Guideline for acute bacterial sinusitis updated

The American Academy of Pediatrics (AAP) has updated its clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years.

The guideline was last published in 2001. Key changes this time include waiting 3 days before prescribing antibiotics for certain children with persistent illness; not ordering imaging studies to distinguish between acute bacterial sinusitis and viral upper respiratory infection (URI) because they add nothing to the diagnosis; and the addition of a clinical presentation called “worsening course.”

The new guideline was developed by the AAP Subcommittee on Acute Sinusitis, which based its recommendations on 17 randomized studies about sinusitis in children and a recently published systematic review of the effectiveness of available medications. However, the researchers are careful to explain that only 3 studies met inclusion criteria and because of significant heterogeneity they did not pursue meta-analyses.

The guideline states that clinicians should make a diagnosis of acute bacterial sinusitis when the patient presents with nasal discharge and cough lasting more than 10 days without improvement; with worsening respiratory symptoms of nasal discharge, daytime cough, or fever after initial improvement; or with severe onset including concurrent high fever and purulent nasal discharge for at least 3 consecutive days.

In contrast to the original guideline, which recommended antibiotic therapy for all children diagnosed with the condition, the new guideline recommends that health care workers wait and watch less sick patients for an additional 3 days to see if the infection begins to clear on its own. The move to wait an additional 3 days before prescribing antibiotics is partly because research shows antibiotics increase the incidence of diarrhea and abdominal pain in children, compared with placebo, and also because of the issue of overprescribing antibiotics and increasing bacterial resistance. First-line treatment once the decision is made to treat should be amoxicillin with or without clavulanate.

The guideline does not apply to those children with chronic sinusitis or to those who are aged younger than 1 year.