Other CNS Infections Goals of Treatment The goal is to rapidly identify infections which may result in intracranial extension, and to recognize that the empiric antibiotic selection in these cases must include antibiotics that are both bactericidal and achieve adequate CNS penetrance CLINICAL PEARLS AND PITFALLS The most common comorbidity in children with brain abscesses is congenital heart disease Staphylococci and streptococci are the most common organisms isolated One common regimen to treat suspected CNS invasion from contiguous structures is the combination of vancomycin, ceftriaxone or cefotaxime, and metronidazole, all at meningitic doses If multiply resistant gram-negative organisms have been isolated from a child previously, empiric meropenem can be considered after consultation with infectious diseases Fewer data exist for other antibiotics (e.g., piperacillin-tazobactam, ampicillin-clavulanate) crossing the blood–brain barrier Brain Abscesses Brain abscesses can result from contiguous spread from head and neck infections (e.g., mastoiditis, sinusitis, odontogenic) or from direct seeding from septic emboli, most commonly in children with congenital heart disease The latter remains the most common risk factor for pediatric brain abscesses The most common organisms are streptococci (aerobic and anaerobic streptococci, GAS, and pneumococcus) and S aureus, followed by fungal (primarily Aspergillus ) and Enterobacteriaceae Early symptoms are nonspecific and can include fever, malaise, vomiting, and headache The most common signs are focal neurologic deficits (particularly cranial nerve VI), papilledema, meningeal signs, hemiparesis, and ataxia, although symptoms will vary by abscess location (cerebral hemisphere is the most common location) and size Mental status changes are late signs with ominous prognoses LP rarely yields an organism, and blood cultures infrequently are positive ED-based diagnosis can be made by contrast CT of the brain, although magnetic resonance imaging (MRI) will better delineate brainstem and cerebellar abscesses Early neurosurgical intervention is critical Empiric antibiotics should be broad-spectrum antibiotics with CNS penetrance covering staphylococci, streptococci, and anaerobes One regimen would be vancomycin, cefotaxime, and metronidazole, all at meningitic doses Standard precautions should be used Acute Flaccid Paralysis Acute flaccid myelitis (AFM) has historically been caused by polio, transmitted via the fecal–oral route Polio is now only endemic in Afghanistan and Pakistan More recently, other enteroviruses (A71, D68), adenovirus, herpesviruses, and flaviviruses have been causing AFM on an every-other-year pattern A prodromal upper respiratory tract infection, with or without pyrexia, is often noted within weeks of the development of acuteonset extremity weakness MRI shows gray matter spinal cord lesions and a CSF pleocytosis often is noted The differential diagnosis includes acute transverse myelitis and Guillain–Barré syndrome In addition to routine studies on CSF, PCR for enteroviruses, EBV, CMV, HSV, and arboviruses should be considered Sinusitis Sinusitis is an inflammation of the paranasal sinuses While the ethmoid and maxillary sinuses are present at birth, the frontal and sphenoid sinuses not develop until children are school aged The most common etiologies mimic those causing acute otitis media and include pneumococcus, nontypeable H influenzae, Moraxella, and GAS The most common signs and symptoms of acute sinusitis are listed in e-Table 94.3 Children with chronic sinusitis can have milder, more indolent symptoms, such as cough that is often worse when the child is supine and rhinorrhea; pyrexia is less common in this group of children, and physical examination often is normal The diagnostic criteria are summarized in e-Table 94.4 Complications of sinusitis include orbital cellulitis, brain abscess, epidural or subdural empyema, and cavernous sinus thrombosis Most sinusitis is managed solely with medical therapy in the outpatient setting Amoxicillin (80 to 90 mg/kg/day) remains the mainstay of therapy; a 10-day course is recommended for most cases of uncomplicated acute sinusitis Two- to 3-week courses may be needed for chronic sinusitis or for immunocompromised or