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Transcript of CLINICAL PRACTICE GUIDELINE Clinical Practice Guideline ... · PDF fileCLINICAL PRACTICE...


Clinical Practice Guideline for the Diagnosis andManagement of Acute Bacterial Sinusitis in ChildrenAged 1 to 18 Years

abstractOBJECTIVE: To update the American Academy of Pediatrics clinicalpractice guideline regarding the diagnosis and management of acutebacterial sinusitis in children and adolescents.

METHODS: Analysis of the medical literature published since the lastversion of the guideline (2001).

RESULTS: The diagnosis of acute bacterial sinusitis is made when a childwith an acute upper respiratory tract infection (URI) presents with (1)persistent illness (nasal discharge [of any quality] or daytime cough orboth lasting more than 10 days without improvement), (2) a worseningcourse (worsening or new onset of nasal discharge, daytime cough, orfever after initial improvement), or (3) severe onset (concurrent fever[temperature 39C/102.2F] and purulent nasal discharge for at least3 consecutive days). Clinicians should not obtain imaging studies of anykind to distinguish acute bacterial sinusitis from viral URI, because theydo not contribute to the diagnosis; however, a contrast-enhancedcomputed tomography scan of the paranasal sinuses should beobtained whenever a child is suspected of having orbital or centralnervous system complications. The clinician should prescribe antibiotictherapy for acute bacterial sinusitis in children with severe onset orworsening course. The clinician should either prescribe antibiotictherapy or offer additional observation for 3 days to children withpersistent illness. Amoxicillin with or without clavulanate is the first-line treatment of acute bacterial sinusitis. Clinicians should reassessinitial management if there is either a caregiver report of worsening(progression of initial signs/symptoms or appearance of new signs/symptoms) or failure to improve within 72 hours of initial management.If the diagnosis of acute bacterial sinusitis is confirmed in a child withworsening symptoms or failure to improve, then clinicians may changethe antibiotic therapy for the child initially managed with antibiotic orinitiate antibiotic treatment of the child initially managed withobservation.

CONCLUSIONS: Changes in this revision include the addition of a clin-ical presentation designated as worsening course, an option to treatimmediately or observe children with persistent symptoms for 3 daysbefore treating, and a review of evidence indicating that imaging isnot necessary in children with uncomplicated acute bacterial sinus-itis. Pediatrics 2013;132:e262e280

Ellen R. Wald, MD, FAAP, Kimberly E. Applegate, MD, MS,FAAP, Clay Bordley, MD, FAAP, David H. Darrow, MD, DDS,FAAP, Mary P. Glode, MD, FAAP, S. Michael Marcy, MD, FAAP,Carrie E. Nelson, MD, MS, Richard M. Rosenfeld, MD, FAAP,Nader Shaikh, MD, MPH, FAAP, Michael J. Smith, MD, MSCE,FAAP, Paul V. Williams, MD, FAAP, and Stuart T. Weinberg,MD, FAAP

KEY WORDSacute bacterial sinusitis, sinusitis, antibiotics, imaging, sinusaspiration

ABBREVIATIONSAAPAmerican Academy of PediatricsAOMacute otitis mediaCTcomputed tomographyPCV-1313-valent pneumococcal conjugate vaccineRABSrecurrent acute bacterial sinusitisRCTrandomized controlled trialURIupper respiratory tract infection

This document is copyrighted and is property of the AmericanAcademy of Pediatrics and its Board of Directors. All authorshave filed conflict of interest statements with the AmericanAcademy of Pediatrics. Any conflicts have been resolved througha process approved by the Board of Directors. The AmericanAcademy of Pediatrics has neither solicited nor accepted anycommercial involvement in the development of the content ofthis publication.

The recommendations in this report do not indicate an exclusivecourse of treatment or serve as a standard of medical care.Variations, taking into account individual circumstances, may beappropriate.


PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright 2013 by the American Academy of Pediatrics


Organizational Principles to Guide and Define the ChildHealth Care System and/or Improve the Health of all Children

by guest on March 10, from


Acute bacterial sinusitis is a commoncomplication of viral upper respiratoryinfection (URI) or allergic inflammation.Using stringent criteria to define acutesinusitis, it has been observed that be-tween 6% and 7% of children seekingcare for respiratory symptoms has anillness consistent with this definition.14

This clinical practice guideline is a re-vision of the clinical practice guidelinepublished by the American Academy ofPediatrics (AAP) in 2001.5 It has beendeveloped by a subcommittee of theSteering Committee on Quality Improve-ment and Management that includedphysicians with expertise in the fields ofprimary care pediatrics, academic gen-eral pediatrics, family practice, allergy,epidemiology and informatics, pediatricinfectious diseases, pediatric otolaryn-gology, radiology, and pediatric emer-gency medicine. None of the participantshad financial conflicts of interest, andonly money from the AAP was used tofund the development of the guideline.The guideline will be reviewed in 5 yearsunless new evidence emerges thatwarrants revision sooner.

The guideline is intended for use ina variety of clinical settings (eg, office,emergency department, hospital) by

clinicians who treat pediatric patients.The data on which the recom-mendations are based are included ina companion technical report, pub-lished in the electronic pages.6 ThePartnership for Policy Implementationhas developed a series of definitionsusing accepted health informationtechnology standards to assist in theimplementation of this guideline incomputer systems and quality mea-surement efforts. This document isavailable at:

This revision focuses on the diagnosisand management of acute sinusitis inchildren between 1 and 18 years of age.It does not apply to children with sub-acute or chronic sinusitis. Similar to theprevious guideline, this document doesnot consider neonates and childrenyounger than 1 year or children withanatomic abnormalities of the sinuses,immunodeficiencies, cystic fibrosis, orprimary ciliary dyskinesia. The mostsignificant areas of change from the2001 guideline are in the addition ofa clinical presentation designated asworsening course, inclusion of newdata on the effectiveness of antibioticsin children with acute sinusitis,4 anda review of evidence indicating that

imaging is not necessary to identifythose children who will benefit fromantimicrobial therapy.


The Subcommittee on Management ofSinusitis met in June 2009 to identifyresearch questions relevant to guide-line revision. The primary goal was toupdate the 2001 report by identifyingand reviewing additional studies ofpediatric acute sinusitis that havebeen performed over the past decade.

Searches of PubMed were performedby using the same search term as inthe 2001 report. All searches werelimited to English-language and humanstudies. Three separate searches wereperformed to maximize retrieval of themost recent and highest-quality evi-dence for pediatric sinusitis. The firstlimited results to all randomizedcontrolled trials (RCTs) from 1966 to2009, the second to all meta-analysesfrom 1966 to 2009, and the third toall pediatric studies (limited to ages

and November 2012 to capture re-cently published studies. The com-plete results of the literature revieware published separately in the tech-nical report.6 In summary, 17 ran-domized studies of sinusitis inchildren were identified and reviewed.Only 3 trials met inclusion criteria.Because of significant heterogeneityamong these studies, formal meta-analyses were not pursued.

The results from the literature reviewwere used to guide development of thekey action statements included in thisdocument. These action statementswere generated by using BRIDGE-Wiz(Building Recommendations in a Devel-opers Guideline Editor, Yale School ofMedicine, New Haven, CT), an interactivesoftware tool that leads guideline de-velopment through a series of ques-tions that are intended to create a moreactionable set of key action statements.7

BRIDGE-Wiz also incorporates the qualityof available evidence into the final de-termination of the strength of eachrecommendation.

The AAP policy statement ClassifyingRecommendations for Clinical PracticeGuidelines was followed in designating

levels of recommendations (Fig 1).8

Definitions of evidence-based state-ments are provided in Table 1. Thisguideline was reviewed by multiplegroups in the AAP and 2 externalorganizations. Comments were com-piled and reviewed by the subcom-mittee, and relevant changes wereincorporated into the guideline.


Key Action Statement 1

Clinicians should make a pre-sumptive diagnosis of acute bacterialsinusitis when a child with an acuteURI presents with the following:

Persistent illness, ie, nasal dis-charge (of any quality) or daytimecough or both lasting more than10 days without improvement;


Worsening course, ie, worsen-ing or new onset of nasal dis-charge, daytime cough, orfever after initial improvement;


Severe onset, ie, concurrent fe-ver (temperature 39C/102.2F)and purulent nasal discharge forat least 3 consecutive days (Evi-dence Quality: B; Recommenda-tion).

KAS Profile 1

Aggregate evidence quality: B

Benefit Diagnosis allows decisions regarding management to be made. Childrenlikely to benefit from antimicrobial therapy will be identified