xRead - Nasal Obstruction (September 2024) Full Articles

20426984, 2021, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/alr.22741 by Stanford University, Wiley Online Library on [01/07/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License

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Orlandi et al.

penicillins and moderate to severe ABRS, a combination of clindamycin and cefixime is suggested. 2290 A fluoro quinolone, such as levofloxacin, may also be used to treat ABRS in patients with a severe penicillin allergy. 2290 It should be noted that levofloxacin does not have a US FDA approved indication for ABRS in children and has poten tially serious side effects, including tendonitis and tendon rupture, which should be considered prior to the initiation of therapy. In contrast, the 2012 Infectious Disease Society of Amer ica clinical guideline for the management of ABRS rec ommends amoxicillin-clavulanate for empiric therapy for ABRS in children. 31 The ISDA guidelines also recom mended that high-dose amoxicillin-clavulanate, defined as 90 mg/kg/d orally twice daily, be used as a first line therapy in children who live in a geographic region with high endemic rates of penicillin-nonsusceptible S. pneu moniae , with a severe infection. Additionally this regimen is recommended for children who attend daycare, are less than 2 years old, who have had a recent hospitalization, who have used an antibiotic within the past month, or who are in an immunocompromised state. 31 Macrolides, trimethoprim-sulfamethoxazole, as well as second-and third-generation cephalosporins were not recommended for empiric monotherapy of ABRS. The recommendation against the use of cephalosporins for empiric monother apy in penicillin allergic patients is in contrast to that made by the AAP. The combination of a third-generation cephalosporin with clindamycin was recommended as second-line therapy for children with non–type I penicillin allergy or from geographic regions with high endemic rates of penicillin-nonsusceptible S. pneumoniae . 31 Levofloxacin was the antibiotic of choice for children with a history of type I hypersensitivity to penicillin, and clindamycin plus a third-generation cephalosporin was recommended for children with a history of non–type I hypersensitivity to penicillin. 3 The ISDA recommends antibiotic treatment for a duration of 10 to 14 days. 31 While these cited guidelines provide us with expert opinion, a 2013 meta-analysis of randomized control tri als for the treatment ARS yielded only 4 articles. 2310 The authors concluded that evidence supports the use of antibi otics for ARS but efficacy could not be adequately demon strated given the variance in study diagnostic and inclusion criteria. 2310 A 2014 Cochrane review failed to detect any evidence supporting the efficacy of nasal decongestants, antihis tamines, or nasal irrigations in the management of pedi atric ARS. 33 A subsequent 2018 meta-analysis of nasal saline irrigation (NSI) for both ARS and CRS in chil dren yielded only 1 article supportive of NSI for ARS. 2311

This lone article by Ragab et al. demonstrated equivalent improvement in ARS outcomes on 2 weeks of NSI with or without antibiotics (amoxicillin). 2312 This article suggests that NSI may be as effective as amoxicillin without the noted observed side effects of antibiotics (eg, diarrhea). 2312 It is difficult to provide a broad recommendation for the use of NSI for ARS based on a single RCT - further investi gation is warranted. Management of Pediatric ARS Aggregate Grade of Evidence: A (Level 1: 7 studies; Table XIII-3). Recommendation 1 : Given the likely viral etiology, antibiotics should not be given for the first 10 days of uncomplicated acute rhinosinusits. Benefit: Avoidance of unnecessary medications. Harm: Potential progression of disease. Cost: None. Benefits-Harm Assessment: Benefits likely out weigh harms and costs. Value Judgments: Parental preference often plays a large role in decision-making. Policy Level: Recommendation. Intervention: Antibiotics should not be given for the first 10 days of uncomplicated ARS. Recommendation 2 : For patients without penicillin allergy, amoxicillin or amoxicillin-clavulanate may be prescribed for ABRS (defined as 2 nasal symptoms lasting greater than 10 days, or acute onset of severe symptoms). Benefit: Reduction in duration and severity of symptoms. Harm: Antibiotic resistance, gastrointestinal com plications, risk of allergic reaction (see Table II-1). Cost: moderate for antibiotics other than amoxi cillin. Benefits-Harm Assessment: Benefits likely out weigh harms and costs. Value Judgments: Parental preference often plays Intervention: For patients without penicillin allergy, amoxicillin or amoxicillin-clavulanate may be prescribed for ABRS (defined as 2 nasal symptoms lasting greater than 10 days). a large role in decision-making. Policy Level: Recommendation.