Gregory P. DeMuri

Complications of Acute Bacterial Sinusitis in Children

Complications of acute bacterial sinusitis are rare, occurring in <1% of cases. These complications relate directly to the proximity of the paranasal sinuses to the orbit and the brain. Complications may be categorized as orbital, intracranial, and those involving the bone of the frontal sinus. Orbital manifestations may be divided into preseptal or post-septal infections. Outcomes depend on prompt recognition of orbital and intracranial involvement, early intervention with antimicrobials and, when needed, surgical drainage. This chapter reviews the epidemiology, pathophysiology, clinical presentation, microbiology, and therapy of complications of acute bacterial sinusitis in children.

The Group A Streptococcal Carrier State Reviewed: Still an Enigma

Despite the common nature of group A streptococcal (GAS) infections, the carrier state of this organism is not well understood. In this article, we review the historical and recent research on the definition, epidemiology, and pathogenesis of the GAS carrier state. In addition, we outline trials of antimicrobial agents in the eradication of the carrier state and discuss indications for providing treatment to patients in the clinical setting.

Imaging and antimicrobial prophylaxis following the diagnosis of urinary tract infection in children.

Urinary tract infection (UTI) is the most common serious bacterial infection in children, affecting approximately 3% of boys and 11% of girls. The American Academy of Pediatrics (AAP) has published recommendations for management of children with UTI. These guidelines recommend imaging of the urinary tract using ultrasonography and either voiding cystourethrography (VCUG) or radionuclide cystography in all children ages 2 months to 2 years with UTI to detect anomalies or the presence of vesiculoureteral reflux (VUR). When VUR is discovered, prophylactic antimicrobials are prescribed with the intent of preventing further episodes of UTI and subsequent renal scarring. Despite published guidelines, the compliance of practitioners with the AAP guidelines is startlingly low. In the state of Washington, a large survey of children who experienced UTI in the first year of life showed that only 35% received imaging according to the AAP guidelines, while 51% received recommended antimicrobial prophylaxis. Recent guidelines published in the United Kingdom deviate rather dramatically from the AAP guidelines. Ultrasound is recommended only for children with “atypical” or recurrent UTI. Renal scanning with dimercaptosuccinic acid (DMSA) is recommended for children 3 years of age with atypical UTI, and VCUG is not recommended. Antibiotic prophylaxis following a first UTI is also not recommended regardless of the presence of VUR. This review will discuss the use of imaging following first UTI and review the evidence for the use of antimicrobial prophylaxis in children with VUR. Imaging of the urinary tract following infection has several aims: (1) to localize infection, (2) to identify the presence of reflux, (3) to detect renal scarring, or (4) to identify structural anomalies. Hoberman prospectively evaluated 309 children ages 1–24 months with a first febrile UTI. DMSA scanning and ultrasound were performed within 48 hours of diagnosis, and VCUG 1 month after diagnosis. Of the 309 ultrasonograms, 272 (88%) were normal. Abnormal findings included dilated renal pelvis, pelvocaliectasis, hydronephrosis, dilated ureter, duplicated collecting system, extrarenal pelvis, and calculi. However, treatment was not altered by the findings of an abnormal ultrasound. Ultrasound studies were insensitive in the detection of VUR, with a positive predictive value of only 40%. DMSA scanning showed 61% of children had findings compatible with acute pyelonephritis. Follow-up scanning at 6 months showed that the presence of renal scars was associated with the degree of VUR. VCUG was normal in 61% of children with a first febrile UTI. Grade III or higher VUR was found in 17% of the children studied. The authors conclude that ultrasound detects clinically important findings that modify management 1% of the time, particularly in an era when prenatal ultrasound detects most children with hydronephrosis antenatally. VCUG would only be useful if antimicrobial prophylaxis successfully prevents further episodes of infection and eventual renal scarring, an assumption that is being questioned. In this study DMSA scanning was abnormal in the majority of children. Preda prospectively studied 290 children younger than 1 year of age with a documented UTI using DMSA scintigraphy and VCUG to detect VUR. Only 1 child of 141 with a normal DMSA scan had VUR grade III or higher. The positive and negative predictive values for DMSA scintigraphy to detect higher grade VUR were 17% and 99%, respectively. Thus, a negative DMSA scan may help to rule out VUR but is not diagnostic if positive. Moorthy retrospectively reviewed imaging studies in 108 children with UTI. Subjects underwent ultrasound, VCUG, and DMSA studies within 6 months of a first UTI. VUR was diagnosed in 11.6% of kidneys, and scars were found in 3.7%. Only 16% of kidneys with VUR had scarring, and 50% of scarred kidneys had no VUR. The authors showed that when ultrasound was normal there was no correlation between VUR and renal scarring on DMSA scan. In summary, results of ultrasound and DMSA scan provide little guidance to the long-term management of children with UTI. Moreover, VCUG provides benefit only if antibiotic prophylaxis prevents long-term renal scarring. Such prophylaxis has long been recommended for the prevention of UTI in patients with a history of VUR. This recommendation assumes that: (1) chronic antimicrobial administration will prevent UTI, and (2) that the prevention of UTI will prevent renal scarring. These assumptions, however, have recently been challenged in the medical literature. From the Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI Copyright

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.

Macrolide and Clindamycin Resistance in Group A Streptococci Isolated from Children With Pharyngitis.

Group A streptococcus (GAS) is responsible for 15%–30% of cases of acute pharyngitis in children. Macrolides such as azithromycin have become popular for treating GAS pharyngitis. We report macrolide resistance rates in a primary care setting in our geographic area over the past 5 years and discuss the implications of resistance in making treatment decisions. Throat swabs were collected from children with pharyngitis from May 2011 to May 2015 in a primary care setting in Madison, Wisconsin. Susceptibility testing was performed for erythromycin and clindamycin using the Kirby–Bauer disk diffusion method. GAS was identified on 143 throat cultures. Overall, 15% of GAS isolates demonstrated nonsusceptibility for both clindamycin and erythromycin. Inducible resistance (positive D-test) was detected in 17 isolates (12%). The rate of detection of nonsusceptibility in each year of the study did not change over time. Azithromycin should only be used for patients with pharyngitis and substantial manifestations of penicillin hypersensitivity and when used, susceptibility testing should always be performed.

Dynamics of Bacterial Colonization With Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis During Symptomatic and Asymptomatic Viral Upper Respiratory Tract Infection

Abstract Background Virus is detected in about 80% of upper respiratory tract infections (URTIs) in children and is also detectable in the nasopharynx of 30% of asymptomatic children. The effect of asymptomatic viral infection on the dynamics of bacterial density and colonization of the nasopharynx has not been reported. The current study was performed to assess the presence and density of Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis in the nasopharynx of 4–7-year-old children during URTI and when well. Methods Nasal samples were obtained during 4 surveillance periods when children were asymptomatic and whenever they had symptoms of URTI. Respiratory viruses and bacterial pathogens were identified and quantified using polymerase chain reaction. Results The proportion of children colonized with all 3 bacteria was higher during visits for acute URTI than during asymptomatic surveillance visits. Mean bacterial densities were significantly higher at all visits for all 3 pathogens when a virus was detected. The differences between the means were 1.0, 0.4, and 0.7 log10 colony-forming unit equivalents per milliliter for S. pneumoniae, H. influenzae, and M. catarrhalis, respectively, compared with visits in which virus was not detected. The percentage of children colonized and density were also higher at asymptomatic visits in which virus was detected than at visits in which virus was not detected. Conclusion The density and frequency of colonization with S. pneumoniae, H. influenzae, and M. catarrhalis in nasal wash samples increase during periods of both symptomatic and asymptomatic viral infection. Increases in bacterial colonization observed during asymptomatic viral infection were nearly the same magnitude as when children were symptomatic.

Staphylococcal infection mimicking child abuse: what is the differential diagnosis and appropriate evaluation?

Twins with similar skin lesions are described. Although initially concerning for nonaccidental burn injury, further evaluation led to the diagnosis of bullous impetigo caused by Staphylococcus aureus. Thoughtful assessment is important in such cases to protect the child and prevent misdiagnosis.

Microbiology of Acute, Subacute, and Chronic Rhinosinusitis in Children

Acute, subacute, and chronic rhinosinusitis may involve an infectious etiology. Knowledge of the microbiology of sinusitis is necessary because it impacts the choice of antibiotic therapy. The sinus aspirate is the most reliable source of microbiological data in sinusitis in children. However, sinus aspirates are rarely done in cases of patients with rhinosinusitis; the last time one was done in a child was in 1984. When they are done, sinus aspirate studies of children showed the presence of Streptococcus pneumoniae (S. pneumoniae), Haemophilus influenzae, and Moraxella catarrhalis (M. catarrhalis). Unlike sinus aspirates, nasopharyngeal and middle meatal cultures are not reliable in determining the bacteriology of children with acute sinusitis. The observation of an increase in the proportion of cases of acute otitis media caused by H. influenzae may reflect that in acute sinusitis as well. Staphylococcus aureus does not play a significant role in uncomplicated acute bacterial sinusitis. The microbiology of acute otitis media can be used as a surrogate for that of acute bacterial sinusitis in children. In contrast to bacteria, the contribution of viruses to the pathogenesis of acute bacterial sinusitis has not been studied systematically. The pathogenesis of chronic sinusitis may be related to bacterial biofilms as a stimulant of chronic inflammation.