they thicken mucus and impair its clearance, but they may be useful in patients with predisposing allergic rhinitis or chronic sinusitis. Similarly, intranasal corticosteroids usually are reserved for patients with allergies or chronic sinusitis, but they may be beneficial

as monotherapy or with antibiotics in ABRS. Antimicrobial Therapy

Although many clinical studies have been performed evaluating antibiotics for ABRS, no randomized, double-blind, placebo-controlled studies have used pre- and post-treatment sinus aspirate cultures as an outcome measure. In some studies, antimicrobials result in faster symptom resolution and lower failure rates and complications

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compared with no treatment, particularly in more severe disease. Since diagnosis is based on clinical presentation and not sinus aspirate cultures, clinicians must attempt to differentiate ABRS from viral rhinosinusitis. Therefore, it is important to limit antimicrobial use to cases where infection is unlikely to resolve without causing prolonged disease: patients with moderately severe symptoms that persist for greater than 10 days or worsen after initial improvement and patients with severe symptoms.

Treatment guidelines reflect antimicrobial choices that are likely to result in favorable clinical and bacteriologic outcomes based on pathogen distribution, spontan-

eous resolution rates, and nationwide resistance patterns. ' ' These guidelines (Figs. 72-3 and 72-4) stratify therapy based on severity of disease and risk of infection with resistant organisms, defined as prior antibiotic use within 4 to 6 weeks. Oth

er risk factors for resistance include daycare attendance or frequent exposure to children in daycare and recurrent disease. Severe disease requires evaluation and treatment in conjunction with specialized physicians such as otolaryngologists.

Antimicrobial therapy (Table 72-4) is targeted against S. pneumoniae, but consideration must be given to other pathogens such as H. influenzae, M. catarrhalis, S.

aureus, and PRSP. Patients with mild disease and no prior antimicrobial exposure should receive initial therapy with amoxicillin or amoxicillin-clavulanate. Amoxicillin is effective for most mild infections and can be used in high doses to cover PRSP. It is less expensive and better tolerated than amoxicillin-clavulanate, which provides expanded coverage against ^-lactamase-producing bacteria. Patients who are allergic to penicillins can be treated with an appropriate cephalosporin; severe penicillin allergies require treatment with alternative agents that may be less effective based solely on microbial resistance trends and not clinical data11'2 '24 (see Fig. 72-3). Initial therapy for patients with moderate symptoms or those with recent antimicrobial exposure includes high-dose amoxicillin-clavulanate or a respiratory fluoroquino-lone23'24 (see Fig. 72-4).

Table 72-4 Antimicrobials" for the Treatment of ABRS

Drill]

AduU Ot»r

Pediatric Uo-ie'

Corrnn»ntj

Amoaicilin

Amotfcilin-

tljMjIdrijIi'

Gtfdinli

("efpodoxiine panel il tflirffrniiflt ."iK^Iil Celliuxone

Timethopnm

H#«nMhaaHlt Achromycin

1.5-4 tvUiy In i-3 dowi 1,73-1 q/ciiy in i- J dosfi

rrg twice dally twtae i-lily 1 3 UiWV every 2A hour lWl-'iffiJ intp (I K Nibie<) twke daily

SM mg x 1day, J50 mg/day x 4 day* 500 rrigAiay X i dayi; 1 g * i cfwe m^/VvKJiy in i (¿(«i ■tt mtyligAlay in ? denies

10 mg/Vgiday In ? dcs« IS-30 ifkVlflAJiy ift ?dWK 50 mg/kg IM/1V every J4 hotn fl-10 mg/Jg/dayoiHinwIhcpiri iOfflpiyitfifl In 2 dfiitt l£i mg/Vg x. I djy, S mg/kg/day * 4 dJyi; 10 fiVj/tej/aty *

Ucks «tnew^? ^n« (Jisciamase prcdujicrs Hinkl fOivr.vjp iMiitfutirlyYT-ih high doiti. AjucjincnlinJiR 12 g every 12 houi} MrgiWd reward MSP

Preferred oral liquid cephalosporin owing to good palmab*(y f xpem leconmtnd a Sday Liedfncnt

Considerable pneumococrafl leiiilaira

BmtHuwof ihfttgcn increasing pneumococcal imitanoe and limited H nifJti(7M3e»nivi[y; singie-doae regimen His hlqh intklence tit njuKi. vomiting, and diarrhea

CLiiiih'Ofn/f

JOajtyiIUM?

IwoikMdcin i'linclamjtln

SOU rcvj twice daily of I q once dally 15 mg/fc^Alay in 1 tkrjei PlOrtM

lOOimgiiMUC i L>ily

I in iiilklroi. Ul¥ltr 6 yfjri

S0Q-750 mgoriedaity

{750 cr>g x 5 lI^KI JlXJ mq oiviettoiiy lia-lio mn i ■-1 [¡met dally awiildWe Hot jvjjijiiie

XL (ablet* nepoilied to hawefewet Gl protfcni j ind tas» dMutHncH'ltun rwirp daily pnpfiaratfcm CiniJuio (inJtoitniiiKiiy.Cl pe&itrtis, tooth si.ir.mcj (n JWjnj ihildrert nuny llrUl|-(Jniy I WeiiCIISni tWtttCkJt, HQTV

iifiumi)

Common NuoftxitHralone skle-cCf^Ci a<e nivWi, irjginidi (JijrilKM. diflin«5: mjny drug-drug interaclnra^aniKidSvfloni tAluN: ItfuJun lilpulfe phmo«<Ai[iY>1yr ijl p*okiiK)a[pon paiiiMpifOii iiimil.il to jimwicJin/clavulandle No giam ne^tlve rowwise, use In tombinal ion

■Spiff Co Table 7J-J fDf mart1 Infom-Hion on antibMlriOlhei FDA jpfifovpilantiblolKifcf ABfii nol Included In tte Smut and AHorgy Heatih P«irlW!<!hipG! AmcifcJH Academy of FVdiatiiti guidelines CifJilCir, Ccfpritfil, itfi*imertipi,olloiiHiii.t.'iythMjm^ln, irtwf.

jimylrl dwe Ikjl CO iBtWd aduK 00« AKKi, .Kljli' liK Hfi.ll l1lirH;*,llHJM[ii, FiLUTi heft. 21,24.

■Spiff Co Table 7J-J fDf mart1 Infom-Hion on antibMlriOlhei FDA jpfifovpilantiblolKifcf ABfii nol Included In tte Smut and AHorgy Heatih P«irlW!<!hipG! AmcifcJH Academy of FVdiatiiti guidelines CifJilCir, Ccfpritfil, itfi*imertipi,olloiiHiii.t.'iythMjm^ln, irtwf.

jimylrl dwe Ikjl CO iBtWd aduK 00« AKKi, .Kljli' liK Hfi.ll l1lirH;*,llHJM[ii, FiLUTi heft. 21,24.

FIGURE 72-3. Treatment algorithm a for ABRS in patients with mild disease without recent antibiotic exposure. a Antimicrobials are listed in order of predicted efficacy based on predicted clinical and bacteriologic efficacy rates, clinical studies, safety, and tolerability. Doses can be found in Table 72-4. bCephalosp orins should be considered for patients with nontype I hypersensitivity to penicillins; they are more likely to be effective than the alternative agents. cHigh doses are recommended for adults with daycare contacts or frequent infections and most children. (From Refs. 23, 24.)

FIGURE 72-3. Treatment algorithm a for ABRS in patients with mild disease without recent antibiotic exposure. a Antimicrobials are listed in order of predicted efficacy based on predicted clinical and bacteriologic efficacy rates, clinical studies, safety, and tolerability. Doses can be found in Table 72-4. bCephalosp orins should be considered for patients with nontype I hypersensitivity to penicillins; they are more likely to be effective than the alternative agents. cHigh doses are recommended for adults with daycare contacts or frequent infections and most children. (From Refs. 23, 24.)

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