International Journal of Pediatric Otorhinolaryngology Extra
Volume 3, Issue 3 , Pages 113-116, September 2008

Two cases of extraordinary chronic rhinosinusitis in pediatrics: Take care of antibiotic overprescribing in primary care

  • Bulent M. Ertugrul

      Affiliations

    • Department of Infectious Diseases and Clinical Microbiology, Adnan Menderes University, School of Medicine, Aydın, Turkey
    • Corresponding Author InformationCorresponding author. Tel.: +90 532 645 66 21; fax: +90 256 214 64 95.
    • ,
  • Okay Basak

      Affiliations

    • Department of Family Practice, Adnan Menderes University, School of Medicine, Aydın, Turkey
    • Tel.: +90 256 2121850.
    • ,
  • Mete Eyigor

      Affiliations

    • Department of Microbiology and Clinical Microbiology, Adnan Menderes University, School of Medicine, Aydın, Turkey
    • Tel.: +90 256 2120020 415.
    • ,
  • Ayşe Yenigun

      Affiliations

    • Department of Pediatrics, Adnan Menderes University, School of Medicine, Aydın, Turkey
    • Tel.: +90 256 4441256.
    • ,
  • Sema Basak

      Affiliations

    • Department of Otolaryngology, Adnan Menderes University, School of Medicine, Aydın, Turkey
    • Tel.: +90 533 7693146.

Received 31 October 2007; received in revised form 29 December 2007; accepted 5 January 2008. published online 07 March 2008.

Article Outline

Summary 

Two cases of pediatric chronic rhinosinusitis with Pseudomonas aeruginosa as pathogen organism are presented. Both children had gastroesophageal reflux and one of them was allergic. The results of sweat test were within normal limits. Cystic fibrosis transmembrane conductance regulator mutations were not identified in the patients. They had been treated a lot of times with antimicrobial agents with the diagnosis of respiratory tract infection. We suggest that the frequent use of antibiotics has led to the selective suppression and as a result P. aeruginosa has been detected as the cause of chronic rhinosinusitis in otherwise healthy children.

Keywords: Children, Chronic rhinosinusitis, Pseudomonas aeruginosa, Overprescribing antibiotics

 

Pediatric chronic rhinosinusitis is a frequent infectious disease that is poorly understood [1]. A major drawback for a better understanding of the disease is that there are numerous risk factors associated with chronic rhinosinusitis in children such as allergy, adenoid vegetation, gastroesophageal reflux (GER), immunedeficiency, and cystic fibrosis (CF) [2]. The spectrum of aerobic and anaerobic patogens of pediatric chronic rhinosinusitis, like its adult counterpart, appears well-established [1]. Coagulase-negative Staphylococcus, alphastreptococci, diphtheroids and Staphylococcus aureus are the most commonly encountered pathogens of chronic rhinosinusitis as well as Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis found in acute rhinosinusitis [1]. In recent years, Pseudomonas aeruginosa has more frequently been reported as the cause of rhinosinusitis in adults [3], [4], [5], [6]. On the other hand, there is no case series in the literature that P. aeruginosa is reported as the cause of rhinosinusitis in otherwise healthy children. In this article, we present two cases of pediatric chronic rhinosinusitis with P. aeruginosa as pathogen organism, and discuss the reasons of P. aeruginosa being the cause of chronic rhinosinusitis in otherwise healthy children.

Back to Article Outline

1 Two case presentations 

1.1 Case 1 

A 3-year-old boy applied several times to primary care with the complaints of cough and nasal discharge in 2003. He was prescribed antibiotics as cures of 2–3 weeks for eight times with the diagnosis of upper respiratory tract infection (acut rhinosinusitis, tonsillitis, etc.) in 1 year. According to his health records, antibiotics like amoxicillin-clavunat, sefuroxim axetil, ampiciline sulbactam, sefaclor, amoxicillin, and azitromycine were administered to him in short intervals. Because the complaints of cough and abundent purulent discharge persisted, he was brought to the pediatrics outpatient clinic of medical school at Adnan Menderes University in January of 2004. Physical examination at pediatrics clinic revealed no abnormalities except the finding of nasal and postnasal purulent discharge. The result of sweat test was in normal limits. An immunodeficiency was ruled out by his normal serum immunoglobulin levels. A reflux attack extending to the proximal esophagus was observed at the 11th minute in scintigraphy. Among aeroallergens cocksfoot (g3) was reported as 1 positive and cladosporium herbarum (M2) as 2 positive, whereas food allergens were negative. Oral antibiotics were empirically administered as five cures at the period till May 2004. In addition to the antibiotics domperidon and ketotiphen were used. A few weeks later, since cough, nasal congestion and nasal discharge persisted, the patient was consulted to the department of otolaryngology. Otolaryngologic examination revealed abundent purulent nasal discharge and endoscopically directed middle meatal aspiration culture by Juhn-Tym Tab (Xomed®) was obtained under sedation [7].

The culture grew P. aeruginosa, sensitive to the piperacillin, mesocillin, sephepim, sephtazidim and gentamicin. The department of infectious diseases and clinical microbiology was consulted and IV sephepim (100mg/kg/day) was started for 15 days with complete improvement. Since the culture grew P. aeruginosa, cystic fibrosis transmembrane conductance regulator (CFTR) mutations were screened using molecular diagnostic test, however no obvious disease-related mutations were identified in the patient. The patient had no further problems with sinus infections in 1 year follow-up except for an acute otitis media episode.

1.2 Case 2 

A 5 year-old boy applied to the otolaryngology clinics in March 2005 with a 2-month history of nasal congestion, thick nasal discharge and hyponasal speech. He was born in France, and admitted to a hospital with the diagnosis of bronchiolitis when he was 2 months old. He underwent two adenoidectomy operations, first in France when he was 18 months old and second in Turkey when he was 4 years old. In 2004 he had been treated over 10 times with a variety of oral antimicrobial agents (a few weeks each time) with the diagnosis of respiratory tract infection. Amoxicillin-clavunat, sefuroxim axetil, ampicillin-sulbaktam and sephaclor were among the antibiotics prescribed. Within the period of 1 year, the patient had been admitted to a hospital and IV antibiotic given for 10 days with the diagnosis of pneumonia. Nasal examination revealed purulent discharge in the right nasal passage. The result of sweat test was within normal limits. An immunodeficiency was ruled out by his normal serum immunoglobulin levels. Aeroallergens and food allergens were negative. A reflux attack extending to the proximal esophagus was observed at the 6th and 13th minute in scintigraphy. Amoxicillin-clavunat was orally given to the patient and adenotonsillectomy was recommended. Because of continuing nasal discharge, the dosage of the amoxicillin was increased at the 2nd week of treatment. At the 5th week, nasal discharge was thought to be ceased on anterior rhinoscopy and the patient was taken to the operation. Nasal endoscopic examination performed before starting the operation revealed adenoid tissue obstructing both nasal choana in addition to purulent discharge in both middle meatus. Material for culture was obtained from the right nasal passage by Juhn-Tym Tab (Xomed®). The culture grew P. aeruginosa and the patient was started on meropenem (500mg t.i.d) and amicacin (500mg/day). In addition to the antibiotics domperidon was used. Within 10 days the nasal prulence resolved and he has been free of sinus infection since then. Since the culture grew P. aeruginosa, CFTR mutations were screened using molecular diagnostic test, but no obvious disease-related mutations were identified in the patient.

Back to Article Outline

2 Discussion 

P. aeruginosa is not a common cause of community acquired infections in children. It is generally grown in the cultures obtained from the patients who have other diseases like CF, chronic bronchitis, immunodeficiency, etc. There is one case of chronic sinusitis reported in the literature but it is not certain whether P. aeruginosa was grown in otherwise healthy child or not (Orobello 1991).

Recently, it has been suggested that there is an increased occurrence of CFTR mutations in children who have chronic rhinosinusitis and do not meet diagnostic criteria for CF. So the CFTR gene mutations should be investigated as a predisposing factor for chronic rhinosinusitis even in the absence of overt CF [8], [9]. On the other hand, according to Hytonen et al. routine screening of patients for CFTR gene mutations provides no additional information on the etiology of chronic rhinosinusitis [10]. Since P. aeruginosa was the pathogen of chronic rhinosinusitis we screened for mutations in the CFTR gene in both of the patients with no obvious mutations.

How can we explain that P. aeruginosa, which is not a common cause of community acquired infections, leads to rhinosinusitis in a healthy child? This question can be answered in relation to the question of Slack et al. [1]. They ask what role the overprescription of antibiotics for acute respiratory disease has in increasing selection pressure for resistant strains and emphasize that broad spectrum antibiotics are increasingly prescribed for upper respiratory tract infections in primary care. There are some other studies which have indicated that irrational use and overprescription of antibiotics in primary care has increased [11], [12]. Larsson et al. have put forward that self antibiotic medication by patients and antibiotic overprescribing by doctors lead to the development of resistance among respiratory pathogens [11]. It is a well known fact that the high rate of antibiotic use forms resistant microorganisms through selective pressure and this fact has experimentally been proven [13], [14], [15], [16]. The frequent and overdose use of antibiotics leads to disappearance of the easy treatable and sensitive community-acquired bacterias, and the respiratory flora which is a natural barrier against infections.

As a result, respiratory tract colonization and infection occur by different and resistant bacterias which are not expected to form community acquired infection. In both of the cases presented here, it is striking that there exists overuse of antibiotics in recent years with the diagnosis of upper respiratory tract infection. In Turkey, drugs which are so important and mass deaths may occur in the lack of them are unfortunately available from pharmacies without a prescription. Antibiotics are within this group of drugs as well. The antibiotic expectation of patients and the pressure on doctors for prescribing antibiotics are considerably high.

In Turkey, the cost of drug consumption was 3 billion dollars in 2002, whereas this number increased to 4.2 billion dollars in 2003, with an increase rate of %40 in a year [17]. Another study indicated that over 115 million boxes of antibiotic were used in Turkey in the first 10 months of 2001 and the total cost was nearly 400 million dollars [18]. Turkey was the second in the world among the countries with a rapidly growing drug marketing in 2003 [17].

The use of antibiotics without any indication, e.g. in the absence of infection or bacterial agents, is among the most important reasons of frequent and irrational use of antibiotics. These mistakes of usage are generally seen in the treatment of upper respiratory tract infections in primary care. In conclusion, we suggest that the frequent use of antibiotics has led to the selective suppression and as a result P. aeruginosa has been detected as the cause of chronic rhinosinusitis in two otherwise healthy children, while it is not commonly expected to be a cause of infection in the community.

Back to Article Outline

References 

  1. Slack CL, Dahn KA, Abzug MJ, Chan KH. Antibiotic-resistant bacteria in pediatric chronic sinusitis. Pediatr. Infect. Dis. J. 2001;20:247–250
  2. Steele RW. Chronic sinusitis in children. Clin. Pediatr. (Phila.). 2005;44:465–471
  3. Yildirim A, Oh C, Erdem H, Kunt T. Bacteriology in patients with chronic sinusitis who have been medically and surgically treated. Ear Nose Throat J. 2004;83:836–838
  4. Brook I. Bacteriology of acute and chronic sphenoid sinusitis. Ann. Otol. Rhinol. Laryngol. 2002;111:1002–1004
  5. Fried MP, Kelly JH, Strome M. Pseudomonas rhinosinusitis. Laryngoscope. 1984;94:192–196
  6. Koltai PJ, Maisel BO, Goldstein JC. Pseudomonas aeruginosa in chronic maxillary sinusitis. Laryngoscope. 1985;95:34–37
  7. Gold SM, Tami TA. Role of middle meatus aspiration culture in the diagnosis of chronic sinusitis. Laryngoscope. 1997;107:1586–1589
  8. Raman V, Clary R, Siegrist KL, Zehnbauer B, Chatila TA. Increased prevalence of mutations in the cystic fibrosis transmembrane conductance regulator in children with chronic rhinosinusitis. Pediatrics. 2002;109:E13
  9. Wang X, Kim J, McWilliams R, Cutting GR. Increased prevalence of chronic rhinosinusitis in carriers of a cystic fibrosis mutation. Arch. Otolaryngol. Head Neck Surg. 2005;131:237–240
  10. Hytonen M, Patjas M, Vento SI, Kauppi P, Malmberg H, Ylikoski J, et al. Cystic fibrosis gene mutations deltaF508 and 394delTT in patients with chronic sinusitis in Finland. Acta Otolaryngol. 2001;121:945–947
  11. Larsson M, Falkenberg T, Dardashti A, Ekman T, Tornquist S, Kim Chuc NT, et al. Overprescribing of antibiotics to children in rural Vietnam. Scand. J. Infect. Dis. 2005;37:442–448
  12. Akkerman AE, Kuyvenhoven MM, van der Wouden JC, Verheij TJ. Determinants of antibiotic overprescribing in respiratory tract infections in general practice. J. Antimicrob. Chemother. 2005;56:930–936
  13. Gaynes R. The impact of antimicrobial use on the emergence of antimicrobial-resistant bacteria in hospitals. Infect. Dis. Clin. North Am. 1997;11:757–765
  14. O’Brien TF. The global epidemic nature of antimicrobial resistance and the need to monitor and manage it locally. Clin. Infect. Dis. 1997;1(Suppl.):S2–S8
  15. Veldkamp H, Harder VGH, Laanbroek HJ W. Competition among bacteri: an overview. In:  Klug MJ,  Reddy CA editor. Current Perspectives in Microbial Ecology. Washington DC: American Society for Microbiology; 1984;pp. 279–290
  16. Doganci L. Antibiyotik direncinin sikligi uzerine antibiyotik kullaniminin etkisi. Klimik Derg. 2001;14:57–61
  17. Ucer A. Ilacta cozum onerileri. Cumhuriyet Bilim Teknik Derg. 2004;9:7
  18. Cakir N. Rasyonel olmayan antibiyotik kullaniminin ekonomik sonuclari. Klimik Derg. 2001;14:35–40

PII: S1871-4048(08)00002-6

doi:10.1016/j.pedex.2008.01.006

International Journal of Pediatric Otorhinolaryngology Extra
Volume 3, Issue 3 , Pages 113-116, September 2008

Article Tools