Anon Jack B
Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213, USA.
Paediatr Drugs. 2003;5 Suppl 1:25-33.
In children, acute bacterial rhinosinusitis is a common infection and although rare, carries a potential for serious, life threatening complications. Bacterial rhinosinusitis usually follows a viral infection or allergic rhinitis. Early, effective antibacterial therapy is essential to shorten the duration of infection and illness, to diminish mucosal damage, and to prevent contiguous infectious involvement of the orbit or central nervous system. Because the signs and symptoms of acute bacterial rhinosinusitis are similar to those of viral upper respiratory tract infection, establishing an accurate diagnosis in children poses a clinical challenge. Infection with Streptococcus pneumoniae accounts for 30-66% of episodes of acute bacterial rhinosinusitis in children. Other important pathogens include Haemophilus influenzae (20-30%) and Moraxella catarrhalis (12-28%). In selecting initial antimicrobial therapy, priority should be given to drugs with activity against S. pneumoniae. The oral agents that currently offer the greatest activity against this pathogen include amoxicillin, amoxicillin-clavulanate, cefdinir, cefpodoxime proxetil, and cefuroxime axetil; all are considered appropriate for the initial treatment of acute bacterial rhinosinusitis in children. Amoxicillin is customarily used as first-line therapy for uncomplicated acute bacterial rhinosinusitis. For patients who are allergic to amoxicillin, second- or third-generation oral cephalosporins may be used as first-line therapy. Clarithromycin has been suggested as an alternative to amoxicillin or cephalosporins in beta-lactam allergic patients. Clindamycin may also be indicated as first-line treatment in patients who have culture-proven penicillin-resistant S. pneumoniae. If no clinical response occurs within 72 hours, the choice of a second-line antibiotic is governed by the drug's known antimicrobial efficacy, resistance patterns, dosing schedules, the potential for compliance, and knowledge of the patient's drug allergies. High-dose amoxicillin-clavulanate (90 mg/kg/d of the amoxicillin component) has been recommended for high-risk children (e.g. those in day care, and those who have recently received antibiotics) who show no improvement after treatment with the usual dose of amoxicillin (45 mg/kg/d). Broad-spectrum, third-generation oral cephalosporins, such as cefdinir, should be considered as second-line agents when standard therapy has failed or when patients show hypersensitivity to penicillin. Intramuscular ceftriaxone may be appropriate for patients who fail on a second course of antibiotic treatment.
在儿童中，急性细菌性鼻窦炎是一种常见的感染性疾病，虽然罕见，但有引发严重的、危及生命的并发症的可能。细菌性鼻窦炎通常继发于病毒感染或过敏性鼻炎之后。早期、有效的抗菌治疗对于缩短感染病程、减轻黏膜损伤以及预防眼眶或中枢神经系统的邻近感染扩散至关重要。由于急性细菌性鼻窦炎的体征和症状与病毒性上呼吸道感染相似，因此在儿童中做出准确诊断面临临床挑战。肺炎链球菌感染占儿童急性细菌性鼻窦炎发作的30% - 66%。其他重要病原体包括流感嗜血杆菌（20% - 30%）和卡他莫拉菌（12% - 28%）。在选择初始抗菌治疗时，应优先选用对肺炎链球菌有活性的药物。目前对该病原体活性最强的口服药物包括阿莫西林、阿莫西林 - 克拉维酸、头孢地尼、头孢泊肟酯和头孢呋辛酯；所有这些药物都被认为适用于儿童急性细菌性鼻窦炎的初始治疗。阿莫西林通常用作无并发症的急性细菌性鼻窦炎的一线治疗药物。对于对阿莫西林过敏的患者，第二代或第三代口服头孢菌素可作为一线治疗药物。在对β - 内酰胺类过敏的患者中，克拉霉素已被建议作为阿莫西林或头孢菌素的替代药物。对于经培养证实对青霉素耐药的肺炎链球菌感染患者，克林霉素也可作为一线治疗药物。如果在72小时内没有临床反应，二线抗生素的选择取决于药物已知的抗菌疗效、耐药模式、给药方案、患者的依从性以及对患者药物过敏情况的了解。对于高风险儿童（如日托儿童以及近期接受过抗生素治疗的儿童），在使用常规剂量阿莫西林（45mg/kg/d）治疗后无改善的情况下，推荐使用高剂量阿莫西林 - 克拉维酸（阿莫西林成分90mg/kg/d）。当标准治疗失败或患者对青霉素过敏时，广谱第三代口服头孢菌素如头孢地尼应被视为二线药物。对于抗生素第二疗程治疗失败的患者，肌内注射头孢曲松可能是合适的。
