Cefuroxime axetil versus placebo for children with acute respiratory infection and imaging evidence of sinusitis: a randomized, controlled trial

Antibiotics for Acute Sinusitis in Children: A Meta-Analysis

CONTEXT

Acute sinusitis is one of the leading causes of antibiotic prescriptions in children. No recent systematic reviews have examined the efficacy of antibiotics compared with placebo.

OBJECTIVE

We sought to determine if antibiotics are superior to placebo in the treatment of acute sinusitis in children.

DATA SOURCES

Medline and Embase were searched from their origin to July 2023.

STUDY SELECTION

We considered randomized placebo-controlled studies focusing on the treatment of acute sinusitis. In all studies, symptoms were present for <4 weeks and subjects were <18 years of age.

DATA EXTRACTION

Two authors independently extracted the data. We pooled data primarily using fixed-effects models.

RESULTS

Analysis of 6 included studies showed that antibiotic treatment reduced the rate of treatment failure by 41% (with a risk ratio of 0.59; 95% confidence interval 0.49-0.72) compared with placebo. There was substantial heterogeneity between the studies (I2 = 69.7%), which decreased substantially when the 1 study with a high risk of bias was removed (I2 = 26.9%). Children treated with antibiotics were 1.6 times more likely to have diarrhea than those who were not treated with antibiotics (risk ratio = 1.62, 95% confidence interval 1.04-2.51).

LIMITATIONS

A small number of studies were eligible for inclusion. Included studies differed in their methodology.

CONCLUSIONS

In children with clinically diagnosed acute sinusitis, antibiotics significantly reduced the rate of treatment failure compared with placebo. However, given the favorable natural history of sinusitis, our results could also support close observation without immediate antibiotic treatment.

Antibiotic prescriptions for child sinusitis varied between specialties after Finnish guidelines were updated in 2018

AIM

We evaluated antibiotic prescriptions issued for Finnish children with acute sinusitis by a nationwide private outpatient clinic network from 2014-2020. Data were compared before and after updated guidelines in 2018.

METHODS

The study comprised data on 45 296 children aged 2-17 years with acute sinusitis, namely diagnoses, ages, dates, the doctor's specialty and any antibiotics. We measured compliance with the updated 2018 Finnish guidelines, which recommended amoxicillin or amoxicillin-clavulanic acid for children under 12 years old, with doxycycline as an alternative for 12 years plus.

RESULTS

There were 6621-7585 visits per year for acute sinusitis in 2014-2019 and 2954 in 2020. Antibiotics were prescribed for 37.9%-41.6% of patients during the study years. Amoxicillin, including penicillin, accounted for 35.9% of prescriptions, followed by amoxicillin-clavulanic acid (26.9%). Macrolides accounted for 20.6% and, encouragingly, decreased by 38% from 2014-2019. Doxycycline accounted for 5.3%. Paediatricians, general practitioners (GPs) and ear, nose and throat specialists followed the guidelines in 75.1%, 73.8% and 66.7% of cases, respectively. GPs prescribed antibiotics more often than other physicians.

CONCLUSION

Antibiotics were prescribed for about 40% of acute sinusitis visits by Finnish children from 2014-2019. Specialities differed with regard to prescribing rates and whether they followed the guidelines.

Antibiotic adverse effects in pediatric acute rhinosinusitis: Systematic review and meta-analysis

BACKGROUND

Pediatric acute bacterial rhinosinusitis (ABRS) is often treated with oral antibiotics, with limited insight into adverse effects (AEs) across drug classes. In this systematic review and meta-analysis, we characterize AE incidence associated with oral antibiotics in these patients.

METHODOLOGY/PRINCIPAL

We searched PubMed and Embase for English-language articles published from 1985 to September 2020 reporting AEs of oral antibiotic therapy for ABRS patients aged 0-18 years. Six-hundred and sixty-six articles underwent title and abstract screening, identifying 154 articles for full-length review.

RESULTS

Eleven articles were included, most of which reported individual and aggregate AE incidences. Amoxicillin/clavulanate, amoxicillin, cephalosporin/carbacephem, and placebo groups were identified. Random-effects meta-analysis of prospective groups identified appreciable incidences of diarrhea and abdominal pain, and low incidence of rash, for amoxicillin-clavulanate and amoxicillin. All antibiotics as well as placebo were associated with non-zero overall AE incidence. Children receiving antibiotics were about twice as likely to incur any AE during treatment in placebo-controlled studies, though this association was not significant. High heterogeneity limited most point estimates, with risk of bias, typically in outcomes measurement, detected in most studies.

CONCLUSIONS

Reporting of AEs associated with oral antibiotic use in pediatric ABRS is limited in current literature. Adverse effects are non-negligible, but may not significantly exceed placebo.

The management of paediatric rhinosinusitis

Paediatric rhinosinusitis (PDRS) is commonly used as a synonym for rhinitis within healthcare. Although they may share common symptoms, the pathophysiology does differ; PDRS is the inflammation of the nasal mucosa in addition to the sinuses whereas rhinitis is the inflammation of just nasal mucosa. This review provides a comprehensive overview of the epidemiology, pathophysiology, symptoms, diagnosis and management of PDRS. There is a greater emphasis on the diagnosis and management of PDRS within this review due to a lack of clear guidelines, which can lead to the common misconception that PDRS can be treated indifferently to rhinitis and other upper respiratory conditions. PDRS has detrimental effects on children's current health, long-term health into adulthood and education. Therefore, having a comprehensive guide of PDRS would provide a greater understanding of the condition as well as improved diagnosis and management. This article primarily focuses on the position of Europe and the United Kingdom; however, the recommendations can be applied to other countries as the causes and treatments would not differ significantly.

Antibiotics for acute rhinosinusitis in adults

BACKGROUND

Acute rhinosinusitis is an acute infection of the nasal passages and paranasal sinuses that lasts less than four weeks. Diagnosis of acute rhinosinusitis is generally based on clinical signs and symptoms in ambulatory care settings. Technical investigations are not routinely performed, nor are they recommended in most countries. Some trials show a trend in favour of antibiotics, but the balance of benefit versus harm is unclear.We merged two Cochrane Reviews for this update, which comprised different approaches with overlapping populations, resulting in different conclusions. For this review update, we maintained the distinction between populations diagnosed by clinical signs and symptoms, or imaging.

OBJECTIVES

To assess the effects of antibiotics versus placebo or no treatment in adults with acute rhinosinusitis in ambulatory care settings.

SEARCH METHODS

We searched CENTRAL (2017, Issue 12), which contains the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE (January 1950 to January 2018), Embase (January 1974 to January 2018), and two trials registers (January 2018). We also checked references from identified trials, systematic reviews, and relevant guidelines.

SELECTION CRITERIA

Randomised controlled trials of antibiotics versus placebo or no treatment in people with rhinosinusitis-like signs or symptoms or sinusitis confirmed by imaging.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data about cure and side effects and assessed the risk of bias. We contacted trial authors for additional information as required.

MAIN RESULTS

We included 15 trials involving 3057 participants. Of the 15 included trials, 10 appeared in our 2012 review, and five (631 participants) are legacy trials from merging two reviews. No new studies were included from searches for this update. Overall, risk of bias was low. Without antibiotics, 46% of participants with rhinosinusitis, whether or not confirmed by radiography, were cured after 1 week and 64% after 14 days. Antibiotics can shorten time to cure, but only 5 to 11 more people per 100 will be cured faster if they receive antibiotics instead of placebo or no treatment: clinical diagnosis (odds ratio (OR) 1.25, 95% confidence interval (CI) 1.02 to 1.54; number needed to treat for an additional beneficial outcome (NNTB) 19, 95% CI 10 to 205; I² = 0%; 8 trials; high-quality evidence) and diagnosis confirmed by radiography (OR 1.57, 95% CI 1.03 to 2.39; NNTB 10, 95% CI 5 to 136; I² = 0%; 3 trials; moderate-quality evidence). Cure rates with antibiotics were higher when a fluid level or total opacification in any sinus was found on computed tomography (OR 4.89, 95% CI 1.75 to 13.72; NNTB 4, 95% CI 2 to 15; 1 trial; moderate-quality evidence). Purulent secretion resolved faster with antibiotics (OR 1.58, 95% CI 1.13 to 2.22; NNTB 10, 95% CI 6 to 35; I² = 0%; 3 trials; high-quality evidence). However, 13 more people experienced side effects with antibiotics compared to placebo or no treatment (OR 2.21, 95% CI 1.74 to 2.82; number needed to treat for an additional harmful outcome (NNTH) 8, 95% CI 6 to 12; I² = 16%; 10 trials; high-quality evidence). Five fewer people per 100 will experience clinical failure if they receive antibiotics instead of placebo or no treatment (Peto OR 0.48, 95% CI 0.36 to 0.63; NNTH 19, 95% CI 15 to 27; I² = 21%; 12 trials; high-quality evidence). A disease-related complication (brain abscess) occurred in one participant (of 3057) one week after receiving open antibiotic therapy (clinical failure, control group).

AUTHORS' CONCLUSIONS

The potential benefit of antibiotics to treat acute rhinosinusitis diagnosed either clinically (low risk of bias, high-quality evidence) or confirmed by imaging (low to unclear risk of bias, moderate-quality evidence) is marginal and needs to be seen in the context of the risk of adverse effects. Considering antibiotic resistance, and the very low incidence of serious complications, we conclude there is no place for antibiotics for people with uncomplicated acute rhinosinusitis. We could not draw conclusions about children, people with suppressed immune systems, and those with severe sinusitis, because these populations were not included in the available trials.

Antibiotic duration and timing of the switch from intravenous to oral route for bacterial infections in children: systematic review and guidelines

Few studies are available to inform duration of intravenous antibiotics for children and when it is safe and appropriate to switch to oral antibiotics. We have systematically reviewed antibiotic duration and timing of intravenous to oral switch for 36 paediatric infectious diseases and developed evidence-graded recommendations on the basis of the review, guidelines, and expert consensus. We searched databases and obtained information from references identified and relevant guidelines. All eligible studies were assessed for quality. 4090 articles were identified and 170 studies were included. Evidence relating antibiotic duration to outcomes in children for some infections was supported by meta-analyses or randomised controlled trials; in other infections data were from retrospective series only. Criteria for intravenous to oral switch commonly included defervescence and clinical improvement with or without improvement in laboratory markers. Evidence suggests that intravenous to oral switch can occur earlier than previously recommended for some infections. We have synthesised recommendations for antibiotic duration and intravenous to oral switch to support clinical decision making and prospective research.

Decongestants, antihistamines and nasal irrigation for acute sinusitis in children

BACKGROUND

The efficacy of decongestants, antihistamines and nasal irrigation in children with clinically diagnosed acute sinusitis has not been systematically evaluated.

OBJECTIVES

To determine the efficacy of decongestants, antihistamines or nasal irrigation in improving symptoms of acute sinusitis in children.

SEARCH METHODS

We searched CENTRAL (2014, Issue 5), MEDLINE (1950 to June week 1, 2014) and EMBASE (1950 to June 2014).

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and quasi-RCTs, which evaluated children younger than 18 years of age with acute sinusitis, defined as 10 to 30 days of rhinorrhea, congestion or daytime cough. We excluded trials of children with chronic sinusitis and allergic rhinitis.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed each study for inclusion.

MAIN RESULTS

Of the 662 studies identified through the electronic searches and handsearching, none met all the inclusion criteria.

AUTHORS' CONCLUSIONS

There is no evidence to determine whether the use of antihistamines, decongestants or nasal irrigation is efficacious in children with acute sinusitis. Further research is needed to determine whether these interventions are beneficial in the treatment of children with acute sinusitis.

Acute rhinosinusitis in children

Acute rhinosinusitis in children is a common disorder that is characterized by some or all of the following symptoms: fever, rhinorrhea, nasal congestion, cough, postnasal drainage, and facial pain/headache. It often starts as an upper respiratory tract infection that is complicated by a bacterial infection in which the symptoms worsen, persist, or are particularly severe. The accurate diagnosis of acute rhinosinusitis is challenging because of the overlap of symptoms with other common diseases, heavy reliance on subjective reporting of symptoms by the parents, and difficulties related to the physical examination of the child. Antibiotics are the mainstay of treatment. There is no strong evidence for the use of ancillary therapy. Orbital and intracranial complications may occur and are best treated early and aggressively. This article reviews the diagnosis, pathophysiology, bacteriology, treatment, and complications of acute rhinosinusitis in children.

Duration of symptoms of respiratory tract infections in children: systematic review

OBJECTIVE

To determine the expected duration of symptoms of common respiratory tract infections in children in primary and emergency care.

DESIGN

Systematic review of existing literature to determine durations of symptoms of earache, sore throat, cough (including acute cough, bronchiolitis, and croup), and common cold in children.

DATA SOURCES

PubMed, DARE, and CINAHL (all to July 2012).

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Randomised controlled trials or observational studies of children with acute respiratory tract infections in primary care or emergency settings in high income countries who received either a control treatment or a placebo or over-the-counter treatment. Study quality was assessed with the Cochrane risk of bias framework for randomised controlled trials, and the critical appraisal skills programme framework for observational studies.

MAIN OUTCOME MEASURES

Individual study data and, when possible, pooled daily mean proportions and 95% confidence intervals for symptom duration. Symptom duration (in days) at which each symptom had resolved in 50% and 90% of children.

RESULTS

Of 22,182 identified references, 23 trials and 25 observational studies met inclusion criteria. Study populations varied in age and duration of symptoms before study onset. In 90% of children, earache was resolved by seven to eight days, sore throat between two and seven days, croup by two days, bronchiolitis by 21 days, acute cough by 25 days, common cold by 15 days, and non-specific respiratory tract infections symptoms by 16 days.

CONCLUSIONS

The durations of earache and common colds are considerably longer than current guidance given to parents in the United Kingdom and the United States; for other symptoms such as sore throat, acute cough, bronchiolitis, and croup the current guidance is consistent with our findings. Updating current guidelines with new evidence will help support parents and clinicians in evidence based decision making for children with respiratory tract infections.

Acute sinusitis in children: do antibiotics have any role?

Bacteria can be recovered from paranasal sinuses in the majority of patients given the diagnosis of acute bacterial sinusitis (ABS), and bacteriologic cure can be achieved with appropriate antibiotic treatment. The critical question is whether bacteriologic cure correlates with meaningful clinical endpoints such as clinical improvement, reduction in recurrent disease, or prevention of complications. Of the 4 pediatric placebo-controlled randomized clinical trials (PCRCTs), 2 suggest superiority of antibiotic treatment and 2 suggest lack of superiority. PCRCTs in adults are mixed as to clinical benefit. Pediatric and adult meta-analyses demonstrate modest benefit of antibiotic therapy and rates of spontaneous recovery without antibiotics of 60-65%. Although retrospective studies indicate that some patients who develop orbital or neurologic complications of sinusitis were pre-treated with antibiotic therapy, a low rate of complications precludes determination of whether antibiotic treatment prevents complications in some proportion of patients. Like the literature evidence, expert guideline recommendations are mixed. Although the evidence base is incomplete and conflicting, the limited data suggest that antibiotics probably do have a role in the treatment of pediatric ABS. The most compelling rationale is prevention of serious complications, but proof for this rationale is lacking.

Acute bacterial sinusitis in children

On the basis of strong research evidence, the pathogenesis of sinusitis involves 3 key factors: sinusostia obstruction, ciliary dysfunction, and thickening of sinus secretions. On the basis of studies of the microbiology of otitis media, H influenzae is playing an increasingly important role in the etiology of sinusitis, exceeding that of S pneumoniae in some areas, and b-lactamase production by H influenzae is increasing in respiratory isolates in the United States. On the basis of some research evidence and consensus,the presentation of acute bacterial sinusitis conforms to 1 of 3 predicable patterns; persistent, severe, and worsening symptoms. On the basis of some research evidence and consensus,the diagnosis of sinusitis should be made by applying strict clinical criteria. This approach will select children with upper respiratory infection symptoms who are most likely to benefit from an antibiotic. On the basis of some research evidence and consensus,imaging is not indicated routinely in the diagnosis of sinusitis. Computed tomography or magnetic resonance imaging provides useful information when complications of sinusitis are suspected. On the basis of some research evidence and consensus,amoxicillin-clavulanate should be considered asa first-line agent for the treatment of sinusitis.

Clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years

OBJECTIVE

To update the American Academy of Pediatrics clinical practice guideline regarding the diagnosis and management of acute bacterial sinusitis in children and adolescents.

METHODS

Analysis of the medical literature published since the last version of the guideline (2001).

RESULTS

The diagnosis of acute bacterial sinusitis is made when a child with an acute upper respiratory tract infection (URI) presents with (1) persistent illness (nasal discharge [of any quality] or daytime cough or both lasting more than 10 days without improvement), (2) a worsening course (worsening or new onset of nasal discharge, daytime cough, or fever after initial improvement), or (3) severe onset (concurrent fever[temperature ≥39°C/102.2°F] and purulent nasal discharge for at least 3 consecutive days). Clinicians should not obtain imaging studies of any kind to distinguish acute bacterial sinusitis from viral URI, because they do not contribute to the diagnosis; however, a contrast-enhanced computed tomography scan of the paranasal sinuses should be obtained whenever a child is suspected of having orbital or central nervous system complications. The clinician should prescribe antibiotic therapy for acute bacterial sinusitis in children with severe onset or worsening course. The clinician should either prescribe antibiotic therapy or offer additional observation for 3 days to children with persistent illness. Amoxicillin with or without clavulanate is the firstline treatment of acute bacterial sinusitis. Clinicians should reassess initial management if there is either a caregiver report of worsening(progression of initial signs/symptoms or appearance of new signs/symptoms) or failure to improve within 72 hours of initial management.If the diagnosis of acute bacterial sinusitis is confirmed in a child with worsening symptoms or failure to improve, then clinicians may change the antibiotic therapy for the child initially managed with antibiotic or initiate antibiotic treatment of the child initially managed with observation.

CONCLUSIONS

Changes in this revision include the addition of a clinical presentation designated as “worsening course,” an option to treat immediately or observe children with persistent symptoms for 3 days before treating, and a review of evidence indicating that imaging is not necessary in children with uncomplicated acute bacterial sinusitis.

Evidence for the diagnosis and treatment of acute uncomplicated sinusitis in children: a systematic review

In 2001, the American Academy of Pediatrics published clinical practice guidelines for the management of acute bacterial sinusitis (ABS) in children. The technical report accompanying those guidelines included 21 studies that assessed the diagnosis and management of ABS in children. This update to that report incorporates studies of pediatric ABS that have been performed since 2001. Overall, 17 randomized controlled trials of the treatment of sinusitis in children were identified and analyzed. Four randomized, double-blind, placebo-controlled trials of antimicrobial therapy have been published. The results of these studies varied, likely due to differences in inclusion and exclusion criteria. Because of this heterogeneity, formal meta-analyses were not performed. However, qualitative analysis of these studies suggests that children with greater severity of illness at presentation are more likely to benefit from antimicrobial therapy. An additional 5 trials compared different antimicrobial therapies but did not include placebo groups. Six trials assessed a variety of ancillary treatments for ABS in children,and 3 focused on subacute sinusitis. Although the number of pediatric trials has increased since 2001, there are still limited data to guide the diagnosis and management of ABS in children. Diagnostic and treatment guidelines focusing on severity of illness at the time of presentation have the potential to identify those children most likely to benefit from antimicrobial therapy and at the same time minimize unnecessary use of antibiotics

[Consensus document on the aetiology, diagnosis and treatment of sinusitis]

The Spanish National Consensus (Spanish Society of Pediatric Infectious Diseases, Spanish Association of Primary Care Pediatrics, Spanish Society of Pediatric Outpatient and Primary Care, Spanish Society of Otorhinolaryngology and Cervical-Facial Pathology) on Sinusitis is presented. Rhinosinusitis is a difficult to diagnose and often unrecognised disease. The document discusses the aetiology, the clinical signs and symptoms, and the diagnostic criteria. A proposal for treatment is made based on the epidemiological situation in our country. Oral amoxicillin is the treatment of choice (80mg/kg/day divided every 8hours). Alternative treatment is proposed in special cases and when amoxicillin is not sufficient. The main complications are reviewed.

Antibiotics for clinically diagnosed acute rhinosinusitis in adults

BACKGROUND

In primary care settings, the diagnosis of rhinosinusitis is generally based on clinical signs and symptoms. Technical investigations are not routinely performed, nor recommended. Individual trials show a trend in favour of antibiotics, but the balance of benefit versus harm is unclear.

OBJECTIVES

To assess the effect of antibiotics in adults with clinically diagnosed rhinosinusitis in primary care settings.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2012), MEDLINE (January 1950 to February week 4, 2012) and EMBASE (January 1974 to February 2012).

SELECTION CRITERIA

Randomised controlled trials (RCTs) of antibiotics versus placebo in participants with rhinosinusitis-like signs or symptoms.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data and assessed the risk of bias. We contacted trial authors for additional information. We collected information on adverse effects from the trials.

MAIN RESULTS

We included 10 trials involving 2450 participants. Overall, the risk of bias in these studies was low. Irrespective of the treatment group, 47% of participants were cured after one week and 71% after 14 days. Antibiotics can shorten the time to cure, but only five more participants per 100 will cure faster at any time point between 7 and 14 days if they receive antibiotics instead of placebo (number needed to treat to benefit (NNTB)) 18 (95% confidence interval (CI) 10 to 115, I(2) statistic 0%, eight trials). Purulent secretion resolves faster with antibiotics (odds ratio (OR) 1.58 (95% CI 1.13 to 2.22)), (NNTB 11, 95% CI 6 to 51, I(2) statistic 0%, three trials). However, 27% of the participants who received antibiotics and 15% of those who received placebo experienced adverse events (OR 2.10, 95% CI 1.60 to 2.77) (number needed to treat to harm (NNTH)) 8 (95% CI 6 to 13, I(2) statistic 13%, seven trials). More participants in the placebo group needed to start antibiotic therapy because of an abnormal course of rhinosinusitis (OR 0.49, 95% CI 0.36 to 0.66), NNTH 20 (95% CI 14 to 35, I(2) statistic 0%, eight trials). Only one disease-related complication (brain abscess) occurred in a patient treated with antibiotics.

AUTHORS' CONCLUSIONS

The potential benefit of antibiotics in the treatment of clinically diagnosed acute rhinosinusitis needs to be seen in the context of a high prevalence of adverse events. Taking into account antibiotic resistance and the very low incidence of serious complications, we conclude that there is no place for antibiotics for the patient with clinically diagnosed, uncomplicated acute rhinosinusitis. This review cannot make recommendations for children, patients with a suppressed immune system and patients with severe disease, as these populations were not included in the available trials.

Decongestants, antihistamines and nasal irrigation for acute sinusitis in children

BACKGROUND

The efficacy of decongestants, antihistamines and nasal irrigation in children with clinically diagnosed acute sinusitis has not been systematically evaluated.

OBJECTIVES

To systematically review the efficacy of decongestants, antihistamines and nasal irrigation in children with clinically diagnosed acute sinusitis. We considered the following four interventions: 1) decongestants versus placebo or no medication, 2) antihistamines versus placebo or no medication, 3) decongestant and antihistamine combination versus placebo or no medication, 4) nasal irrigation versus no irrigation. The primary outcomes of the review were symptom resolution (improvement in symptom score from enrolment to day five and overall symptom burden (as measured by average symptom scores while on therapy).

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL 2012, Issue 1), which includes the Acute Respiratory Infections Group's Specialized Register, MEDLINE (1950 to January week 3, 2012) and EMBASE (1950 to January 2012).

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and quasi-RCTs which evaluated children less than 18 years of age with acute sinusitis, defined as 10 to 30 days of rhinorrhea, congestion or daytime cough. We excluded trials of children with chronic sinusitis and allergic rhinitis.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed each study for inclusion.

MAIN RESULTS

Of the 526 studies found through the electronic searches and handsearching, none met all the inclusion criteria.

AUTHORS' CONCLUSIONS

There is no evidence to determine whether the use of antihistamines, decongestants or nasal irrigation is efficacious in children with acute sinusitis. Further research is needed to determine whether these interventions are beneficial in the treatment of children with acute sinusitis.

IDSA Clinical Practice Guideline for Acute Bacterial Rhinosinusitis in Children and Adults

Evidence-based guidelines for the diagnosis and initial management of suspected acute bacterial rhinosinusitis in adults and children were prepared by a multidisciplinary expert panel of the Infectious Diseases Society of America comprising clinicians and investigators representing internal medicine, pediatrics, emergency medicine, otolaryngology, public health, epidemiology, and adult and pediatric infectious disease specialties. Recommendations for diagnosis, laboratory investigation, and empiric antimicrobial and adjunctive therapy were developed.

Decongestants, antihistamines and nasal irrigation for acute sinusitis in children

BACKGROUND

The efficacy of decongestants, antihistamines and nasal irrigation in children with clinically diagnosed acute sinusitis has not been systematically evaluated.

OBJECTIVES

To systematically review the efficacy of decongestants, antihistamines and nasal irrigation in children with clinically diagnosed acute sinusitis. We considered the following four interventions: 1) decongestants versus placebo or no medication, 2) antihistamines versus placebo or no medication, 3) decongestant and antihistamine combination versus placebo or no medication, 4) nasal irrigation versus no irrigation. The primary outcomes of the review were symptom resolution (improvement in symptom score from enrolment to day 5) and overall symptom burden (as measured by average symptom scores while on therapy).

SEARCH STRATEGY

We searched the Cochrane Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2010), which includes the Acute Respiratory Infections Group's Specialized Register, MEDLINE (1950 to May Week 1, 2010) and EMBASE (1950 to January 2010).

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and quasi-RCTs which evaluated children less than 18 years of age with acute sinusitis, defined as 10 to 30 days of rhinorrhea, congestion or daytime cough. We excluded trials of children with chronic sinusitis and allergic rhinitis.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed each study for inclusion.

MAIN RESULTS

Of the 402 studies found through the electronic searches and handsearching, none met all the inclusion criteria.

AUTHORS' CONCLUSIONS

There is no evidence to determine whether the use of antihistamines, decongestants or nasal irrigation is efficacious in children with acute sinusitis. Further research is needed to determine whether these interventions are beneficial in the treatment of children with acute sinusitis.

Timing of rhinosinusitis complications in children

BACKGROUND

Acute rhinosinusitis in a child with signs and symptoms of a cold that persist beyond 10 days is recommended to be treated with antimicrobials. One reason for this recommendation is to prevent the complications of sinus infection. We wanted to find out whether there is any evidence to support this.

METHODS

We reviewed retrospectively all the medical records of children treated in our hospital from February 1996 to March 2006 for complications related to rhinosinusitis.

RESULTS

Twenty children had such complications. Their symptoms of uncomplicated acute respiratory infection had lasted for an average of 5.1 days before the appearance of the complication, and only 3 children had respiratory symptoms lasting longer than 10 days.

CONCLUSIONS

Complications of rhinosinusitis in children appear during the first few days of acute upper respiratory infection. This finding does not support the recommendation that antibiotics should be started if upper respiratory symptoms have lasted longer than 10 days in children. Even though patients with findings suggesting invasive periorbital infection require immediate antimicrobial treatment, we should be critical in our recommendations as to when antibiotics need to be given to patients with only prolonged upper respiratory infections.

Otimizando o diagnóstico para o tratamento adequado das principais infecções agudas em otorrinopediatria: tonsilite, sinusite e otite média

As sinusites, otites médias agudas e tonsilites são muito freqüentes em crianças. A maioria dessas infecções é causada por vírus, mas em geral, elas são tratadas com antibióticos. O uso inapropriado de antibióticos favorece a seleção, crescimento e disseminação de bactérias resistentes que colonizam as vias respiratórias, atingindo toda a comunidade. A emergência de bactérias resistentes dificulta os tratamentos das infecções respiratórias, sendo essencial desenvolver estratégias efetivas para restringir o uso de antibióticos sem prejudicar as crianças que realmente precisam desses medicamentos. OBJETIVO: Analisar os resultados de estudos randomizados e controlados sobre critérios clínicos e laboratoriais utilizados para diagnóstico e tratamento das tonsilites, sinusites e otites. MÉTODOS: Levantamento dos estudos randomizados e controlados sobre o tema, publicados no MEDLINE e SCIELO, de 2000 a 2006. CONCLUSÕES: Como a maioria dessas infecções evolui bem sem antibióticos, deve-se evitar o uso desses medicamentos a menos que a criança pertença aos grupos de alto risco para complicações ou apresente persistência ou piora dos sintomas com tratamento sintomático. É necessário que os médicos e leigos conheçam melhor a evolução natural das infecções respiratórias agudas e que seja garantido o acesso das crianças a serviços médicos de boa qualidade para orientação e reavaliação, quando necessária.

Optimizing the Management of the Main Acute Infections in Pediatric ORL: Tonsillitis, Sinusitis, Otitis media

Sinusitis, acute otitis media and tonsillitis are very frequent in children. Most of these infections are caused by viruses, but are generally treated with antibiotics. Inappropriate use of antibiotics favors the selection, growth and spread of resistant bacteria; these bacteria colonize the airways and affect the entire community. With the emergence of antibiotic-resistant bacteria, respiratory infections have become more difficult to treat. Effective strategies are needed to restrict the use of antibiotics without harming children that truly need these drugs.

Aim

to present a critical analysis of the results of randomized and controlled studies on clinical and laboratory criteria used in diagnosing and treating tonsillitis, sinusitis and otitis.

Methods

a review of randomized and controlled studies about these conditions published in MEDLINE and SCIELO from 2000 to 2006.

Conclusions

Given that most of these infections progress favorably without antibiotics, the use of these drugs should be avoided unless the child belongs to a high risk group for complications, or symptoms persist or worsen with despite symptomatic treatment. Physicians and laypersons should have better knowledge about the natural evolution of acute respiratory infections.

Pelargonium sidoides extract for acute respiratory tract infections

BACKGROUND

Pelargonium sidoides (P. sidoides), also known as Umckaloabo, is a herbal remedy thought to be effective in the treatment of acute respiratory infections (ARIs).

OBJECTIVES

To assess the efficacy and safety of P. sidoides for the treatment of ARIs in children and adults.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2007, issue 4) which includes the Cochrane Acute Respiratory Infections Group's Specialised Register; MEDLINE (1966 to November 2007); EMBASE (1974 to December 2007); and other electronic databases.

SELECTION CRITERIA

Randomized controlled trials (RCTs) examining the efficacy of P. sidoides preparations in ARIs compared to placebo, no treatment or any other treatment. Complete resolution of all symptoms was defined as a primary outcome.

DATA COLLECTION AND ANALYSIS

Three review authors (AT, JG, WK) independently extracted and quality scored the data. Separate analyses were performed by age group and disease entity. Heterogeneity was examined using the I-square (I(2)) statistic. Pooled relative risks (RR) were calculated using a fixed-effect model if heterogeneity was absent (I(2) < 5%; P > 0.1), or a random-effects model in the presence of heterogeneity. If heterogeneity was substantial (I(2) > 50%; P < 0.10), a pooled effect was not calculated.

MAIN RESULTS

Three trials (746 patients) of efficacy in acute bronchitis in adults showed substantial heterogeneity for all relevant outcomes. and three trials (819 children) were similarly inconsistent for acute bronchitis in children. Type of preparation was a potential cause of heterogeneity (not effective in tablet form). One unpublished study in patients with sinusitis (n = 103 adults) showed significant treatment effects (complete resolution at day 21; RR 0.43, 95% CI 0.30, 0.62). One study in the common cold demonstrating efficacy after 10 days, but not five days. Four trials were excluded because of excessive risk of bias. There were no valid data for the treatment of other acute respiratory tract infections. Adverse events were more common with P. sidoides, but none were serious.

AUTHORS' CONCLUSIONS

P. sidoides may be effective in alleviating symptoms of acute rhinosinusitis and the common cold in adults, but doubt exists. It may be effective in relieving symptoms in acute bronchitis in adults and children, and sinusitis in adults. Reliable data on treatment for other ARIs were not identified.

Pediatric chronic rhinosinusitis

PURPOSE OF REVIEW

Pediatric acute and chronic rhinosinusitis are common pediatric ailments averaging six to eight occurrences a year with 0.5-5% of these progressing to acute sinusitis. A yet undefined number of children progress to chronic sinusitis. Significant resources are spent treating children for sinus infections that would otherwise clear on their own. Practice guidelines for chronic sinusitis are needed.

RECENT FINDINGS

Good prospective studies are lacking because of the shear numbers of patients that must be enrolled to obtain a homogeneous population for study. This lack of good prospective studies prevents the development of pediatric practice guidelines for medical and surgical management of chronic rhinosinusitis. Most recent studies focus primarily on pathophysiology and medical management. An area of significant knowledge deficit is the role of gastroesophageal reflux disease in chronic sinusitis. There have been no recent significant changes in the medical or surgical management of chronic rhinosinusitis other than the rationale of performing an adenoidectomy prior to endoscopic sinus surgery for eradication of biofilms.

SUMMARY

Current therapy for pediatric chronic rhinosinusitis continues to be prolonged courses of antibiotics and if the symptoms persist, staged surgical intervention with initial adenoidectomy followed by partial or anterior ethmoidectomy.