Evidence Based Practice-Pediatric Acute Bacterial Sinusitis

Evidence Based Practice-Pediatric Acute Bacterial Sinusitis

Objective: To update the American Academy of Pediatrics clinical practice guideline regarding the diagnosis and management of acute bacterial sinusitis in children and adolescents.

Methods: Analysis of the medical literature published since the last version of the guideline (2001).

Results: The diagnosis of acute bacterial sinusitis is made when a child with an acute upper respiratory tract infection (URI) presents with (1) persistent illness (nasal discharge [of any quality] or daytime cough or both lasting more than 10 days without improvement), (2) a worsening course (worsening or new onset of nasal discharge, daytime cough, or fever after initial improvement), or (3) severe onset (concurrent fever[temperature ≥39°C/102.2°F] and purulent nasal discharge for at least 3 consecutive days). Clinicians should not obtain imaging studies of any kind to distinguish acute bacterial sinusitis from viral URI, because they do not contribute to the diagnosis; however, a contrast-enhanced computed tomography scan of the paranasal sinuses should be obtained whenever a child is suspected of having orbital or central nervous system complications. The clinician should prescribe antibiotic therapy for acute bacterial sinusitis in children with severe onset or worsening course. The clinician should either prescribe antibiotic therapy or offer additional observation for 3 days to children with persistent illness. Amoxicillin with or without clavulanate is the firstline treatment of acute bacterial sinusitis. Clinicians should reassess initial 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 with worsening symptoms or failure to improve, then clinicians may change the antibiotic therapy for the child initially managed with antibiotic or initiate antibiotic treatment of the child initially managed with observation.

Conclusions: 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.

Approximately 6% to 7% of children presenting with respiratory symptoms have acute sinusitis. This practice guideline from the American Academy of Pediatrics (AAP), which updates the 2001 guideline, discusses diagnosis and management of acute bacterial sinusitis in children one to 18 years of age.

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Recommendations

Acute bacterial sinusitis can be diagnosed in children with an acute upper respiratory infection that persists (nasal discharge or daytime cough for more than 10 days with no improvement), that gets worse (worsening or new nasal discharge, daytime cough, or fever after improving at first), or that is severe (concomitant fever of at least 102.2°F [39°C] and purulent nasal discharge for at least three consecutive days).

Plain radiography, contrast-enhanced computed tomography, magnetic resonance imaging, and ultrasonography should not be performed to differentiate acute bacterial sinusitis from viral upper respiratory infection. However, contrast-enhanced computed tomography of the paranasal sinuses or magnetic resonance imaging with contrast media should be performed in children thought to have orbital or central nervous system complications. The most common orbital complications of acute bacterial sinusitis involve children younger than five years who have ethmoid sinusitis. These complications should be suspected in a child with a swollen eye, especially if there is also proptosis or if extraocular muscle function is impaired. Intracranial complications (e.g., subdural and epidural empyema, venous thrombosis, brain abscess, meningitis) are less common, but more serious, and have higher morbidity and mortality rates than orbital complications. These complications should be suspected in a child with a severe headache, photophobia, seizures, or other focal neurologic findings.

Antibiotics should be prescribed in children with severe, worsening, or persistent acute bacterial sinusitis. Outpatient observation for three days is also an option in children with persistent illness. Amoxicillin alone or in combination with clavulanate is the first-line antibiotic choice. Intravenous or intramuscular ceftriaxone (Rocephin), 50 mg per kg once, can be given to children who are vomiting, who cannot take oral medications, or who are not likely to take the initial antibiotic doses as prescribed. After clinical improvement, the treatment can be changed to oral therapy. Children with hypersensitivity to amoxicillin (type 1 and non–type 1) can be treated with cefdinir (Omnicef), cefuroxime (Ceftin), or cefpodoxime. Surveillance studies have shown resistance of pneumococcus and Haemophilus influenzae to trimethoprim/sulfamethoxazole and azithromycin (Zithromax), indicating that they should not be used to treat acute bacterial sinusitis in persons with penicillin hypersensitivity. Recommendations regarding the optimal duration of treatment vary from 10 to 28 days. Alternatively, it has been recommended that patients be treated for seven days after symptoms subside, which provides for individualized treatment, at least 10 days of treatment, and avoiding continued treatment in asymptomatic patients.

If acute bacterial sinusitis is confirmed in a child whose symptoms are getting worse or who is not improving after 72 hours, the antibiotic may be changed (if the child is already taking an antibiotic) or started (if the child is being observed). If a parent indicates that the child’s illness is getting worse (initial signs or symptoms progressing, or new signs or symptoms occurring) or not improving (signs and symptoms persist) after 72 hours of treatment, management decisions should be reevaluated.

There are no recommendations regarding adjuvant therapy for acute bacterial sinusitis, although intranasal corticosteroids, saline nasal irrigation or lavage, topical or oral decongestants, mucolytics, and topical or oral antihistamines may be options. One Cochrane review found no appropriately designed studies to establish the effectiveness of decongestants, antihistamines, and nasal irrigation for acute sinusitis in children.

Only a few high-quality studies on the diagnosis and treatment of acute bacterial sinusitis in children have been published since the 2001 guideline was released. Therefore, evidence on which to base recommendations is limited, and further research is needed in many areas

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