Signs of infection

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Workup

The American Academy of Pediatrics guidelines for criteria for a diagnosis of bacterial sinusitus are available. Though sinusitis is a clinical diagnosis and imaging is not specific and discouraged, diagnosis of sinusitis complications (eg, CVT) requires CT or MR venography.$^{35,36}$

Orbital cellulitis is a clinical diagnosis, but imaging such as a contrast-enhanced CT or MRI is confirmatory and can guide management, especially if there is concern for abscess formation.$^{37}$ Additional workup includes basic laboratory tests, such as a CBC, inflammatory markers, and blood culture.

Initial Treatments

Uncomplicated bacterial sinusitis is treated with oral amoxicillin or amoxicillin-clavulanate.$^{32}$ Initial treatment for complications such as Pott puffy tumor, CVT, and orbital cellulitis usually involves prolonged courses of broad-spectrum IV antibiotics that provide coverage for the most common pathogens, including anaerobic bacteria, and adequate blood-brain barrier penetration. Typically, vancomycin, a third-generation cephalosporin, and metronidazole are used. Surgical intervention for drainage is often necessary in conjunction with antimicrobial treatments.$^{30,33}$ Most pediatric patients with CVT are treated with anticoagulation, such as low-molecular-weight heparin. While studies have shown favorable cognitive outcomes and a slight decrease in mortality, treatment remains controversial. CVT also may be treated adjunctively with corticosteroids.$^{20,30,35-37}$

The clinical presentation of intracranial infection is often in conjunction with other signs of systemic illness, such as fever, fatigue, nausea, and vomiting. Headaches are often holocranial, with pain radiating down the back of the neck. Classically, meningitis also presents with nuchal rigidity and photophobia.$^{30}$ Having a positive Kernig or Brudzinski test on physical examination or a bulging fontanelle can also support the diagnosis of meningitis; however, these findings may not be present in all meningitis cases.$^{31}$ In contrast, encephalitis can present with nonfocal neurologic deficits, seizures, and/or altered mental status. In the neonatal population, the clinical features of intracranial infection can be subtle and nonspecific, such as fussiness or decreased oral intake.$^{26}$