This report was reviewed for medical and scientific accuracy by Amisha Malhotra, MD, Associate Professor of Pediatrics, University of Medicine & Dentistry of New Jersey-Robert Wood Johnson Medical School, New Brunswick, New Jersey

Expert Commentary

Jack B. Anon, MD, FACS, Clinical Associate Professor, Department of Otolaryngology University of Pittsburgh School of Medicine, Erie, Pennsylvania; Chairman, American Academy of Otolaryngology-Head and Neck Surgery’s Rhinology and Paranasal Sinus Disease Committee

Acute otitis media and acute bacterial rhinosinusitis are remarkably similar diseases.¹ Both are infections that share common pathogens, are usually diagnosed on the basis of the patient's history and physical examination, and in the majority of cases, are treated empirically due to the invasive nature of culturing the infection. Although not identical, knowledge of the basic pathophysiology of middle ear disease often assists a clinician in understanding sinus disease. Recognizing these similarities provides a better understanding of their pathophysiology and appropriate treatment.

Acute otitis media and acute bacterial rhinosinusitis are the two primary diagnoses that result in antibacterial therapy.² However, a significant proportion of this antibacterial therapy is medically unjustified due to misdiagnosis. For example, millions of courses of antibiotics are prescribed every year for otitis media with effusion,³ even though antibiotics are of little clinical use in this condition. Similarly, antibiotics are often prescribed for viral rhinosinusitis, which is 20 to 200 times more common than bacterial sinusitis.⁴

The need to understand and appropriately treat these diseases is made more dramatic in an environment of increasing antibiotic resistance, particularly with their common bacterial etiology. Streptococcus pneumoniae (S. pneumoniae), Haemophilus influenzae (H. influenzae), and Moraxella catarrhalis (M. catarrhalis) colonizing the nasopharynx are responsible for acute otitis media in children,⁵ and are the most common bacterial isolates from the maxillary sinuses of patients with acute bacterial rhinosinusitis.⁶ An understanding of factors associated with antibiotic resistance is key to limiting the spread of drug resistance.

This Pediatric Press Newsletter is very timely. As treatment guidelines for acute otitis media and acute bacterial rhinosinusitis are being revised, a review of the similarities and differences between these conditions is clinically prudent and provides a foundation upon which to accept and incorporate the new treatment guidelines into clinical practice.

Common Bacterial Pathogens

Treatment for acute otitis media and acute bacterial rhino-sinusitis must take into account the pathogens most commonly implicated in these conditions (ie, S. pneumoniae, H. influenzae, and M. catarrhalis) (Table 1). The most predominant bacterial pathogen in each of these conditions is S. pneumoniae, followed by H. influenzae (non-typeable strains represent the majority of cases in each condition), with M. catarrhalis generally less frequently involved in acute bacterial rhinosinusitis compared to acute otitis media.

Inappropriate use of antibiotics has contributed to the development of drug resistance among S. pneumoniae, H. influenzae, and M. catarrhalis. The U.S. component of the 1998-2000 Alexander Project demonstrated that 12.0% and 25.0% of the S. pneumoniae isolates were penicillin-intermediate and penicillin-resistant, respectively.⁸ Resistance of H. influenzae strains to β-lactam antibiotics by production of β-lactamase has become more prevalent in the U.S. with contemporary percentages of β-lactamase-producing H. influenzae ranging from 33.4% in 1996-1997 to 31.1% in 1997-1998.^9,10 Most clinical isolates of M. catarrhalis produce β-lactamase.^9,10 Although β-lactam antibiotics are still active against M. catarrhalis, rates of trimethoprim/sulfamethoxazole resistance have been reported as high as 50%.¹⁰

Differentiation

Acute Otitis Media
It is important to differentiate between acute otitis media and otitis media with effusion since the latter does not warrant anti-biotic use.7 Acute otitis media is diagnosed when fluid is present in the middle ear with accompanying signs and/or symptoms of acute illness (eg, otorrhea, ear pain, or fever). Physical examination reveals a reddened tympanic membrane or purulence behind a retracted tympanic membrane¹ (Table 2). In contrast, otitis media with effusion, which also involves fluid in the middle ear (amber or clear), is not accompanied by clinical signs or symptoms of infection (fever, ear pain).³

Acute Bacterial Rhinosinusitis
The diagnosis of acute bacterial rhinosinusitis is based on patient symptoms and physical examination. Differentiation, however, from viral rhinosinusitis is challenging without culture data. Symptoms of nasal congestion and postnasal discharge lasting only a few days are more characteristic of viral origin as compared to worsening of the illness after 5 to 7 days or persistence of symptoms for greater than 10 days as typically observed in acute bacterial rhinosinusitis. These symptoms include facial pain/pressure, facial congestion/fullness, nasal obstruction, nasal/postnasal discharge, fever, fatigue, cough and otalgia¹² (Table 3).The presence of discolored nasal secretions does not predictably indicate bacterial infection; diagnostic specificity is only 52%.¹³

The diagnosis of acute bacterial rhinosinusitis in children is more difficult due to frequent episodes of viral upper respiratory tract infections that children experience per year; taking longer to resolve. Early recognition and management of acute bacterial rhinosinusitis are critical in preventing more serious complications associated with acute bacterial rhinosinusitis such as spread of infection to the orbit and meninges.

Treatment Guidelines

Acute Otitis Media
The American Academy of Pediatrics/American Academy of Family Physicians will soon issue new guidelines for the treatment of acute otitis media in children. These new guidelines will lend more support for observation for children 𕟴 years of age with certain diagnosis who are not seriously ill, or children 𕟸 months of age with an uncertain diagnosis but are not seriously ill.¹⁴ For those children in whom antimicrobial therapy is deemed clinically appropriate, the new treatment guidelines will recommend high-dose amoxicillin (90 mg/kg in two divided doses for 5 to 10 days) as the first-line treatment option for acute otitis media.¹⁵ For those patients with a history of non-type-1 or uncertain allergy to β-lactam antibiotics, first-line treament options include cefdinir, cefuroxime axetil, or cefpodoxime. Moreover, the favorable palability of cefdinir suspension^16,17 may enhance compliance in pediatric patients for whom taste and palatability are significant issues. For those patients with severe allergy or history of anaphylaxis to penicillin, alternative treatment options include macrolide or sulfa-based therapy. For treatment failures, recommended treatment options include high-dose amoxicillin/clavulanate, cefdinir, cefuroxime axetil, cefpodoxime, or ceftriaxone (50 mg/kg intramuscularly daily for 1 to 3 days).

Acute Bacterial Rhinosinusitis
There are currently 2 primary treatment guidelines for acute bacterial rhinosinusitis; one from the American Academy of Pediatrics¹⁸ and the second from the Sinus and Allergy Health Partnership⁶ (revisions to be published in January 2004). The American Academy of Pediatrics recommends that in the absence of any risk factors, approximately 80% of children with acute bacterial rhinosinusitis will respond to treatment with amoxicillin. Risk factors likely to indicate amoxicillin resistance include 1) day care attendance, 2) recent (<90 days) antibacterial treatment, and 3) less than 2 years of age.^19,20 For children less than 2 years of age with uncomplicated acute bacterial rhinosinusitis that is mild to moderate in severity in the absence of risk factors, amoxicillin is recommended at either the usual dose of 45 mg/kg in 2 divided doses or high-dose amoxicillin at 90 mg/kg in 2 divided doses. For those patients allergic to penicillin (non-type-1 reaction), cefdinir (14 mg/kg/day), cefuroxime axetil (30 mg/kg/day), or cefpodoxime (10 mg/kg/day) are recommended treatment options. In patients with history of anaphylaxis to β-lactam antibiotics, macrolide or sulfa-based therapy is appropriate. Most patients with acute bacterial rhinosinusitis will respond promptly (within 48 to 72 hours) when treated with an appropriate antibacterial agent with a corresponding diminution of symptoms. For patients not improving with antibacterial treatment, either the agent is ineffective or the diagnosis is not correct.

For those patients not improving with amoxicillin 45 mg/kg/day and accompanying risk factors, therapy should be initiated with high-dose amoxicillin/clavulanate 80 to 90 mg/kg/day in 2 divided doses. Recommended alternative treatment options include cefdinir, cefuroxime axetil, or cefpodoxime.

The optimal duration of therapy for patients with acute bacterial rhinosinusitis has not been systematically studied; empiric recommendations range from 10 to 28 days of therapy. It has been suggested that antibiotic therapy be continued for an additional 7 days after the patient is symptom-free,²¹ resulting in a minimum course of 10 days.

Conclusion

Acute otitis media and acute bacterial rhinosinusitis are similar diseases requiring similar treatments. Antimicrobial resistance to S. pneumoniae, H. influenzae, and M. catarrhalis has greatly challenged physicians treating these diseases. Current treatment guidelines for acute otitis media and acute bacterial rhinosinusitis recommend amoxicillin as initial therapy with soon to be published guidelines recommending high-dose amoxicillin for acute otitis media. For those patients allergic to penicillin (non-type-1), first-line therapy includes cefdinir, cefuroxime axetil, cefpodoxime, or ceftriaxone. For treatment failures, recommended treatment options include high-dose amoxicillin/clavulanate, cefdinir, cefuroxime axetil, cefpodoxime, or ceftriaxone. In those patients for whom taste and palatability are significant issues, cefdinir offers an advantage.

References

1. Parsons DS, Wald ER. Otitis media and sinusitis: similar diseases. Otolaryngol Clin North Am. 1996;29:11-25.
2. McCaig LF, Besser RE, Hughes JM. Trends in antimicrobial prescribing rates for children and adolescents. JAMA. 2002;287:3096-3102.
3. Dowell SF, Marcy SM, Phillips WR, et al. Otitis media: principles of judicious use of antimicrobial agents. Pediatrics. 1998;101(1 suppl):165-171.
4. O'Brien KL, Dowell SF, Schwartz B, et al. Acute sinusitis: principles of judicious use of antimicrobial agents. Pediatrics. 1998;101(1 suppl):174-177.
5. Long SS, Henretig FM, Teter MJ, McGowen KL. Nasopharyngeal flora and acute otitis media. Infect Immun. 1983;41:987-991.
6. Antimicrobial treatment guidelines for acute bacterial rhinosinusitis. Sinus and Allergy Health Partnership. Otolaryngol Head Neck Surg. 2000;123:S4-S32.
7. File TM, Hadley JA. Rational use of antibiotics to treat respiratory tract infections. Am J Manag Care. 2002;8:713-727.
8. Jacobs MR, Felmingham D, Appelbaum PC, Gruneberg RN; The Alexander Project Group. The Alexander Project Group 1998-2000: susceptibility of pathogens isolated from community-acquired respiratory tract infection to commonly used antimicrobial agents. J Antimicrob Chemother. 2003;52:229-246.
9. Thornsberry C, Oglivie P, Kahn J, Mauriz Y. Surveillance of antimicrobial resistance in Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis in the United States in 1996-1997 respiratory season. The Laboratory Investigator Group. Diagn Microbiol Infect Dis. 1997;29:249-257.
10. Richter SS, Brueggemann AB, Huynh HK, et al. A 1997-1998 national surveillance study: Moraxella catarrhalis and Haemophilus influenzae antimicrobial resistance in 34 United States institutions. Int J Antimicrob Agents. 1999;13:99-107.
11. Pichichero ME. Acute otitis media: Part I. Improving diagnostic accuracy. Am Fam Physician. 2000;61:2051-2056.
12. Lanza D, Kennedy D. Adult rhinosinusitis defined. Otolaryngol Head Neck Surg. 1997;117(suppl):S1-S7.
13. Hadley JA, Schaefer SD. Clinical evaluation of rhinosinusitis: history and physical examination. Otolaryngol Head Neck Surg. 1997;117:8-11.
14. Marcy SM. AAP/AAFP Guidelines: Observation as a Management Option. Presented as part of the CME-symposium "New Treatment Guidelines in Acute Otitis Media: An Interactive Dialogue for Practicing Clinicians" held during the American Academy of Pediatrics 2003 National Conference and Exhibition, November 3, 2003, New Orleans, Louisiana.
15. McCracken GH. The Multidrug Resistance Challenge: Selecting the Appropriate Antibiotic. Presented as part of the CME-symposium "New Treatment Guidelines in Acute Otitis Media: An Interactive Dialogue for Practicing Clinicians" held during the American Academy of Pediatrics 2003 National Conference and Exhibition, November 3, 2003, New Orleans, Louisiana.
16. Steele RW, Thomas MP, Begue RE. Compliance issues related to the selection of antibiotic suspensions for children. Pediatr Infect Dis J. 2001;20:1-5.
17. Powers JL, Gooch WM, Oddo LP. Comparison of the palatability of the oral suspension of cefdinir vs amoxicillin/clavulanate potassium, cefprozil and azithromycin in pediatric patients. Pediatr Infect Dis J. 2000;19:S174-S180.
18. Clinical practice guideline: management of sinusitis. Pediatrics. 2001;108:798-808.
19. Block SL, Harrison CJ, Hedrick JA, et al. Penicillin-resistant Streptococcus pneumoniae in acute otitis media: risk factors, susceptibility patterns and antimicrobial management. Pediatr Infect Dis J. 1995;14:751-759.
20. Levine OS, Farley M, Harrison LH, Lefkowitz L, McGeer A, Schwartz B. Risk factors for invasive pneumococcal disease in children: a population-based case-control study in North America. Pediatrics. 1999;103(3). Available at http:www.pediatrics.org/cgi/content/full/103/3/e28. Accessed December 2, 2003.
21. Wald ER. Sinusitis. Pediatr Ann. 1998;27:811-818.

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Disclosure
Amisha Malhotra,MD
No significant relationships to disclose.

Jack B. Anon, MD, FACS
Consultant-Abbott Laboratories, Bayer AG, GlaxoSmithKline; Speakers Bureau-Abbott Laboratories, Bayer AG, GlaxoSmithKline

This report contains no information on commercial products that are unlabeled for use or investigational uses of products not yet approved.

This report is supported by an educational grant from Abbott Laboratories.

The opinions expressed in this publication are those of the participating faculty and do not necessarily reflect the opinions or the recommendations of their affiliated institutions: University of Medicine & Dentistry of New Jersey; MMC, Inc.; or any other persons. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this publication should not be used by clinicians without evaluation of their patients’ conditions, assessment of possible contraindications or dangers in use, review of any applicable manufacturer’s product information, and comparison with the recommendation of other authorities. This Pediatric Press Newsletter does not include discussion of treatment and indications outside of current approved labeling. This Pediatric Press Newsletter was made possible through an educational grant from Abbott Laboratories.

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