Diagnosis and management of acute bacterial sinusitis

CLINICAL CONTEXT

The American Academy of Pediatrics (AAP) has issued a new clinical practice guideline regarding diagnosis and management of acute bacterial sinusitis in children. Medscape Medical News interviewed lead author Ellen Wald, MD, about changes in the updated guidelines from the 2001 AAP guideline.

Review of the medical literature since 2001 suggests that evidence regarding diagnosis and management of acute bacterial sinusitis in children is still limited. Because of differences in inclusion and exclusion criteria, 4 placebo-controlled studies of antibiotic treatment in children differed in their findings. Nonetheless, these data suggested that antibiotic treatment was more likely to benefit children presenting with more severe illness.

STUDY SYNOPSIS AND PERSPECTIVE

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 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 clinicians 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's condition 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 its 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 (CT) 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

STUDY HIGHLIGHTS

• In the 2001 guidelines, criteria for acute bacterial sinusitis in children were acute URI with nasal discharge and/or daytime cough for more than 10 days, or severe onset of fever (≥ 39°C/102.2°F), purulent nasal discharge, and other respiratory tract symptoms for 3 or more consecutive days.
• The 2013 guidelines maintain the above criteria but add a third criterion: URI with initial improvement followed by worsening symptoms such as nasal discharge, cough, and fever.
• This presentation can be distinguished from the common cold because the fever lasts longer (at least 3 - 4 days), and the purulent nasal discharge appears early along with the fever.
• Using severity of illness at presentation may help identify children who will benefit from antibiotics while minimizing unnecessary use of antibiotics.
• The 2001 guideline recommended antibiotics for all children diagnosed with acute bacterial sinusitis, but the updated guideline notes that clinicians may now observe children with infection lasting more than 10 days for an additional 3 days before prescribing antibiotics.
• However, children with severe onset or worsening symptoms should still receive antibiotics.
• For acute bacterial sinusitis, first-line treatment is amoxicillin with or without clavulanate.
• Some children may be treated with standard-dose amoxicillin (45 mg/kg/day in 2 divided doses), or high-dose amoxicillin (80 - 90 mg/kg/day in 2 divided doses) for patients thought to have resistant Streptococcus pneumoniae.
• Amoxicillin/potassium clavulanate is more effective against beta lactamase–producingHaemophilus influenzae.
• When data are unavailable concerning the relative prevalence of S pneumoniae, H influenzae, and beta lactamase–producing strains, amoxicillin/potassium clavulanate is the most comprehensive option, and it is probably safe to use in regular, rather than high, doses.
• Another antibiotic may be substituted if symptoms do not improve or worsen after 72 hours.
• Regardless of initial management, children whose condition fails to improve or in whom new or progressing signs and symptoms develop within 72 hours should undergo reevaluation and change or initiation of antibiotic therapy if indicated.
• Potentially useful adjunctive therapy includes ibuprofen or acetaminophen for discomfort or fever, saline nasal spray, and humidifiers or vaporizers.
• The evidence review suggests that imaging tests do not distinguish acute bacterial sinusitis from viral URI.
• Therefore, the AAP does not recommend imaging tests to confirm or refute the diagnosis of uncomplicated acute bacterial sinusitis in children.
• Results on radiography, CT, or magnetic resonance imaging scans performed during an uncomplicated cold are frequently abnormal, and these abnormalities are very similar to those seen in children with acute sinusitis.
• However, contrast-enhanced CT of the paranasal sinuses is recommended for children with suspected orbital or central nervous system complications to confirm the presence of the complication, define its extent, and help determine the need for surgical intervention.

CLINICAL IMPLICATIONS

• A change from 2001 in the updated guideline is that clinicians may now observe children with infection lasting more than 10 days for an additional 3 days before prescribing antibiotics. However, children with severe onset or worsening symptoms should still receive antibiotics.
• The AAP does not recommend imaging tests to confirm or refute the diagnosis of uncomplicated acute bacterial sinusitis in children. However, children with suspected orbital or central nervous system complications should undergo contrast-enhanced CT of the paranasal sinuses.

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