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PEDIATRICS Vol. 109 No. 3 March 2002, pp. 557-558

Sinuses, Staph, Strep, Patients, and Families

To the Editor.—

In the "Clinical Practice Guideline: Management of Sinusitis,"¹ it states that Streptococcus aureus is not a pathogen of concern. It seems likely that this was an error compounding Streptococcus pyogenes and Staphylococcus aureus, which both were left out of the list of pathogens of concern. It is surprising that these two bacteria are "not of concern."

Wald² cites S pyogenes as a cause of 2% to 5% of sinus infections. And (since the guidelines state at the outset that "the pathogenesis and microbiology of acute otitis media and acute bacterial sinusitis are similar") Wald’s group³ found 6% of otitis media isolates to be S aureus. Brook⁴ in one study finds 10 of 48 isolates of S aureus. And in another study, Brook⁵ finds 5 of 43 isolates of S pyogenes and 3 of 43 of S aureus.

Cultures of individuals and their families, cared for in continuity in a solo family practice,⁶ show a similar role of S pyogenes and of S aureus in varying manifestations of upper respiratory infection, including acute sinusitus and acute otitis media. But these pathogens, after being introduced to the family, are often seen moving back and forth within the family, with varied and different manifestations in each individual, often in recurrent cycles.

S aureus can have a different range of antibiotic susceptibilities than S pneumoniae, Haemophilus influenzae, and Moraxella. S pyogenes Group A has a different set of possible late sequelae.

Why would the guidelines leave out these pathogens? Should we not be getting cultures and sensitivities whenever possible to know as best as possible how to treat the specific patient? And what should be the focus of our diagnostic and treatment efforts—the sinus, the upper respiratory system, the whole patient? Or are we not often seeing treatment failure because our focus misses the reservoir of pathogens in the family?

Henry R. Bloom, MD, CCFP, ABFP^*,
* Private Practice
Cleveland Heights, OH, USA 44106
Case Western Reserve University School of Medicine
Department of Family Medicine
Cleveland, OH 44106, USA

REFERENCES

1. American Academy of Pediatrics, Subcommittee on Management of Sinusitis and Committee on Quality Improvement. Clinical practice guidelines: management of sinusitis. Pediatrics.2001; 108 :798 –808[Abstract/Full Text]
2. Wald ER. Management of sinusitis in infants and children. Pediatr Infect Dis J.1998; 7 :449 –452
3. Andrade MA, Hoberman A, Glustein J, Paradise JL, Wald ER. Acute otitis media in children with bronchiolitis. Pediatrics.1998; 101 :617 –620[Abstract/Full Text]
4. Brook I, Yocum P, Shah K. Aerobic and anaerobic bacteriology of concurrent chronic otitis media with effusion and chronic sinusitis in children. Arch Otolaryngol Head Neck Surg.2000; 126 :174 –176[Medline]
5. Brook I, Gober AE. Microbiologic characteristics of persistent otitis media. Arch Otolaryngol Head Neck Surg.1998; 124 :1350 –1352[Medline]
6. Bloom H, Zyzanski S, et al. Clinical judgement predicts culture results in upper respiratory infections. An epidemiological study of familial diagnosis and treatment in a solo family practice. JABFP. In press

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In Reply.—

It is very regretful that the typographical error that you noted appeared in the clinical practice guideline.¹ The correction appeared in an erratum published in the November 2001 issue. It is very unfortunate that the error could not be corrected in a more timely fashion. The particular organism that is being designated is Staphylococcus aureus. I can state with confidence that S aureus was never recovered from more than 100 sinus aspirates performed on children with acute, subacute, and recurrent acute sinusitis.^1–3 Accordingly, it is a rare pathogen in children with acute sinus infection. The guidelines only deal with acute, subacute, and recurrent acute sinusitis. S aureus may have a more prominent role in children and adults with chronic or persistent infection of their paranasal sinuses or ears that you referenced in the Brook studies.^4,5 It is important to note that in contrast to the infrequent recovery of S aureus from aspirates of the sinus cavities, it is a very common inhabitant of the nose. Accordingly, it is necessary to be fastidious in the collection of sinus specimens so as to avoid possible contamination from the normal inhabitants of the nose.

S pyogenes is responsible for 3% to 4% of episodes of acute bacterial sinusitis and acute otitis media.¹ As such, it is a minor cause of these 2 syndromes. It is probably more important as a cause of diffuse mucosal inflammation that predisposes to acute otitis media and acute sinusitis than as a cause of the syndromes themselves.⁶

A LOST OPPORTUNITY

"It is a pity that neonatologists who carefully and methodically evaluated surfactant treatment before its widespread use in clinical practice failed to do the same with postnatal corticosteroids."

Halliday HL. Postnatal steroids: a dilemma for the neonatologist. Acta Paediatr. 2001;90:116–118

Submitted by Student

Ellen R. Wald, MD
Department of Pediatrics and Otolaryngology
University of Pittsburgh School of Medicine
Division of Allergy, Immunology and Infectious Diseases
Children’s Hospital of Pittsburgh
Pittsburgh, PA, USA 15213-2583

REFERENCES

1. Wald ER, Milmoe GJ, Bowen A, Ledesma-Medina J, Salamon N, Bluestone CD. Acute maxillary sinusitis in children. N Engl J Med.1981; 304 :749 –754[Abstract]
2. Wald ER, Reilly JS, Casselbrant M, et al. Treatment of acute maxillary sinusitis in childhood: a comparative study of amoxicillin and cefaclor. J Pediatr.1984; 104 :297 –302[Medline]
3. Wald ER, Byers C, Guerra N, Casselbrant M, Beste D. Subacute sinusitis in children. J Pediatr.1989; 115 :28 –32[Medline]
4. Brook I, Yocum P, Shah K. Aerobic and anaerobic bacteriology of concurrent chronic otitis media with effusion and chronic sinusitis in children. Arch Otolaryngol Head Neck Surg.2000; 126 :174 –176[Medline]
5. Brook I, Gober AE. Microbiologic characteristics of persistent otitis media. Arch Otolaryngol Head Neck Surg.1998; 124 :1350 –1352[Medline]
6. Wald ER, Chiponis D, Ledesma-Medina J. Comparative effectiveness of amoxicillin and amoxicillin-clavulanate potassium in acute paranasal sinus infections in children: a double-blind, placebo-controlled trial. Pediatrics.1986; 77 :795 –800[Abstract]

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PEDIATRICS (ISSN 1098-4275). ©2002 by the American Academy of Pediatrics

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This Article Extract Full Text (PDF) Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services E-mail this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Request Permissions Citing Articles Citing Articles via CrossRef Citing Articles via Google Scholar Google Scholar Articles by Bloom, H. R. Articles by Wald, E. R. Search for Related Content PubMed PubMed Citation Articles by Bloom, H. R. Articles by Wald, E. R. Related Collections Related AAP Red Book topics: Haemophilus influenzae Infections Social Bookmarking                         What's this?