Acute Bacterial Sinusitis Addressed in New AAP Guidelines

Laurie Barclay, MD

June 24, 2013

Acute bacterial sinusitis may now be diagnosed in a child with upper respiratory infection (URI) and worsening symptoms after initial improvement, according to updated guidelines from the American Academy of Pediatrics (AAP), published online June 24 in Pediatrics. The new clinical practice guideline addresses diagnosis and judicious antibiotic use, updating the 2001 AAP guideline based on a review of the medical literature since publication of the previous recommendations.

"Acute bacterial sinusitis is a common complication of viral [URI] or allergic inflammation," write Ellen R. Wald, MD, and colleagues from the AAP. "Using stringent criteria to define acute sinusitis, it has been observed that between 6% and 7% of children seeking care for respiratory symptoms [have] an illness consistent with this definition."

Previous criteria for acute bacterial sinusitis in children were acute URI with either nasal discharge and/or daytime cough for longer than 10 days or severe onset of fever (≥39°C/102.2°F), purulent nasal discharge, and other respiratory symptoms for 3 or more consecutive days. A third criterion added to the 2013 guideline is URI with worsening symptoms such as nasal discharge, cough, and fever after initial improvement.

Another change in the updated guideline is that physicians may now observe children with persistent infection lasting longer than 10 days for an additional 3 days before prescribing antibiotics, whereas the 2001 guideline recommended antibiotics for all children diagnosed with acute bacterial sinusitis. However, antibiotics should still be given to children with severe onset or worsening symptoms.

Management Recommendations

First-line therapy for acute bacterial sinusitis is amoxicillin with or without clavulanate. If symptoms worsen or do not improve after 72 hours, another antibiotic may be substituted.

If the caregiver reports progression of initial signs and symptoms or appearance of new signs and symptoms, or if the child fails to improve within 72 hours of initial management, clinicians should reevaluate initial management and change or start antibiotics if indicated.

The AAP does not recommend imaging tests for children with uncomplicated acute bacterial sinusitis, based on their evidence review, because these tests do not distinguish acute bacterial sinusitis from viral URI. However, children with suspected orbital or central nervous system complications should undergo contrast-enhanced computed tomography scanning of the paranasal sinuses.

"Changes in this revision include the addition of a clinical presentation designated as 'worsening course,' an option to treat immediately or observe children with persistent symptoms for 3 days before treating, and a review of evidence indicating that imaging is not necessary in children with uncomplicated acute bacterial sinusitis," the guidelines authors conclude.

Underlying Evidence

In an accompanying technical report, coauthor Michael J. Smith, MD, MSCE, assistant professor of pediatrics, Division of Pediatric Infectious Diseases, University of Louisville School of Medicine, Kentucky, notes that data are limited regarding the diagnosis and management of acute bacterial sinusitis in children. Four placebo-controlled studies of antibiotic treatment in children with acute sinusitis yielded varying results, likely because of varying inclusion and exclusion criteria. Although heterogeneity precluded formal meta-analyses, qualitative analysis suggested that children presenting with greater severity of illness were more likely to benefit from antimicrobial therapy

"It is clear that some children with sinusitis benefit from antibiotic use and some do not," Dr. Smith writes. "Diagnostic and treatment guidelines focusing on severity of illness at the time of presentation have the potential to identify children who will benefit from therapy and at the same time minimize unnecessary use of antibiotics."

The AAP supported development of these guidelines. Dr. Smith has reported receiving financial support from Sanofi Pasteur and Novartis, and one coauthor is employed by McKesson Health Solutions. The remaining authors have disclosed no relevant financial relationships.

Pediatrics. Published online June 24, 2013. Guidelines full text, Technical report full text

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