clinical practice guideline clinical practice guideline ... · clinical practice guideline clinical...

21
CLINICAL PRACTICE GUIDELINE Clinical Practice Guideline for the Diagnosis and Management of Acute Bacterial Sinusitis in Children Aged 1 to 18 Years abstract 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 rst- line 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 conrmed 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 clin- ical 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 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 WORDS acute bacterial sinusitis, sinusitis, antibiotics, imaging, sinus aspiration ABBREVIATIONS AAPAmerican Academy of Pediatrics AOMacute otitis media CTcomputed tomography PCV-1313-valent pneumococcal conjugate vaccine RABSrecurrent acute bacterial sinusitis RCTrandomized controlled trial URIupper respiratory tract infection This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have led conict of interest statements with the American Academy of Pediatrics. Any conicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication. The recommendations in this report do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. www.pediatrics.org/cgi/doi/10.1542/peds.2013-1071 doi:10.1542/peds.2013-1071 PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2013 by the American Academy of Pediatrics e262 FROM THE AMERICAN ACADEMY OF PEDIATRICS Organizational Principles to Guide and Dene the Child Health Care System and/or Improve the Health of all Children by guest on March 10, 2019 www.aappublications.org/news Downloaded from

Upload: vanphuc

Post on 11-Mar-2019

282 views

Category:

Documents


1 download

TRANSCRIPT

Page 1: CLINICAL PRACTICE GUIDELINE Clinical Practice Guideline ... · CLINICAL PRACTICE GUIDELINE Clinical Practice Guideline for the Diagnosis and Management of Acute Bacterial Sinusitis

CLINICAL PRACTICE GUIDELINE

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 ≥39°C/102.2°F] 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:e262–e280

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

ABBREVIATIONSAAP—American Academy of PediatricsAOM—acute otitis mediaCT—computed tomographyPCV-13—13-valent pneumococcal conjugate vaccineRABS—recurrent acute bacterial sinusitisRCT—randomized controlled trialURI—upper 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.

www.pediatrics.org/cgi/doi/10.1542/peds.2013-1071

doi:10.1542/peds.2013-1071

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

Copyright © 2013 by the American Academy of Pediatrics

e262 FROM 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, 2019www.aappublications.org/newsDownloaded from

Page 2: CLINICAL PRACTICE GUIDELINE Clinical Practice Guideline ... · CLINICAL PRACTICE GUIDELINE Clinical Practice Guideline for the Diagnosis and Management of Acute Bacterial Sinusitis

INTRODUCTION

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.1–4

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: http://www2.aap.org/in-formatics/PPI.html.

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 as“worsening 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.

METHODS

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<18 years) published since the lasttechnical report (1999–2009). Addi-tionally, the Web of Science was que-ried to identify studies that cited theoriginal AAP guidelines. This literaturesearch was replicated in July 2010

FIGURE 1Levels of recommendations. Rec, recommendation.

PEDIATRICS Volume 132, Number 1, July 2013 e263

FROM THE AMERICAN ACADEMY OF PEDIATRICS

by guest on March 10, 2019www.aappublications.org/newsDownloaded from

Page 3: CLINICAL PRACTICE GUIDELINE Clinical Practice Guideline ... · CLINICAL PRACTICE GUIDELINE Clinical Practice Guideline for the Diagnosis and Management of Acute Bacterial Sinusitis

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 STATEMENTS

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;

OR

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

OR

� Severe onset, ie, concurrent fe-ver (temperature ≥39°C/102.2°F)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.

Harm Inappropriate diagnosis may lead to unnecessary treatment. A misseddiagnosis may lead to persistent infection or complications

Cost Inappropriate diagnosis may lead to unnecessary cost of antibiotics. Amissed diagnosis leads to cost of persistent illness (loss of time fromschool and work) or cost of caring for complications.

Benefits-harm assessment Preponderance of benefit.Value judgments None.Role of patient preference Limited.Intentional vagueness None.Exclusions Children aged <1 year or older than 18 years and with underlying

conditions.Strength Recommendation.

TABLE 1 Guideline Definitions for Evidence-Based Statements

Statement Definition Implication

Strong recommendation A strong recommendation in favor of a particular action is madewhen the anticipated benefits of the recommendedintervention clearly exceed the harms (as a strongrecommendation against an action is made when theanticipated harms clearly exceed the benefits) and the qualityof the supporting evidence is excellent. In some clearlyidentified circumstances, strong recommendations may bemade when high-quality evidence is impossible to obtain andthe anticipated benefits strongly outweigh the harms.

Clinicians should follow a strong recommendation unlessa clear and compelling rationale for an alternative approachis present.

Recommendation A recommendation in favor of a particular action is made whenthe anticipated benefits exceed the harms but the quality ofevidence is not as strong. Again, in some clearly identifiedcircumstances, recommendations may be made when high-quality evidence is impossible to obtain but the anticipatedbenefits outweigh the harms.

Clinicians would be prudent to follow a recommendation, butshould remain alert to new information and sensitive topatient preferences.

Option Options define courses that may be taken when either the qualityof evidence is suspect or carefully performed studies haveshown little clear advantage to one approach over another.

Clinicians should consider the option in their decision-making,and patient preference may have a substantial role.

No recommendation No recommendation indicates that there is a lack of pertinentpublished evidence and that the anticipated balance ofbenefits and harms is presently unclear.

Clinicians should be alert to new published evidence thatclarifies the balance of benefit versus harm.

e264 FROM THE AMERICAN ACADEMY OF PEDIATRICS by guest on March 10, 2019www.aappublications.org/newsDownloaded from

Page 4: CLINICAL PRACTICE GUIDELINE Clinical Practice Guideline ... · CLINICAL PRACTICE GUIDELINE Clinical Practice Guideline for the Diagnosis and Management of Acute Bacterial Sinusitis

The purpose of this action statement isto guide the practitioner in makinga diagnosis of acute bacterial sinusitison the basis of stringent clinical cri-teria. To develop criteria to be used indistinguishing episodes of acute bac-terial sinusitis from other commonrespiratory infections, it is helpful todescribe the features of an un-complicated viral URI. Viral URIs areusually characterized by nasal symp-toms (discharge and congestion/obstruction) or cough or both. Mostoften, the nasal discharge begins asclear and watery. Often, however, thequality of nasal discharge changesduring the course of the illness. Typi-cally, the nasal discharge becomesthicker and more mucoid and maybecome purulent (thick, colored, andopaque) for several days. Then thesituation reverses, with the purulentdischarge becoming mucoid and thenclear again or simply resolving. Thetransition from clear to purulent toclear again occurs in uncomplicatedviral URIs without the use of antimi-crobial therapy.

Fever, when present in uncomplicatedviral URI, tends to occur early in theillness, often in concert with otherconstitutional symptoms such asheadache and myalgias. Typically, thefever and constitutional symptomsdisappear in the first 24 to 48 hours,and the respiratory symptoms becomemore prominent (Fig 2).

The course of most uncomplicated viralURIs is 5 to 7 days.9–12 As shown in Fig 2,respiratory symptoms usually peak inseverity by days 3 to 6 and then beginto improve; however, resolving symp-toms and signs may persist in somepatients after day 10.9,10

Symptoms of acute bacterial sinusitisand uncomplicated viral URI overlapconsiderably, and therefore it is theirpersistence without improvementthat suggests a diagnosis of acutesinusitis.9,10,13 Such symptoms include

nasal discharge (of any quality: thickor thin, serous, mucoid, or purulent)or daytime cough (which may beworse at night) or both. Bad breath,fatigue, headache, and decreased ap-petite, although common, are notspecific indicators of acute sinusitis.14

Physical examination findings are alsonot particularly helpful in distinguish-ing sinusitis from uncomplicated URIs.Erythema and swelling of the nasalturbinates are nonspecific findings.14

Percussion of the sinuses is not useful.Transillumination of the sinuses is diffi-cult to perform correctly in children andhas been shown to be unreliable.15,16

Nasopharyngeal cultures do not reliablypredict the etiology of acute bacterialsinusitis.14,16

Only a minority (∼6%–7%) of childrenpresenting with symptoms of URI willmeet criteria for persistence.3,4,11 Asa result, before diagnosing acutebacterial sinusitis, it is important forthe practitioner to attempt to (1) dif-ferentiate between sequential epi-sodes of uncomplicated viral URI(which may seem to coalesce in themind of the patient or parent) fromthe onset of acute bacterial sinusitiswith persistent symptoms and (2)establish whether the symptoms areclearly not improving.

A worsening course of signs andsymptoms, termed “double sickening,”in the context of a viral URI is anotherpresentation of acute bacterial sinus-itis.13,17 Affected children experiencesubstantial and acute worsening of

respiratory symptoms (nasal dis-charge or nasal congestion or day-time cough) or a new fever, often onthe sixth or seventh day of illness,after initial signs of recovery from anuncomplicated viral URI. Support forthis definition comes from studies inchildren and adults, for whom antibi-otic treatment of worsening symp-toms after a period of apparentimprovement was associated withbetter outcomes.4

Finally, some children with acutebacterial sinusitis may present withsevere onset, ie, concurrent high fever(temperature >39°C) and purulentnasal discharge. These children usu-ally are ill appearing and need to bedistinguished from children with un-complicated viral infections that areunusually severe. If fever is present inuncomplicated viral URIs, it tends tobe present early in the illness, usuallyaccompanied by other constitutionalsymptoms, such as headache andmyalgia.9,13,18 Generally, the constitu-tional symptoms resolve in the first48 hours and then the respiratorysymptoms become prominent. In mostuncomplicated viral infections, in-cluding influenza, purulent nasal dis-charge does not appear for severaldays. Accordingly, it is the concurrentpresentation of high fever and puru-lent nasal discharge for the first 3 to4 days of an acute URI that helps todefine the severe onset of acute bac-terial sinusitis.13,16,18 This presentationin children is the corollary to acuteonset of headache, fever, and facialpain in adults with acute sinusitis.

Allergic and nonallergic rhinitis arepredisposing causes of some cases ofacute bacterial sinusitis in childhood.In addition, at their onset, these con-ditions may be mistaken for acutebacterial sinusitis. A family history ofatopic conditions, seasonal occur-rences, or occurrences with exposureto common allergens and other

FIGURE 2Uncomplicated viral URI.

PEDIATRICS Volume 132, Number 1, July 2013 e265

FROM THE AMERICAN ACADEMY OF PEDIATRICS

by guest on March 10, 2019www.aappublications.org/newsDownloaded from

Page 5: CLINICAL PRACTICE GUIDELINE Clinical Practice Guideline ... · CLINICAL PRACTICE GUIDELINE Clinical Practice Guideline for the Diagnosis and Management of Acute Bacterial Sinusitis

allergic diatheses in the index patient(eczema, atopic dermatitis, asthma)may suggest the presence of non-infectious rhinitis. The patient mayhave complaints of pruritic eyes andnasal mucosa, which will providea clue to the likely etiology of thecondition. On physical examination,there may be a prominent nasalcrease, allergic shiners, cobblestoningof the conjunctiva or pharyngeal wall,or pale nasal mucosa as other indi-cators of the diagnosis.

Key Action Statement 2A

Clinicians should not obtain imag-ing studies (plain films, contrast-enhanced computed tomography[CT], MRI, or ultrasonography) todistinguish acute bacterial sinusi-tis from viral URI (Evidence Quality:B; Strong Recommendation).

The purpose of this key action state-ment is to discourage the practitionerfrom obtaining imaging studies inchildren with uncomplicated acutebacterial sinusitis. As emphasized inKey Action Statement 1, acute bacterialsinusitis in children is a diagnosis thatis made on the basis of stringentclinical criteria that describe signs,symptoms, and temporal patterns ofa URI. Although historically imaginghas been used as a confirmatoryor diagnostic modality in children

suspected to have acute bacterial si-nusitis, it is no longer recommended.

The membranes that line the nose arecontinuous with the membranes(mucosa) that line the sinus cavities,the middle ear, the nasopharynx, andthe oropharynx. When an individualexperiences a viral URI, there is in-flammation of the nasal mucosa and,often, the mucosa of the middle earand paranasal sinuses as well. Thecontinuity of the mucosa of the upperrespiratory tract is responsible for thecontroversy regarding the usefulnessof images of the paranasal sinuses incontributing to a diagnosis of acutebacterial sinusitis.

As early as the 1940s, observationswere made regarding the frequency ofabnormal sinus radiographs in healthychildren without signs or symptoms of

current respiratory disease.19 In ad-dition, several investigators in the1970s and 1980s observed that childrenwith uncomplicated viral URI had fre-quent abnormalities of the paranasalsinuses on plain radiographs.20–22 Theseabnormalities were the same as thoseconsidered to be diagnostic of acutebacterial sinusitis (diffuse opacification,mucosal swelling of at least 4 mm, oran air-fluid level).16

As technology advanced and CT scan-ning of the central nervous system and

skull became prevalent, several stud-ies reported on incidental abnormali-ties of the paranasal sinuses that wereobserved in children.23,24 Gwaltneyet al25 showed striking abnormalities(including air-fluid levels) in sinusCT scans of young adults with un-complicated colds. Manning et al26

evaluated children undergoing eitherCT or MRI of the head for indicationsother than respiratory complaints orsuspected sinusitis. Each patient un-derwent rhinoscopy and otoscopy be-fore imaging and each patient’sparent was asked to fill out a ques-tionnaire regarding recent symptomsof URI. Sixty-two percent of patientsoverall had physical findings or his-tory consistent with an upper re-spiratory inflammatory process, and55% of the total group showed someabnormalities on sinus imaging; 33%showed pronounced mucosal thick-ening or an air-fluid level. Gordtset al27 made similar observations inchildren undergoing MRI. Finally,Kristo et al28 performed MRI in chil-dren with URIs and confirmed the highfrequency (68%) of major abnormali-ties seen in the paranasal sinuses.

In summary, when the paranasalsinuses are imaged, either with plainradiographs, contrast-enhanced CT, orMRI in children with uncomplicatedURI, the majority of studies will besignificantly abnormal with the samekind of findings that are associatedwith bacterial infection of the sinuses.Accordingly, although normal radio-graphs or CT or MRI results can ensurethat a patient with respiratory symp-toms does not have acute bacterialsinusitis, an abnormal image cannotconfirm the diagnosis. Therefore, it isnot necessary to perform imaging inchildren with uncomplicated episodesof clinical sinusitis. Similarly, the highlikelihood of an abnormal imagingresult in a child with an uncomplicatedURI indicates that radiographic studies

KAS Profile 2A

Aggregate evidence quality: B; overwhelmingly consistent evidence from observational studies.

Benefit Avoids exposure to radiation and costs of studies. Avoidsunnecessary therapy for false-positive diagnoses.

Harm None.Cost Avoids cost of imaging.Benefits-harm assessment Exclusive benefit.Value judgments Concern for unnecessary radiation and costs.Role of patient preference Limited. Parents may value a negative study and avoidance of

antibiotics as worthy of radiation but panel disagrees.Intentional vagueness None.Exclusions Patients with complications of sinusitis.Strength Strong recommendation.

e266 FROM THE AMERICAN ACADEMY OF PEDIATRICS by guest on March 10, 2019www.aappublications.org/newsDownloaded from

Page 6: CLINICAL PRACTICE GUIDELINE Clinical Practice Guideline ... · CLINICAL PRACTICE GUIDELINE Clinical Practice Guideline for the Diagnosis and Management of Acute Bacterial Sinusitis

not be performed in an attempt toeliminate the diagnosis of sinusitis.

Key Action Statement 2B

Clinicians should obtain a contrast-enhanced CT scan of the paranasalsinuses and/or an MRI with con-trast whenever a child is suspectedof having orbital or central nervoussystem complications of acute bac-terial sinusitis (Evidence Quality: B;Strong Recommendation).

The purpose of this key action state-ment is to have the clinician obtaincontrast-enhanced CT images whenchildren are suspected of having se-rious complications of acute bacterialsinusitis. The most common complica-tion of acute sinusitis involves the orbitin children with ethmoid sinusitiswho are younger than 5 years.29–31

Orbital complications should be sus-pected when the child presents witha swollen eye, especially if accompa-nied by proptosis or impaired functionof the extraocular muscles. Orbitalcomplications of acute sinusitis havebeen divided into 5 categories: sym-pathetic effusion, subperiosteal ab-scess, orbital cellulitis, orbital abscess,and cavernous sinus thrombosis.32 Al-though sympathetic effusion (inflam-matory edema) is categorized as an

orbital complication, the site of in-fection remains confined to the sinuscavities; eye swelling is attributableto the impedance of venous drain-age secondary to congestion withinthe ethmoid sinuses. Alternativeterms for sympathetic effusion (in-flammatory edema) are preseptal orperiorbital cellulitis. The remaining“true” orbital complications are bestvisualized by contrast-enhanced CTscanning.

Intracranial complications of acute si-nusitis, which are substantially lesscommon than orbital complications, aremore serious, with higher morbidityand mortality than those involving theorbit. Intracranial complications shouldbe suspected in the patient who pres-ents with a very severe headache,photophobia, seizures, or other focalneurologic findings. Intracranial com-plications include subdural empyema,epidural empyema, venous thrombosis,brain abscess, and meningitis.29 Typi-cally, patients with intracranial compli-cations of acute bacterial sinusitis arepreviously healthy adolescent maleswith frontal sinusitis.33,34

There have been no head-to-headcomparisons of the diagnostic accu-racy of contrast-enhanced CT scanningto MRI with contrast in the evaluation

of orbital and intracranial complica-tions of sinusitis in children. In gen-eral, the contrast-enhanced CT scanhas been the preferred imaging studywhen complications of sinusitis aresuspected.35,36 However, there aredocumented cases in which a contrast-enhanced CT scan has not revealedthe abnormality responsible for theclinical presentation and the MRI withcontrast has, especially for intra-cranial complications and rarely fororbital complications.37,38 Accordingly,the most recent appropriateness cri-teria from the American College ofRadiology endorse both MRI withcontrast and contrast-enhanced CT ascomplementary examinations whenevaluating potential complications ofsinusitis.35 The availability and speed ofobtaining the contrast-enhanced CT aredesirable; however, there is increasingconcern regarding exposure to radia-tion. The MRI, although very sensitive,takes longer than the contrast-enhanced CT and often requires seda-tion in young children (which carriesits own risks). In older children andadolescents who may not require se-dation, MRI with contrast, if available,may be preferred when intracranialcomplications are likely. Furthermore,MRI with contrast should be performedwhen there is persistent clinical con-cern or incomplete information hasbeen provided by the contrast-enhanced CT scan.

Key Action Statement 3

Initial Management of Acute BacterialSinusitis

3A: “Severe onset and worseningcourse” acute bacterial sinusitis.The clinician should prescribe an-tibiotic therapy for acute bacterialsinusitis in children with severeonset or worsening course (signs,symptoms, or both) (EvidenceQuality: B; Strong Recommenda-tion).

KAS Profile 2B

Aggregate evidence quality: B; overwhelmingly consistent evidence from observational studies.

Benefit Determine presence of abscesses, which may require surgicalintervention; avoid sequelae because of appropriate aggressivemanagement.

Harm Exposure to ionizing radiation for CT scans; need for sedation forMRI.

Cost Direct cost of studies.Benefits-harm assessment Preponderance of benefit.Value judgments Concern for significant complication that may be unrecognized

and, therefore, not treated appropriately.Role of patient preference Limited.Intentional vagueness None.Exclusions None.Strength Strong recommendation.

PEDIATRICS Volume 132, Number 1, July 2013 e267

FROM THE AMERICAN ACADEMY OF PEDIATRICS

by guest on March 10, 2019www.aappublications.org/newsDownloaded from

Page 7: CLINICAL PRACTICE GUIDELINE Clinical Practice Guideline ... · CLINICAL PRACTICE GUIDELINE Clinical Practice Guideline for the Diagnosis and Management of Acute Bacterial Sinusitis

3B: “Persistent illness.” The clini-cian should either prescribe anti-biotic therapy OR offer additionaloutpatient observation for 3 daysto children with persistent illness(nasal discharge of any quality orcough or both for at least 10 dayswithout evidence of improvement)(Evidence Quality: B; Recommenda-tion).

The purpose of this section is to offerguidance on initial management ofpersistent illness sinusitis by helpingclinicians choose between the follow-ing 2 strategies:

1. Antibiotic therapy, defined as initialtreatment of acute bacterial sinusitiswith antibiotics, with the intent ofstarting antibiotic therapy as soonas possible after the encounter.

2. Additional outpatient observation, de-fined as initial management of acutebacterial sinusitis limited to contin-ued observation for 3 days, with com-mencement of antibiotic therapy ifeither the child does not improveclinically within several days of diag-nosis or if there is clinical worseningof the child’s condition at any time.

In contrast to the 2001 AAP guideline,5

which recommended antibiotic therapyfor all children diagnosed with acutebacterial sinusitis, this guideline allowsfor additional observation of childrenpresenting with persistent illness (na-sal discharge of any quality or daytimecough or both for at least 10 dayswithout evidence of improvement). Inboth guidelines, however, children pre-senting with severe or worsening ill-ness (which was not defined explicitlyin the 2001 guideline5) are to receiveantibiotic therapy. The rationale for thisapproach (Table 2) is discussed below.

Antibiotic Therapy for Acute BacterialSinusitis

In the United States, antibiotics areprescribed for 82% of children withacute sinusitis.39 The rationale forantibiotic therapy of acute bacterialsinusitis is based on the recovery ofbacteria in high density (≥104 colony-forming units/mL) in 70% of maxillarysinus aspirates obtained from chil-dren with a clinical syndrome char-acterized by persistent nasal discharge,daytime cough, or both.16,40 Childrenwho present with severe-onset acutebacterial sinusitis are presumed tohave bacterial infection, because atemperature of at least 39°C/102.2°Fcoexisting for at least 3 consecutivedays with purulent nasal discharge isnot consistent with the well-documentedpattern of acute viral URI. Similarly,children with worsening-course acutebacterial sinusitis have a clinical coursethat is also not consistent with thesteady improvement that character-izes an uncomplicated viral URI.9,10

KAS Profile 3A

Aggregate evidence quality: B; randomized controlled trials with limitations.

Benefit Increase clinical cures, shorten illness duration, and mayprevent suppurative complications in a high-risk patientpopulation.

Harm Adverse effects of antibiotics.Cost Direct cost of therapy.Benefits-harm assessment Preponderance of benefit.Value judgments Concern for morbidity and possible complications

if untreated.Role of patient preference Limited.Intentional vagueness None.Exclusions None.Strength Strong recommendation.

KAS Profile 3B

Aggregate evidence quality: B; randomized controlled trials with limitations.

Benefit Antibiotics increase the chance of improvement or cure at 10 to14 days (number needed to treat, 3–5); additionalobservation may avoid the use of antibiotics with attendantcost and adverse effects.

Harm Antibiotics have adverse effects (number needed to harm, 3)and may increase bacterial resistance. Observation mayprolong illness and delay start of needed antibiotic therapy.

Cost Direct cost of antibiotics as well as cost of adversereactions; indirect costs of delayed recovery whenobservation is used.

Benefits-harm assessment Preponderance of benefit (because both antibiotic therapy andadditional observation with rescue antibiotic, if needed, areappropriate management).

Value judgments Role for additional brief observation period for selected childrenwith persistent illness sinusitis, similar to what isrecommended for acute otitis media, despite the lack ofrandomized trials specifically comparing additionalobservation with immediate antibiotic therapy and longerduration of illness before presentation.

Role of patient preference Substantial role in shared decision-making that shouldincorporate illness severity, child’s quality of life, andcaregiver values and concerns.

Intentional vagueness None.Exclusions Children who are excluded from randomized clinical trials of

acute bacterial sinusitis, as defined in the text.Strength Recommendation.

e268 FROM THE AMERICAN ACADEMY OF PEDIATRICS by guest on March 10, 2019www.aappublications.org/newsDownloaded from

Page 8: CLINICAL PRACTICE GUIDELINE Clinical Practice Guideline ... · CLINICAL PRACTICE GUIDELINE Clinical Practice Guideline for the Diagnosis and Management of Acute Bacterial Sinusitis

Three RCTs have compared antibiotictherapy with placebo for the initialmanagement of acute bacterial sinusitisin children. Two trials by Wald et al4,41

found an increase in cure or improve-ment after antibiotic therapy comparedwith placebo with a number needed totreat of 3 to 5 children. Most children inthese studies had persistent acutebacterial sinusitis, but children withsevere or worsening illness were alsoincluded. Conversely, Garbutt et al,42

who studied only children with persis-tent acute bacterial sinusitis, found nodifference in outcomes for antibioticversus placebo. Another RCT by Kristoet al,43 often cited as showing no benefitfrom antibiotics for acute bacterial si-nusitis, will not be considered furtherbecause of methodologic flaws, in-cluding weak entry criteria and in-adequate dosing of antibiotic treatment.

The guideline recommends antibiotictherapy for severe or worsening acutebacterial sinusitis because of the ben-efits revealed in RCTs4,41 and a theo-retically higher risk of suppurativecomplications than for children whopresent with persistent symptoms. Or-bital and intracranial complications ofacute bacterial sinusitis have not beenobserved in RCTs, even when placebowas administered; however, samplesizes have inadequate power to pre-clude an increased risk. This risk,however, has caused some investigatorsto exclude children with severe acutebacterial sinusitis from trial entry.42

Additional Observation for PersistentOnset Acute Bacterial Sinusitis

The guideline recommends either anti-biotic therapy or an additional briefperiod of observation as initial man-agement strategies for children withpersistent acute bacterial sinusitis be-cause, although there are benefits toantibiotic therapy (number needed totreat, 3–5), some children improve ontheir own, and the risk of suppurative

complications is low.4,41 Symptoms ofpersistent acute bacterial sinusitis maybe mild and have varying effects ona given child’s quality of life, rangingfrom slight (mild cough, nasal dis-charge) to significant (sleep disturbance,behavioral changes, school or child careabsenteeism). The benefits of antibiotictherapy in some trials4,41 must also bebalanced against an increased risk ofadverse events (number need to harm,3), most often self-limited diarrhea, butalso including occasional rash.4

Choosing between antibiotic therapy oradditional observation for initial man-agement of persistent illness sinusitispresents an opportunity for shareddecision-making with families (Table 2).Factors that might influence this de-cision include symptom severity, thechild’s quality of life, recent antibioticuse, previous experience or outcomeswith acute bacterial sinusitis, cost ofantibiotics, ease of administration, care-giver concerns about potential adverseeffects of antibiotics, persistence of re-spiratory symptoms, or development ofcomplications. Values and preferencesexpressed by the caregiver should betaken into consideration (Table 3).

Children with persistent acute bacterialsinusitis who received antibiotic therapyin the previous 4 weeks, those withconcurrent bacterial infection (eg,pneumonia, suppurative cervical adeni-tis, group A streptococcal pharyngitis, oracute otitis media), those with actual or

suspected complications of acute bac-terial sinusitis, or those with underlyingconditions should generally be managedwith antibiotic therapy. The latter groupincludes children with asthma, cysticfibrosis, immunodeficiency, previous si-nus surgery, or anatomic abnormalitiesof the upper respiratory tract.

Limiting antibiotic use in children withpersistent acute bacterial sinusitis whomay improve on their own reducescommon antibiotic-related adverseevents, such as diarrhea, diaper der-matitis, and skin rash. The most recentRCT of acute bacterial sinusitis inchildren4 found adverse events of 44%with antibiotic and 14% with placebo.

Limiting antibiotics may also reducethe prevalence of resistant bacterialpathogens. Although this is alwaysa desirable goal, no increase in re-sistant bacterial species was observedwithin the group of children treatedwith a single course of antimicrobialagents (compared with those receivingplacebo) in 2 recent large studies ofantibiotic versus placebo for childrenwith acute otitis media.44,45

Key Action Statement 4

Clinicians should prescribe amoxi-cillin with or without clavulanateas first-line treatment when a de-cision has been made to initiateantibiotic treatment of acute bac-terial sinusitis (Evidence Quality: B;Recommendation).

KAS Profile 4

Aggregate evidence quality: B; randomized controlled trials with limitations.

Benefit Increase clinical cures with narrowest spectrum drug; stepwise increase inbroadening spectrum as risk factors for resistance increase.

Harm Adverse effects of antibiotics including development of hypersensitivity.Cost Direct cost of antibiotic therapy.Benefits-harm assessment Preponderance of benefit.Value judgments Concerns for not encouraging resistance if possible.Role of patient preference Potential for shared decision-making that should incorporate the caregiver’s

experiences and values.Intentional vagueness None.Exclusions May include allergy or intolerance.Strength Recommendation.

PEDIATRICS Volume 132, Number 1, July 2013 e269

FROM THE AMERICAN ACADEMY OF PEDIATRICS

by guest on March 10, 2019www.aappublications.org/newsDownloaded from

Page 9: CLINICAL PRACTICE GUIDELINE Clinical Practice Guideline ... · CLINICAL PRACTICE GUIDELINE Clinical Practice Guideline for the Diagnosis and Management of Acute Bacterial Sinusitis

The purpose of this key action state-ment is to guide the selection of an-timicrobial therapy once the diagnosisof acute bacterial sinusitis has beenmade. The microbiology of acutebacterial sinusitis was determinednearly 30 years ago through directmaxillary sinus aspiration in childrenwith compatible signs and symptoms.The major bacterial pathogens re-covered at that time were Strepto-coccus pneumoniae in approximately30% of children and nontypeableHaemophilus influenzae and Morax-ella catarrhalis in approximately 20%each.16,40 Aspirates from the remain-ing 25% to 30% of children weresterile.

Maxillary sinus aspiration is rarelyperformed at the present time unlessthe course of the infection is unusuallyprolonged or severe. Although someauthorities have recommended obtain-ing cultures from the middle meatus todetermine the cause of a maxillary si-nus infection, there are no data inchildren with acute bacterial sinusitisthat have compared such cultures withcultures of a maxillary sinus aspirate.Furthermore, there are data indi-cating that the middle meatus inhealthy children is commonly colonized

with S pneumoniae, H influenzae, andM catarrhalis.46

Recent estimates of the microbiologyof acute sinusitis have, of necessity,been based primarily on that of acuteotitis media (AOM), a condition withrelatively easy access to infective flu-id through performance of tympano-centesis and one with a similarpathogenesis to acute bacterial si-nusitis.47,48 The 3 most common bac-terial pathogens recovered from themiddle ear fluid of children with AOMare the same as those that have beenassociated with acute bacterial si-nusitis: S pneumoniae, nontypeable Hinfluenzae, and M catarrhalis.49 Theproportion of each has varied fromstudy to study depending on criteriaused for diagnosis of AOM, patientcharacteristics, and bacteriologictechniques. Recommendations sincethe year 2000 for the routine use ininfants of 7-valent and, more recently,13-valent pneumococcal conjugatevaccine (PCV-13) have been associatedwith a decrease in recovery of Spneumoniae from ear fluid of childrenwith AOM and a relative increase inthe incidence of infections attribut-able to H influenzae.50 Thus, on thebasis of the proportions of bacteria

found in middle ear infections, it is es-timated that S pneumoniae and Hinfluenzae are currently each respon-sible for approximately 30% of cases ofacute bacterial sinusitis in children, andM catarrhalis is responsible for ap-proximately 10%. These percentagesare contingent on the assumption thatapproximately one-quarter of aspiratesof maxillary sinusitis would still besterile, as reported in earlier studies.Staphylococcus aureus is rarely iso-lated from sinus aspirates in childrenwith acute bacterial sinusitis, and withthe exception of acute maxillary sinusi-tis associated with infections of dentalorigin,51 respiratory anaerobes are alsorarely recovered.40,52 Although S aureusis a very infrequent cause of acutebacterial sinusitis in children, it isa significant pathogen in the orbital andintracranial complications of sinusitis.The reasons for this discrepancy areunknown.

Antimicrobial susceptibility patternsfor S pneumoniae vary considerablyfrom community to community. Iso-lates obtained from surveillance cen-ters nationwide indicate that, at thepresent time, 10% to 15% of upperrespiratory tract isolates of S pneu-moniae are nonsusceptible to penicil-lin53,54; however, values for penicillinnonsusceptibility as high as 50% to60% have been reported in someareas.55,56 Of the organisms that areresistant, approximately half are highlyresistant to penicillin and the remain-ing half are intermediate in resis-tance. 53,54,56–59 Between 10% and 42%of H influenzae56–59 and close to 100%of M catarrhalis are likely to beβ-lactamase positive and nonsus-ceptible to amoxicillin. Because ofdramatic geographic variability in theprevalence of β-lactamase–positive Hinfluenzae, it is extremely desirable forthe practitioner to be familiar with lo-cal patterns of susceptibility. Risk fac-tors for the presence of organisms

TABLE 2 Recommendations for Initial Use of Antibiotics for Acute Bacterial Sinusitis

Clinical Presentation Severe AcuteBacterial Sinusitisa

Worsening AcuteBacterial Sinusitisb

Persistent AcuteBacterial Sinusitisc

Uncomplicated acute bacterialsinusitis without coexistingillness

Antibiotic therapy Antibiotic therapy Antibiotic therapy oradditional observationfor 3 daysd

Acute bacterial sinusitis withorbital or intracranialcomplications

Antibiotic therapy Antibiotic therapy Antibiotic therapy

Acute bacterial sinusitis withcoexisting acute otitis media,pneumonia, adenitis, orstreptococcal pharyngitis

Antibiotic therapy Antibiotic therapy Antibiotic therapy

a Defined as temperature ≥39°C and purulent (thick, colored, and opaque) nasal discharge present concurrently for atleast 3 consecutive days.b Defined as nasal discharge or daytime cough with sudden worsening of symptoms (manifested by new-onset fever ≥38°C/100.4°F or substantial increase in nasal discharge or cough) after having experienced transient improvement ofsymptoms.c Defined as nasal discharge (of any quality), daytime cough (which may be worse at night), or both, persisting for >10days without improvement.d Opportunity for shared decision-making with the child’s family; if observation is offered, a mechanism must be in placeto ensure follow-up and begin antibiotics if the child worsens at any time or fails to improve within 3 days of observation.

e270 FROM THE AMERICAN ACADEMY OF PEDIATRICS by guest on March 10, 2019www.aappublications.org/newsDownloaded from

Page 10: CLINICAL PRACTICE GUIDELINE Clinical Practice Guideline ... · CLINICAL PRACTICE GUIDELINE Clinical Practice Guideline for the Diagnosis and Management of Acute Bacterial Sinusitis

likely to be resistant to amoxicillin in-clude attendance at child care, receiptof antimicrobial treatment within theprevious 30 days, and age youngerthan 2 years.50,55,60

Amoxicillin remains the antimicrobialagent of choice for first-line treatmentof uncomplicated acute bacterial si-nusitis in situations in which antimi-crobial resistance is not suspected.This recommendation is based onamoxicillin’s effectiveness, safety, ac-ceptable taste, low cost, and relativelynarrow microbiologic spectrum. Forchildren aged 2 years or older withuncomplicated acute bacterial sinusi-tis that is mild to moderate in degreeof severity who do not attend childcare and who have not been treatedwith an antimicrobial agent within thelast 4 weeks, amoxicillin is recom-mended at a standard dose of 45 mg/kgper day in 2 divided doses. In com-munities with a high prevalence ofnonsusceptible S pneumoniae (>10%,including intermediate- and high-levelresistance), treatment may be initi-ated at 80 to 90 mg/kg per day in 2divided doses, with a maximum of 2 gper dose.55 This high-dose amoxicillintherapy is likely to achieve sinus fluidconcentrations that are adequateto overcome the resistance of Spneumoniae, which is attributable toalteration in penicillin-binding pro-teins on the basis of data derivedfrom patients with AOM.61 If, within thenext several years after licensure ofPCV-13, a continuing decrease in iso-lates of S pneumoniae (including adecrease in isolates of nonsusceptibleS pneumoniae) and an increase inβ-lactamase–producing H influenzaeare observed, standard-dose amoxicillin-clavulanate (45 mg/kg per day) may bemost appropriate.

Patients presenting with moderate tosevere illness as well as those youngerthan 2 years, attending child care, orwho have recently been treated with

an antimicrobial may receive high-dose amoxicillin-clavulanate (80–90mg/kg per day of the amoxicillincomponent with 6.4 mg/kg per dayof clavulanate in 2 divided doseswith a maximum of 2 g per dose).The potassium clavulanate levels areadequate to inhibit all β-lactamase–producing H influenzae and M catar-rhalis.56,59

A single 50-mg/kg dose of ceftriaxone,given either intravenously or intra-muscularly, can be used for childrenwho are vomiting, unable to tolerate oralmedication, or unlikely to be adherent tothe initial doses of antibiotic.62–64 The3 major bacterial pathogens involved inacute bacterial sinusitis are susceptibleto ceftriaxone in 95% to 100% ofcases.56,58,59 If clinical improvement isobserved at 24 hours, an oral antibioticcan be substituted to complete thecourse of therapy. Children who are stillsignificantly febrile or symptomatic at24 hours may require additional par-enteral doses before switching to oraltherapy.

The treatment of patients with pre-sumed allergy to penicillin has beencontroversial. However, recent pub-lications indicate that the risk ofa serious allergic reaction to second-and third-generation cephalosporinsin patients with penicillin or amoxi-cillin allergy appears to be almost niland no greater than the risk amongpatients without such allergy.65–67

Thus, patients allergic to amoxicillinwith a non–type 1 (late or delayed,>72 hours) hypersensitivity reac-tion can safely be treated with cefdinir,cefuroxime, or cefpodoxime.66–68

Patients with a history of a serioustype 1 immediate or accelerated(anaphylactoid) reaction to amoxicillincan also safely be treated withcefdinir, cefuroxime, or cefpodoxime.In both circumstances, clinicians maywish to determine individual toleranceby referral to an allergist for penicillin

and/or cephalosporin skin-testing be-fore initiation of therapy.66–68 Thesusceptibility of S pneumoniae tocefdinir, cefpodoxime, and cefuroximevaries from 60% to 75%,56–59 and thesusceptibility of H influenzae to theseagents varies from 85% to 100%.56,58

In young children (<2 years) witha serious type 1 hypersensitivity topenicillin and moderate or more se-vere sinusitis, it may be prudent touse a combination of clindamycin (orlinezolid) and cefixime to achieve themost comprehensive coverage againstboth resistant S pneumoniae and Hinfluenzae. Linezolid has excellent ac-tivity against all S pneumoniae, in-cluding penicillin-resistant strains, butlacks activity against H influenzae andM catarrhalis. Alternatively, a quino-lone, such as levofloxacin, which hasa high level of activity against both Spneumoniae and H influenzae, maybe prescribed.57,58 Although the useof quinolones is usually restricted be-cause of concerns for toxicity, cost,and emerging resistance, their usein this circumstance can be justified.

Pneumococcal and H influenzae sur-veillance studies have indicated thatresistance of these organisms totrimethoprim-sulfamethoxazole andazithromycin is sufficient to precludetheir use for treatment of acute bacte-rial sinusitis in patients with penicillinhypersensitivity.56,58,59,69

The optimal duration of antimicrobialtherapy for patients with acute bac-terial sinusitis has not received sys-tematic study. Recommendationsbased on clinical observations havevaried widely, from 10 to 28 days oftreatment. An alternative suggestionhas been made that antibiotic therapybe continued for 7 days after the pa-tient becomes free of signs andsymptoms.5 This strategy has the ad-vantage of individualizing the treat-ment of each patient, results in aminimum course of 10 days, and

PEDIATRICS Volume 132, Number 1, July 2013 e271

FROM THE AMERICAN ACADEMY OF PEDIATRICS

by guest on March 10, 2019www.aappublications.org/newsDownloaded from

Page 11: CLINICAL PRACTICE GUIDELINE Clinical Practice Guideline ... · CLINICAL PRACTICE GUIDELINE Clinical Practice Guideline for the Diagnosis and Management of Acute Bacterial Sinusitis

avoids prolonged antimicrobial ther-apy in patients who are asymptomaticand therefore unlikely to adhere tothe full course of treatment.5

Patients who are acutely ill and appeartoxic when first seen (see below) canbe managed with 1 of 2 options.Consultation can be requested from anotolaryngologist for consideration ofmaxillary sinus aspiration (with ap-propriate analgesia/anesthesia) toobtain a sample of sinus secretionsfor Gram stain, culture, and suscep-tibility testing so that antimicrobialtherapy can be adjusted precisely.Alternatively, inpatient therapy can beinitiated with intravenous cefotaximeor ceftriaxone, with referral to anotolaryngologist if the patient’s con-dition worsens or fails to show im-provement within 48 hours. If acomplication is suspected, manage-ment will differ depending on the siteand severity.

A recent guideline was published bythe Infectious Diseases Society ofAmerica for acute bacterial rhinosi-nusitis in children and adults.70

Their recommendation for initial em-pirical antimicrobial therapy for acutebacterial sinusitis in children wasamoxicillin-clavulanate based on theconcern that there is an increasingprevalence of H influenzae as a causeof sinusitis since introduction of thepneumococcal conjugate vaccinesand an increasing prevalence ofβ-lactamase production among thesestrains. In contrast, this guidelinefrom the AAP allows either amoxicillinor amoxicillin-clavulanate as first-lineempirical therapy and is thereforeinclusive of the Infectious DiseasesSociety of America’s recommendation.Unfortunately, there are scant dataavailable regarding the precise mi-crobiology of acute bacterial sinusitisin the post–PCV-13 era. Prospectivesurveillance of nasopharyngeal cul-tures may be helpful in completely

aligning these recommendations inthe future.

Key Action Statement 5A

Clinicians should reassess initialmanagement if there is eithera caregiver report of worsening(progression of initial signs/symptoms or appearance of newsigns/symptoms) OR failure toimprove (lack of reduction inall presenting signs/symptoms)within 72 hours of initial manage-ment (Evidence Quality: C; Recom-mendation).

The purpose of this key action state-ment is to ensure that patients withacute bacterial sinusitis who fail toimprove symptomatically after initialmanagement are reassessed to becertain that they have been correctlydiagnosed and to consider initiation ofalternate therapy to hasten resolutionof symptoms and avoid complications.“Worsening” is defined as progressionof presenting signs or symptoms ofacute bacterial sinusitis or onset ofnew signs or symptoms. “Failure toimprove” is lack of reduction in pre-senting signs or symptoms of acute

bacterial sinusitis by 72 hours afterdiagnosis and initial management;patients with persistent but improvingsymptoms do not meet this definition.

The rationale for using 72 hours as thetime to assess treatment failure foracute bacterial sinusitis is based onclinical outcomes in RCTs. Wald et al41

found that 18 of 35 patients (51%) re-ceiving placebo demonstrated symp-tomatic improvement within 3 days ofinitiation of treatment; only an addi-tional 3 patients receiving placebo(9%) improved between days 3 and 10.In the same study, 48 of 58 patients

(83%) receiving antibiotics werecured or improved within 3 days; at 10days, the overall rate of improvementwas 79%, suggesting that no addi-tional patients improved betweendays 3 and 10. In a more recent study,17 of 19 children who ultimatelyfailed initial therapy with either an-tibiotic or placebo demonstratedfailure to improve within 72 hours.4

Although Garbutt et al42 did not re-port the percentage of patients whoimproved by day 3, they did demon-strate that the majority of improve-ment in symptoms occurred within

KAS Profile 5A

Aggregate evidence quality: C; observational studies

Benefits Identification of patients who may have been misdiagnosed,those at risk of complications, and those who requirea change in management.

Harm Delay of up to 72 hours in changing therapy if patient fails toimprove.

Cost Additional provider and caregiver time and resources.Benefits-harm assessment Preponderance of benefit.Value judgments Use of 72 hours to assess progress may result in excessive

classification as treatment failures if premature; emphasison importance of worsening illness in defining treatmentfailures.

Role of patient preferences Caregivers determine whether the severity of the patient’sillness justifies the report to clinician of the patient’sworsening or failure to improve.

Intentional vagueness None.Exclusions Patients with severe illness, poor general health, complicated

sinusitis, immune deficiency, previous sinus surgery, orcoexisting bacterial illness.

Strength Recommendation.

e272 FROM THE AMERICAN ACADEMY OF PEDIATRICS by guest on March 10, 2019www.aappublications.org/newsDownloaded from

Page 12: CLINICAL PRACTICE GUIDELINE Clinical Practice Guideline ... · CLINICAL PRACTICE GUIDELINE Clinical Practice Guideline for the Diagnosis and Management of Acute Bacterial Sinusitis

the first 3 days of study entrywhether they received active treat-ment or placebo.

Reporting of either worsening orfailure to improve implies a sharedresponsibility between clinician andcaregiver. Although the clinicianshould educate the caregiver re-garding the anticipated reduction insymptoms within 3 days, it is in-cumbent on the caregiver to appro-priately notify the clinician of concernsregarding worsening or failure toimprove. Clinicians should emphasizethe importance of reassessing thosechildren whose symptoms are wors-ening whether or not antibiotic ther-apy was prescribed. Reassessmentmay be indicated before the 72-hour

mark if the patient is substantiallyworse, because it may indicate thedevelopment of complications ora need for parenteral therapy. Con-versely, in some cases, caregiversmay think that symptoms are notsevere enough to justify a change toan antibiotic with a less desirablesafety profile or even the time, effort,and resources required for reas-sessment. Accordingly, the circum-stances under which caregiversreport back to the clinician and the

process by which such reportingoccurs should be discussed at thetime the initial management strategyis determined.

Key Action Statement 5B

If the diagnosis of acute bacterialsinusitis is confirmed in a childwith worsening symptoms or fail-ure to improve in 72 hours, thenclinicians may change the antibi-otic therapy for the child initiallymanaged with antibiotic OR initiateantibiotic treatment of the childinitially managed with observation(Evidence Quality: D; Option basedon expert opinion, case reports,and reasoning from first princi-ples).

The purpose of this key action state-ment is to ensure optimal antimicro-bial treatment of children with acutebacterial sinusitis whose symptomsworsen or fail to respond to the initialintervention to prevent complicationsand reduce symptom severity andduration (see Table 4).

Clinicians who are notified by a care-giver that a child’s symptoms areworsening or failing to improveshould confirm that the clinical di-agnosis of acute bacterial sinusitis

corresponds to the patient’s patternof illness, as defined in Key ActionStatement 1. If caregivers reportworsening of symptoms at any time ina patient for whom observation wasthe initial intervention, the clinicianshould begin treatment as discussedin Key Action Statement 4. For patientswhose symptoms are mild and whohave failed to improve but have notworsened, initiation of antimicrobialagents or continued observation (forup to 3 days) is reasonable.

If caregivers report worsening ofsymptoms after 3 days in a patientinitially treated with antimicrobialagents, current signs and symptomsshould be reviewed to determinewhether acute bacterial sinusitis isstill the best diagnosis. If sinusitis isstill the best diagnosis, infection withdrug-resistant bacteria is probable,and an alternate antimicrobial agentmay be administered. Face-to-facereevaluation of the patient is desir-able. Once the decision is made tochange medications, the clinicianshould consider the limitations of theinitial antibiotic coverage, the antici-pated susceptibility of residual bacte-rial pathogens, and the ability ofantibiotics to adequately penetratethe site of infection. Cultures of sinusor nasopharyngeal secretions in pa-tients with initial antibiotic failurehave identified a large percentageof bacteria with resistance to theoriginal antibiotic.71,72 Furthermore,multidrug-resistant S pneumoniaeand β-lactamase–positive H influenzaeand M catarrhalis are more commonlyisolated after previous antibiotic expo-sure.73–78 Unfortunately, there are nostudies in children that have inves-tigated the microbiology of treatmentfailure in acute bacterial sinusitis orcure rates using second-line antimi-crobial agents. As a result, the likeli-hood of adequate antibiotic coveragefor resistant organisms must be

KAS Profile 5B

Aggregate evidence quality: D; expert opinion and reasoning from first principles.

Benefit Prevention of complications, administration of effective therapy.Harm Adverse effects of secondary antibiotic therapy.Cost Direct cost of medications, often substantial for second-line

agents.Benefits-harm assessment Preponderance of benefit.Value judgments Clinician must determine whether cost and adverse effects

associated with change in antibiotic is justified given theseverity of illness.

Role of patient preferences Limited in patients whose symptoms are severe or worsening,but caregivers of mildly affected children who are failing toimprove may reasonably defer change in antibiotic.

Intentional vagueness None.Exclusions None.Strength Option.

PEDIATRICS Volume 132, Number 1, July 2013 e273

FROM THE AMERICAN ACADEMY OF PEDIATRICS

by guest on March 10, 2019www.aappublications.org/newsDownloaded from

Page 13: CLINICAL PRACTICE GUIDELINE Clinical Practice Guideline ... · CLINICAL PRACTICE GUIDELINE Clinical Practice Guideline for the Diagnosis and Management of Acute Bacterial Sinusitis

addressed by extrapolations fromstudies of acute otitis media in chil-dren and sinusitis in adults and byusing the results of data generatedin vitro. A general guide to manage-ment of the child who worsens in 72hours is shown in Table 4.

NO RECOMMENDATION

Adjuvant Therapy

Potential adjuvant therapy for acutesinusitis might include intranasalcorticosteroids, saline nasal irrigationor lavage, topical or oral decongest-ants, mucolytics, and topical or oralantihistamines. A recent Cochranereview on decongestants, antihist-amines, and nasal irrigation for acutesinusitis in children found no appro-priately designed studies to determinethe effectiveness of these inter-ventions.79

Intranasal Steroids

The rationale for the use of intranasalcorticosteroids in acute bacterial si-nusitis is that an antiinflammatoryagent may reduce the swelling aroundthe sinus ostia and encourage drain-age, thereby hastening recovery. How-ever, there are limited data on howmuch inflammation is present, whetherthe inflammation is responsive to ste-roids, and whether there are dif-ferences in responsivity according toage. Nonetheless, there are several RCTsin adolescents and adults, most of whichdo show significant differences com-pared with placebo or active compara-tor that favor intranasal steroids in thereduction of symptoms and the patient’sglobal assessment of overall improve-ment.80–85 Several studies in adults withacute bacterial sinusitis provide datasupporting the use of intranasal ste-roids as either monotherapy or adju-vant therapy to antibiotics.81,86 Only onestudy did not show efficacy.85

There have been 2 trials of intranasalsteroids performed exclusively in

children: one comparing intranasalcorticosteroids versus an oral de-congestant87 and the other comparingintranasal corticosteroids with pla-cebo.88 These studies showed a great-er rate of complete resolution87 orgreater reduction in symptoms inpatients receiving the steroid prepa-ration, although the effects weremodest.88 It is important to note thatnearly all of these studies (both thosereported in children and adults) suf-fered from substantial methodologicproblems. Examples of these meth-odologic problems are as follows: (1)variable inclusion criteria for sinusitis,(2) mixed populations of allergic andnonallergic subjects, and (3) differentoutcome criteria. All of these factorsmake deriving a clear conclusion dif-ficult. Furthermore, the lack of strin-gent criteria in selecting the subjectpopulation increases the chance thatthe subjects had viral URIs or evenpersistent allergies rather than acutebacterial sinusitis.

The intranasal steroids studied to dateinclude budesonide, flunisolide, fluti-casone, and mometasone. There is noreason to believe that one steroidwould be more effective than another,provided equivalent doses are used.

Potential harm in using nasal steroidsin children with acute sinusitis in-cludes the increased cost of therapy,difficulty in effectively administeringnasal sprays in young children, nasalirritation and epistaxis, and potentialsystemic adverse effects of steroiduse. Fortunately, no clinically signifi-cant steroid adverse effects have beendiscovered in studies in children.89–96

Saline Irrigation

Saline nasal irrigation or lavage (notsaline nasal spray) has been used toremove debris from the nasal cavityand temporarily reduce tissue edema(hypertonic saline) to promote drain-age from the sinuses. There have been

very few RCTs using saline nasal irri-gation or lavage in acute sinusitis, andthese have had mixed results.97,98 The1 study in children showed greaterimprovement in nasal airflow andquality of life as well as a better rateof improvement in total symptomscore when compared with placeboin patients treated with antibioticsand decongestants.98 There are 2Cochrane reviews published on theuse of saline nasal irrigation in acutesinusitis in adults that showed vari-able results. One review published in200799 concluded that it is a beneficialadjunct, but the other, published in2010,100 concluded that most trialswere too small or contained too higha risk of bias to be confident aboutbenefits.

Nasal Decongestants, Mucolytics, andAntihistamines

Data are insufficient to make anyrecommendations about the use oforal or topical nasal decongestants,mucolytics, or oral or nasal sprayantihistamines as adjuvant therapy foracute bacterial sinusitis in children.79

It is the opinion of the expert panelthat antihistamines should not beused for the primary indication ofacute bacterial sinusitis in any child,although such therapy might behelpful in reducing typical allergicsymptoms in patients with atopy whoalso have acute sinusitis.

OTHER RELATED CONDITIONS

Recurrence of Acute BacterialSinusitis

Recurrent acute bacterial sinusitis(RABS) is an uncommon occurrence inhealthy children and must be distin-guished from recurrent URIs, exacer-bations of allergic rhinitis, and chronicsinusitis. The former is defined byepisodes of bacterial infection of theparanasal sinuses lasting fewer than30 days and separated by intervals of

e274 FROM THE AMERICAN ACADEMY OF PEDIATRICS by guest on March 10, 2019www.aappublications.org/newsDownloaded from

Page 14: CLINICAL PRACTICE GUIDELINE Clinical Practice Guideline ... · CLINICAL PRACTICE GUIDELINE Clinical Practice Guideline for the Diagnosis and Management of Acute Bacterial Sinusitis

at least 10 days during which thepatient is asymptomatic. Some expertsrequire at least 4 episodes in a calen-dar year to fulfill the criteria for thiscondition. Chronic sinusitis is manifestas 90 or more uninterrupted days ofrespiratory symptoms, such as cough,nasal discharge, or nasal obstruction.

Children with RABS should be evalu-ated for underlying allergies, partic-ularly allergic rhinitis; quantitativeand functional immunologic defect(s),

chiefly immunoglobulin A and immu-noglobulin G deficiency; cystic fibrosis;gastroesophageal reflux disease; ordysmotile cilia syndrome.101 Anatom-ic abnormalities obstructing one ormore sinus ostia may be present.These include septal deviation, nasalpolyps, or concha bullosa (pneumati-zation of the middle turbinate); atypi-cal ethmoid cells with compromiseddrainage; a lateralized middle turbinate;and intrinsic ostiomeatal anomalies.102

Contrast-enhanced CT, MRI, or en-doscopy or all 3 should be performedfor detection of obstructive con-ditions, particularly in children withgenetic or acquired craniofacial ab-normalities.

The microbiology of RABS is similar tothat of isolated episodes of acutebacterial sinusitis and warrants thesame treatment.72 It should be rec-ognized that closely spaced sequentialcourses of antimicrobial therapy mayfoster the emergence of antibiotic-resistant bacterial species as thecausative agent in recurrent episodes.There are no systematically evaluatedoptions for prevention of RABS in chil-dren. In general, the use of prolongedprophylactic antimicrobial therapyshould be avoided and is not usuallyrecommended for children with re-current acute otitis media. However,when there are no recognizable pre-disposing conditions to remedy inchildren with RABS, prophylactic anti-microbial agents may be used forseveral months during the respiratoryseason. Enthusiasm for this strategy istempered by concerns regarding theencouragement of bacterial resistance.Accordingly, prophylaxis should onlybe considered in carefully selectedchildren whose infections have beenthoroughly documented.

Influenza vaccine should be administeredannually, and PCV-13 should be admin-istered at the recommended ages for allchildren, including those with RABS. In-tranasal steroids and nonsedating anti-histamines can be helpful for childrenwith allergic rhinitis, as can antirefluxmedications for those with gastro-esophageal reflux disease. Children withanatomic abnormalities may requireendoscopic surgery for removal of orreduction in ostiomeatal obstruction.

The pathogenesis of chronic sinusitisis poorly understood and appears tobe multifactorial; however, many ofthe conditions associated with RABS

TABLE 3 Parent Information Regarding Initial Management of Acute Bacterial Sinusitis

How common are sinus infections in children? Thick, colored, or cloudy mucus from your child’snose frequently occurs with a common cold orviral infection and does not by itself mean yourchild has sinusitis. In fact, fewer than 1 in 15children get a true bacterial sinus infectionduring or after a common cold.

How can I tell if my child has bacterialsinusitis or simply a common cold?

Most colds have a runny nose with mucus thattypically starts out clear, becomes cloudy or colored,and improves by about 10 d. Some colds will alsoinclude fever (temperature >38°C [100.4°F]) for 1 to2 days. In contrast, acute bacterial sinusitis islikely when the pattern of illness is persistent,severe, or worsening.1. Persistent sinusitis is the most common type,defined as runny nose (of any quality), daytimecough (which may be worse at night), or bothfor at least 10 days without improvement.

2. Severe sinusitis is present when fever(temperature ≥39°C [102.2°F]) lasts for at least3 days in a row and is accompanied by nasalmucus that is thick, colored, or cloudy.

3. Worsening sinusitis starts with a viral cold,which begins to improve but then worsenswhen bacteria take over and cause new-onsetfever (temperature ≥38°C [100.4°F]) ora substantial increase in daytime cough orrunny nose.

If my child has sinusitis, should he orshe take an antibiotic?

Children with persistent sinusitis may be managedwith either an antibiotic or with an additionalbrief period of observation, allowing the child upto another 3 days to fight the infection andimprove on his or her own. The choice to treat orobserve should be discussed with your doctorand may be based on your child’s quality of lifeand how much of a problem the sinusitis iscausing. In contrast, all children diagnosed withsevere or worsening sinusitis should startantibiotic treatment to help them recover fasterand more often.

Why not give all children with acute bacterialsinusitis an immediate antibiotic?

Some episodes of persistent sinusitis includerelatively mild symptoms that may improve ontheir own in a few days. In addition, antibioticscan have adverse effects, which may includevomiting, diarrhea, upset stomach, skin rash,allergic reactions, yeast infections, anddevelopment of resistant bacteria (that makefuture infections more difficult to treat).

PEDIATRICS Volume 132, Number 1, July 2013 e275

FROM THE AMERICAN ACADEMY OF PEDIATRICS

by guest on March 10, 2019www.aappublications.org/newsDownloaded from

Page 15: CLINICAL PRACTICE GUIDELINE Clinical Practice Guideline ... · CLINICAL PRACTICE GUIDELINE Clinical Practice Guideline for the Diagnosis and Management of Acute Bacterial Sinusitis

have also been implicated in chronicsinusitis, and it is clear that thereis an overlap between the 2 syn-dromes.101,102 In some cases, theremay be episodes of acute bacterialsinusitis superimposed on a chronicsinusitis, warranting antimicrobialtherapy to hasten resolution of theacute infection.

Complications of Acute BacterialSinusitis

Complications of acute bacterial si-nusitis should be diagnosed when thepatient develops signs or symptoms oforbital and/or central nervous system(intracranial) involvement. Rarely,complicated acute bacterial sinusitiscan result in permanent blindness,other neurologic sequelae, or death ifnot treated promptly and appropriately.Orbital complications have been clas-sified by Chandler et al.32 Intracranialcomplications include epidural orsubdural abscess, brain abscess, ve-nous thrombosis, and meningitis.

Periorbital and intraorbital inflam-mation and infection are the mostcommon complications of acute si-nusitis and most often are secondary toacute ethmoiditis in otherwise healthyyoung children. These disorders arecommonly classified in relation to theorbital septum; periorbital or preseptalinflammation involves only the eyelid,whereas postseptal (intraorbital) in-flammation involves structures of theorbit. Mild cases of preseptal cellulitis(eyelid <50% closed) may be treatedon an outpatient basis with appropriate

oral antibiotic therapy (high-doseamoxicillin-clavulanate for comprehen-sive coverage) for acute bacterial si-nusitis and daily follow-up until definiteimprovement is noted. If the patientdoes not improve within 24 to 48 hoursor if the infection is progressive, it isappropriate to admit the patient to thehospital for antimicrobial therapy.Similarly, if proptosis, impaired visualacuity, or impaired and/or painfulextraocular mobility is present on ex-amination, the patient should be hos-pitalized, and a contrast-enhanced CTshould be performed. Consultation withan otolaryngologist, an ophthalmolo-gist, and an infectious disease expert isappropriate for guidance regarding theneed for surgical intervention and theselection of antimicrobial agents.

Intracranial complications are mostfrequently encountered in previouslyhealthy adolescent males with frontalsinusitis.33,34 In patients with alteredmental status, severe headache, orPott’s puffy tumor (osteomyelitis ofthe frontal bone), neurosurgical con-sultation should be obtained. Acontrast-enhanced CT scan (preferablycoronal thin cut) of the head, orbits,and sinuses is essential to confirmintracranial or intraorbital suppurativecomplications; in such cases, in-travenous antibiotics should be startedimmediately. Alternatively, an MRI mayalso be desirable in some cases ofintracranial abnormality. Appropriateantimicrobial therapy for intraorbitalcomplications include vancomycin(to cover possible methicillin-resistant

S aureus or penicillin-resistant Spneumoniae) and either ceftriaxone,ampicillin-sulbactam, or piperacillin-tazobactam.103 Given the polymicrobialnature of sinogenic abscesses, cover-age for anaerobes (ie, metronidazole)should also be considered for intra-orbital complications and should bestarted in all cases of intracranial com-plications if ceftriaxone is prescribed.

Patients with small orbital, subperi-osteal, or epidural abscesses andminimal ocular and neurologic abnor-malities may be managed with in-travenous antibiotic treatment for 24 to48 hours while performing frequentvisual and mental status checks.104 Inpatients who develop progressive signsand symptoms, such as impaired visualacuity, ophthalmoplegia, elevated in-traocular pressure (>20 mm), severeproptosis (>5 mm), altered mentalstatus, headache, or vomiting, as wellas those who fail to improve within 24to 48 hours while receiving antibiotics,prompt surgical intervention anddrainage of the abscess should be un-dertaken.104 Antibiotics can be tailoredto the results of culture and sensitivitystudies when they become available.

AREAS FOR FUTURE RESEARCH

Since the publication of the originalguideline in 2001, only a small numberof high-quality studies of the diagnosisand treatment of acute bacterial si-nusitis in children have been pub-lished.5 Ironically, the number ofpublished guidelines on the topic (5)exceeds the number of prospective,

TABLE 4 Management of Worsening or Lack of Improvement at 72 Hours

Initial Management Worse in 72 Hours Lack of Improvement in 72 Hours

Observation Initiate amoxicillin with or without clavulanate Additional observation or initiate antibiotic based on shareddecision-making

Amoxicillin High-dose amoxicillin-clavulanate Additional observation or high-dose amoxicillin-clavulanatebased on shared decision-making

High-dose amoxicillin-clavulanate Clindamycina and cefixime OR linezolid and cefixime ORlevofloxacin

Continued high-dose amoxicillin-clavulanate OR clindamycina

and cefixime OR linezolid and cefixime OR levofloxacina Clindamycin is recommended to cover penicillin-resistant S pneumoniae. Some communities have high levels of clindamycin-resistant S pneumoniae. In these communities, linezolid ispreferred.

e276 FROM THE AMERICAN ACADEMY OF PEDIATRICS by guest on March 10, 2019www.aappublications.org/newsDownloaded from

Page 16: CLINICAL PRACTICE GUIDELINE Clinical Practice Guideline ... · CLINICAL PRACTICE GUIDELINE Clinical Practice Guideline for the Diagnosis and Management of Acute Bacterial Sinusitis

placebo-controlled clinical trials ofeither antibiotics or ancillary treat-ments of acute bacterial sinusitis.Thus, as was the case in 2001, thereare scant data on which to base rec-ommendations. Accordingly, areas forfuture research include the following:

Etiology

1. Reexamine the microbiology ofacute sinusitis in children in thepostpneumococcal conjugate vac-cine era and determine the valueof using newer polymerase chainreaction–based respiratory testingto document viral, bacterial, andpolymicrobial disease.

2. Correlate cultures obtained fromthe middle meatus of the maxillarysinus of infected children with cul-tures obtained from the maxillarysinus by puncture of the antrum.

3. Conduct more and larger studies tomore clearly define and correlatethe clinical findings with the variousavailable diagnostic criteria ofacute bacterial sinusitis (eg, sinusaspiration and treatment outcome).

4. Develop noninvasive strategies toaccurately diagnose acute bacte-rial sinusitis in children.

5. Develop imaging technology that dif-ferentiates bacterial infection fromviral infection or allergic inflamma-tion, preferably without radiation.

Treatment

1. Determine the optimal duration ofantimicrobial therapy for childrenwith acute bacterial sinusitis.

2. Evaluate a “wait-and-see prescrip-tion” strategy for children with

persistent symptom presentationof acute sinusitis.

3. Determine the optimal antimicro-bial agent for children with acutebacterial sinusitis, balancing theincentives of choosing narrow-spectrum agents against the knownmicrobiology of the disease and re-sistance patterns of likely patho-gens.

4. Determine the causes and treat-ment of subacute, recurrent acute,and chronic bacterial sinusitis.

5. Determine the efficacy of prophy-laxis with antimicrobial agents toprevent RABS.

6. Determine the effects of bacterialresistance among S pneumoniae,H influenzae, and M catarrhalison outcome of treatment with anti-biotics by the performance ofrandomized, double-blind, placebo-controlled studies in well-definedpopulations of patients.

7. Determine the role of adjuvanttherapies (antihistamines, nasalcorticosteroids, mucolytics, decon-gestants, nasal irrigation, etc) inpatients with acute bacterial si-nusitis by the performance of pro-spective, randomized clinicaltrials.

8. Determine whether early treat-ment of acute bacterial sinusitisprevents orbital or central ner-vous system complications.

9. Determine the role of complemen-tary and alternative medicinestrategies in patients with acutebacterial sinusitis by performingsystematic, prospective, random-ized clinical trials.

10. Develop new bacterial and viralvaccines to reduce the incidenceof acute bacterial sinusitis.

SUBCOMMITTEE ON ACUTE SINUSITISEllen R. Wald, MD, FAAP (Chair, Pediatric In-fectious Disease Physician: no financial con-flicts; published research related to sinusitis)Kimberly E. Applegate, MD, MS, FAAP (Radi-ologist, AAP Section on Radiology: no conflicts)Clay Bordley, MD, MPH, FAAP (PediatricEmergency and Hospitalist Medicine physician:no conflicts)David H. Darrow, MD, FAAP (Otolaryngologist,AAP Section on Otolaryngology–Head and NeckSurgery: no conflicts)Mary P. Glode, MD, FAAP (Pediatric InfectiousDisease Physician, AAP Committee on InfectiousDisease: no conflicts)S. Michael Marcy, MD, FAAP (General Pedia-trician with Infectious Disease Expertise, AAPSection on Infectious Diseases: no conflicts)Nader Shaikh, MD, FAAP (General AcademicPediatrician: no financial conflicts; publishedresearch related to sinusitis)Michael J. Smith, MD, MSCE, FAAP (Epide-miologist, Pediatric Infectious Disease Physi-cian: research funding for vaccine clinicaltrials from Sanofi Pasteur and Novartis)Paul V. Williams, MD, FAAP (Allergist, AAPSection on Allergy, Asthma, and Immunology:no conflicts)Stuart T. Weinberg, MD, FAAP (PPI Informa-tician, General Academic Pediatrician: no con-flicts)Carrie E. Nelson, MD, MS (Family Physician,American Academy of Family Physicians:employed by McKesson Health Solutions)Richard M. Rosenfeld, MD, MPH, FAAP (Oto-laryngologist, AAP Section on Otolaryngology–Head and Neck Surgery, American Academy ofOtolaryngology–Head and Neck Surgery: no fi-nancial conflicts; published research related tosinusitis)

CONSULTANTRichard N. Shiffman, MD, FAAP (Informa-tician, Guideline Methodologist, General Aca-demic Pediatrician: no conflicts)

STAFFCaryn Davidson, MA

REFERENCES

1. Aitken M, Taylor JA. Prevalence of clinicalsinusitis in young children followed up byprimary care pediatricians. Arch PediatrAdolesc Med. 1998;152(3):244–248

2. Kakish KS, Mahafza T, Batieha A, Ekteish F,Daoud A. Clinical sinusitis in children at-tending primary care centers. PediatrInfect Dis J. 2000;19(11):1071–1074

3. Ueda D, Yoto Y. The ten-day mark asa practical diagnostic approach for acuteparanasal sinusitis in children. PediatrInfect Dis J. 1996;15(7):576–579

PEDIATRICS Volume 132, Number 1, July 2013 e277

FROM THE AMERICAN ACADEMY OF PEDIATRICS

by guest on March 10, 2019www.aappublications.org/newsDownloaded from

Page 17: CLINICAL PRACTICE GUIDELINE Clinical Practice Guideline ... · CLINICAL PRACTICE GUIDELINE Clinical Practice Guideline for the Diagnosis and Management of Acute Bacterial Sinusitis

4. Wald ER, Nash D, Eickhoff J. Effectivenessof amoxicillin/clavulanate potassium inthe treatment of acute bacterial sinusitisin children. Pediatrics. 2009;124(1):9–15

5. American Academy of Pediatrics, Sub-committee on Management of Sinusitisand Committee on Quality Improvement.Clinical practice guideline: managementof sinusitis. Pediatrics. 2001;108(3):798–808

6. Smith MJ. AAP technical report: evidencefor the diagnosis and treatment of acuteuncomplicated sinusitis in children:a systematic review. 2013, In press.

7. Shiffman RN, Michel G, Rosenfeld RM,Davidson C. Building better guidelineswith BRIDGE-Wiz: development and evalu-ation of a software assistant to promoteclarity, transparency, and implement-ability. J Am Med Inform Assoc. 2012;19(1):94–101

8. American Academy of Pediatrics, SteeringCommittee on Quality Improvement andManagement. Classifying recommenda-tions for clinical practice guidelines. Pe-diatrics. 2004;114(3):874–877

9. Gwaltney JM, Jr, Hendley JO, Simon G,Jordan WS Jr. Rhinovirus infections in anindustrial population. II. Characteristics ofillness and antibody response. JAMA.1967;202(6):494–500

10. Pappas DE, Hendley JO, Hayden FG,Winther B. Symptom profile of commoncolds in school-aged children. Pediatr In-fect Dis J. 2008;27(1):8–11

11. Wald ER, Guerra N, Byers C. Frequency andseverity of infections in day care: three-year follow-up. J Pediatr. 1991;118(4 pt 1):509–514

12. Wald ER, Guerra N, Byers C. Upper re-spiratory tract infections in young children:duration of and frequency of complications.Pediatrics. 1991;87(2):129–133

13. Meltzer EO, Hamilos DL, Hadley JA, et al.Rhinosinusitis: establishing definitions forclinical research and patient care. J Al-lergy Clin Immunol. 2004;114(6 suppl):155–212

14. Shaikh N, Wald ER. Signs and symptoms ofacute sinusitis in children. Pediatr InfectDis J. 2013; in press

15. Wald ER. The diagnosis and managementof sinusitis in children: diagnostic con-siderations. Pediatr Infect Dis. 1985;4(6suppl):S61–S64

16. Wald ER, Milmoe GJ, Bowen A, Ledesma-Medina J, Salamon N, Bluestone CD. Acutemaxillary sinusitis in children. N Engl JMed. 1981;304(13):749–754

17. Lindbaek M, Hjortdahl P, Johnsen UL. Useof symptoms, signs, and blood tests to

diagnose acute sinus infections in pri-mary care: comparison with computedtomography. Fam Med. 1996;28(3):183–188

18. Wald ER. Beginning antibiotics for acuterhinosinusitis and choosing the righttreatment. Clin Rev Allergy Immunol. 2006;30(3):143–152

19. Maresh MM, Washburn AH. Paranasalsinuses from birth to late adolescence. II.Clinical and roentgenographic evidence ofinfection. Am J Dis Child. 1940;60:841–861

20. Glasier CM, Mallory GB, Jr, Steele RW.Significance of opacification of the maxil-lary and ethmoid sinuses in infants. JPediatr. 1989;114(1):45–50

21. Kovatch AL, Wald ER, Ledesma-Medina J,Chiponis DM, Bedingfield B. Maxillary si-nus radiographs in children with non-respiratory complaints. Pediatrics. 1984;73(3):306–308

22. Shopfner CE, Rossi JO. Roentgen evalua-tion of the paranasal sinuses in children.Am J Roentgenol Radium Ther Nucl Med.1973;118(1):176–186

23. Diament MJ, Senac MO, Jr, Gilsanz V,Baker S, Gillespie T, Larsson S. Prevalenceof incidental paranasal sinuses opacifi-cation in pediatric patients: a CT study. JComput Assist Tomogr. 1987;11(3):426–431

24. Glasier CM, Ascher DP, Williams KD. In-cidental paranasal sinus abnormalities onCT of children: clinical correlation. AJNRAm J Neuroradiol. 1986;7(5):861–864

25. Gwaltney JM, Jr, Phillips CD, Miller RD,Riker DK. Computed tomographic study ofthe common cold. N Engl J Med. 1994;330(1):25–30

26. Manning SC, Biavati MJ, Phillips DL. Cor-relation of clinical sinusitis signs andsymptoms to imaging findings in pediatricpatients. Int J Pediatr Otorhinolaryngol.1996;37(1):65–74

27. Gordts F, Clement PA, Destryker A,Desprechins B, Kaufman L. Prevalence ofsinusitis signs on MRI in a non-ENT pae-diatric population. Rhinology. 1997;35(4):154–157

28. Kristo A, Uhari M, Luotonen J, et al. Par-anasal sinus findings in children duringrespiratory infection evaluated withmagnetic resonance imaging. Pediatrics.2003;111(5 pt 1):e586–e589

29. Brook I. Microbiology and antimicrobialtreatment of orbital and intracranialcomplications of sinusitis in children andtheir management. Int J Pediatr Oto-rhinolaryngol. 2009;73(9):1183–1186

30. Sultesz M, Csakanyi Z, Majoros T, Farkas Z,Katona G. Acute bacterial rhinosinusitisand its complications in our pediatric

otolaryngological department between1997 and 2006. Int J Pediatr Otorhinolar-yngol. 2009;73(11):1507–1512

31. Wald ER. Periorbital and orbital infections.Infect Dis Clin North Am. 2007;21(2):393–408

32. Chandler JR, Langenbrunner DJ, StevensER. The pathogenesis of orbital compli-cations in acute sinusitis. Laryngoscope.1970;80(9):1414–1428

33. Kombogiorgas D, Seth R, Modha J, SinghJ. Suppurative intracranial complicationsof sinusitis in adolescence. Single in-stitute experience and review of the lit-erature. Br J Neurosurg. 2007;21(6):603–609

34. Rosenfeld EA, Rowley AH. Infectious in-tracranial complications of sinusitis,other than meningitis in children: 12 yearreview. Clin Infect Dis. 1994;18(5):750–754

35. American College of Radiology. Appropri-ateness criteria for sinonasal disease.2009. Available at: www.acr.org/∼/media/8172B4DE503149248E64856857674BB5.pdf.Accessed November 6, 2012

36. Triulzi F, Zirpoli S. Imaging techniques inthe diagnosis and management of rhino-sinusitis in children. Pediatr AllergyImmunol. 2007;18(suppl 18):46–49

37. McIntosh D, Mahadevan M. Failure ofcontrast enhanced computed tomographyscans to identify an orbital abscess. Thebenefit of magnetic resonance imaging. JLaryngol Otol. 2008;122(6):639–640

38. Younis RT, Anand VK, Davidson B. The roleof computed tomography and magneticresonance imaging in patients with si-nusitis with complications. Laryngoscope.2002;112(2):224–229

39. Shapiro DJ, Gonzales R, Cabana MD, HershAL. National trends in visit rates and an-tibiotic prescribing for children withacute sinusitis. Pediatrics. 2011;127(1):28–34

40. Wald ER, Reilly JS, Casselbrant M, et al.Treatment of acute maxillary sinusitis inchildhood: a comparative study of amoxi-cillin and cefaclor. J Pediatr. 1984;104(2):297–302

41. Wald ER, Chiponis D, Ledesma-Medina J.Comparative effectiveness of amoxicillinand amoxicillin-clavulanate potassium inacute paranasal sinus infections in chil-dren: a double-blind, placebo-controlledtrial. Pediatrics. 1986;77(6):795–800

42. Garbutt JM, Goldstein M, Gellman E,Shannon W, Littenberg B. A randomized,placebo-controlled trial of antimicrobialtreatment for children with clinically di-agnosed acute sinusitis. Pediatrics. 2001;107(4):619–625

e278 FROM THE AMERICAN ACADEMY OF PEDIATRICS by guest on March 10, 2019www.aappublications.org/newsDownloaded from

Page 18: CLINICAL PRACTICE GUIDELINE Clinical Practice Guideline ... · CLINICAL PRACTICE GUIDELINE Clinical Practice Guideline for the Diagnosis and Management of Acute Bacterial Sinusitis

43. Kristo A, Uhari M, Luotonen J, Ilkko E,Koivunen P, Alho OP. Cefuroxime axetilversus placebo for children with acuterespiratory infection and imaging evi-dence of sinusitis: a randomized, con-trolled trial. Acta Paediatr. 2005;94(9):1208–1213

44. Hoberman A, Paradise JL, Rockette HE,et al. Treatment of acute otitis media inchildren under 2 years of age. N Engl JMed. 2011;364(2):105–115

45. Tahtinen PA, Laine MK, Huovinen P, JalavaJ, Ruuskanen O, Ruohola A. A placebo-controlled trial of antimicrobial treat-ment for acute otitis media. N Engl J Med.2011;364(2):116–126

46. Gordts F, Abu Nasser I, Clement PA,Pierard D, Kaufman L. Bacteriology of themiddle meatus in children. Int J PediatrOtorhinolaryngol. 1999;48(2):163–167

47. Parsons DS, Wald ER. Otitis media andsinusitis: similar diseases. OtolaryngolClin North Am. 1996;29(1):11–25

48. Revai K, Dobbs LA, Nair S, Patel JA, GradyJJ, Chonmaitree T. Incidence of acute oti-tis media and sinusitis complicating up-per respiratory tract infection: the effectof age. Pediatrics. 2007;119(6). Available at:www.pediatrics.org/cgi/content/full/119/6/e1408

49. Klein JO, Bluestone CD. Textbook of Pedi-atric Infectious Diseases. 6th ed. Phila-delphia, PA: Saunders; 2009

50. Casey JR, Adlowitz DG, Pichichero ME. Newpatterns in the otopathogens causingacute otitis media six to eight years afterintroduction of pneumococcal conjugatevaccine. Pediatr Infect Dis J. 2010;29(4):304–309

51. Brook I, Gober AE. Frequency of recoveryof pathogens from the nasopharynx ofchildren with acute maxillary sinusitisbefore and after the introduction of vac-cination with the 7-valent pneumococcalvaccine. Int J Pediatr Otorhinolaryngol.2007;71(4):575–579

52. Wald ER. Microbiology of acute andchronic sinusitis in children. J Allergy ClinImmunol. 1992;90(3 pt 2):452–456

53. Centers for Disease Control and Pre-vention. Effects of new penicillin suscep-tibility breakpoints for Streptococcuspneumoniae—United States, 2006-2007.MMWR Morb Mortal Wkly Rep. 2008;57(50):1353–1355

54. Centers for Disease Control and Preven-tion. Active Bacterial Core Surveillance(ABCs): Emerging Infections Program Net-work. 2011. Available at: www.cdc.gov/abcs/reports-findings/survreports/spneu09.html.Accessed November 6, 2012

55. Garbutt J, St Geme JW, III, May A, Storch GA,Shackelford PG. Developing community-specific recommendations for first-linetreatment of acute otitis media: is high-dose amoxicillin necessary? Pediatrics.2004;114(2):342–347

56. Harrison CJ, Woods C, Stout G, Martin B,Selvarangan R. Susceptibilities of Haemo-philus influenzae, Streptococcus pneumo-niae, including serotype 19A, andMoraxella catarrhalis paediatric isolatesfrom 2005 to 2007 to commonly usedantibiotics. J Antimicrob Chemother. 2009;63(3):511–519

57. Critchley IA, Jacobs MR, Brown SD,Traczewski MM, Tillotson GS, Janjic N.Prevalence of serotype 19A Streptococcuspneumoniae among isolates from U.S.children in 2005-2006 and activity of far-openem. Antimicrob Agents Chemother.2008;52(7):2639–2643

58. Jacobs MR, Good CE, Windau AR, et al. Ac-tivity of ceftaroline against recent emergingserotypes of Streptococcus pneumoniae inthe United States. Antimicrob Agents Che-mother. 2010;54(6):2716–2719

59. Tristram S, Jacobs MR, Appelbaum PC.Antimicrobial resistance in Haemophilusinfluenzae. Clin Microbiol Rev. 2007;20(2):368–389

60. Levine OS, Farley M, Harrison LH, LefkowitzL, McGeer A, Schwartz B. Risk factors forinvasive pneumococcal disease in chil-dren: a population-based case-controlstudy in North America. Pediatrics. 1999;103(3). Available at: www.pediatrics.org/cgi/content/full/103/3/e28

61. Seikel K, Shelton S, McCracken GH Jr.Middle ear fluid concentrations of amox-icillin after large dosages in children withacute otitis media. Pediatr Infect Dis J.1997;16(7):710–711

62. Cohen R, Navel M, Grunberg J, et al. Onedose ceftriaxone vs. ten days ofamoxicillin/clavulanate therapy for acuteotitis media: clinical efficacy and changein nasopharyngeal flora. Pediatr Infect DisJ. 1999;18(5):403–409

63. Green SM, Rothrock SG. Single-dose in-tramuscular ceftriaxone for acute otitismedia in children. Pediatrics. 1993;91(1):23–30

64. Leibovitz E, Piglansky L, Raiz S, Press J,Leiberman A, Dagan R. Bacteriologic andclinical efficacy of one day vs. three dayintramuscular ceftriaxone for treatmentof nonresponsive acute otitis media inchildren. Pediatr Infect Dis J. 2000;19(11):1040–1045

65. DePestel DD, Benninger MS, Danziger L,et al. Cephalosporin use in treatment of

patients with penicillin allergies. J AmPharm Assoc. 2008;48(4):530–540

66. Pichichero ME. A review of evidence sup-porting the American Academy of Pediat-rics recommendation for prescribingcephalosporin antibiotics for penicillin-allergic patients. Pediatrics. 2005;115(4):1048–1057

67. Pichichero ME, Casey JR. Safe use ofselected cephalosporins in penicillin-allergic patients: a meta-analysis. Oto-laryngol Head Neck Surg. 2007;136(3):340–347

68. Park MA, Koch CA, Klemawesch P, Joshi A,Li JT. Increased adverse drug reactions tocephalosporins in penicillin allergypatients with positive penicillin skin test.Int Arch Allergy Immunol. 2010;153(3):268–273

69. Jacobs MR. Antimicrobial-resistant Strep-tococcus pneumoniae: trends and man-agement. Expert Rev Anti Infect Ther. 2008;6(5):619–635

70. Chow AW, Benninger MS, Brook I, et al;Infectious Diseases Society of America.IDSA clinical practice guideline for acutebacterial rhinosinusitis in children andadults. Clin Infect Dis. 2012;54(8):e72–e112

71. Brook I, Gober AE. Resistance to anti-microbials used for therapy of otitis mediaand sinusitis: effect of previous antimi-crobial therapy and smoking. Ann OtolRhinol Laryngol. 1999;108(7 pt 1):645–647

72. Brook I, Gober AE. Antimicrobial re-sistance in the nasopharyngeal flora ofchildren with acute maxillary sinusitisand maxillary sinusitis recurring afteramoxicillin therapy. J Antimicrob Chemo-ther. 2004;53(2):399–402

73. Dohar J, Canton R, Cohen R, Farrell DJ,Felmingham D. Activity of telithromycinand comparators against bacterialpathogens isolated from 1,336 patientswith clinically diagnosed acute sinusitis.Ann Clin Microbiol Antimicrob. 2004;3(3):15–21

74. Jacobs MR, Bajaksouzian S, Zilles A, Lin G,Pankuch GA, Appelbaum PC. Susceptibili-ties of Streptococcus pneumoniae andHaemophilus influenzae to 10 oral anti-microbial agents based on pharmacody-namic parameters: 1997 U.S. surveillancestudy. Antimicrob Agents Chemother.1999;43(8):1901–1908

75. Jacobs MR, Felmingham D, Appelbaum PC,Gruneberg RN. The Alexander Project1998-2000: susceptibility of pathogensisolated from community-acquired re-spiratory tract infection to commonlyused antimicrobial agents. J AntimicrobChemother. 2003;52(2):229–246

PEDIATRICS Volume 132, Number 1, July 2013 e279

FROM THE AMERICAN ACADEMY OF PEDIATRICS

by guest on March 10, 2019www.aappublications.org/newsDownloaded from

Page 19: CLINICAL PRACTICE GUIDELINE Clinical Practice Guideline ... · CLINICAL PRACTICE GUIDELINE Clinical Practice Guideline for the Diagnosis and Management of Acute Bacterial Sinusitis

76. Lynch JP, III, Zhanel GG. Streptococcuspneumoniae: epidemiology and risk fac-tors, evolution of antimicrobial resistance,and impact of vaccines. Curr Opin PulmMed. 2010;16(3):217–225

77. Sahm DF, Jones ME, Hickey ML, Diakun DR,Mani SV, Thornsberry C. Resistance sur-veillance of Streptococcus pneumoniae,Haemophilus influenzae and Moraxellacatarrhalis isolated in Asia and Europe,1997-1998. J Antimicrob Chemother. 2000;45(4):457–466

78. Sokol W. Epidemiology of sinusitis in theprimary care setting: results from the1999-2000 respiratory surveillance pro-gram. Am J Med. 2001;111(suppl 9A):19S–24S

79. Shaikh N, Wald ER, Pi M. Decongestants,antihistamines and nasal irrigation foracute sinusitis in children. Cochrane Da-tabase Syst Rev. 2010;(12):CD007909

80. Dolor RJ, Witsell DL, Hellkamp AS, WilliamsJW, Jr, Califf RM, Simel DL. Comparison ofcefuroxime with or without intranasal flu-ticasone for the treatment of rhinosinusitis.The CAFFS Trial: a randomized controlledtrial. JAMA. 2001;286(24):3097–3105

81. Meltzer EO, Bachert C, Staudinger H.Treating acute rhinosinusitis: comparingefficacy and safety of mometasone furo-ate nasal spray, amoxicillin, and placebo.J Allergy Clin Immunol. 2005;116(6):1289–1295

82. Meltzer EO, Charous BL, Busse WW,Zinreich SJ, Lorber RR, Danzig MR. Addedrelief in the treatment of acute recurrentsinusitis with adjunctive mometasonefuroate nasal spray. The Nasonex SinusitisGroup. J Allergy Clin Immunol. 2000;106(4):630–637

83. Meltzer EO, Orgel HA, Backhaus JW, et al.Intranasal flunisolide spray as an adjunctto oral antibiotic therapy for sinusitis. JAllergy Clin Immunol. 1993;92(6):812–823

84. Nayak AS, Settipane GA, Pedinoff A, et al.Effective dose range of mometasonefuroate nasal spray in the treatment ofacute rhinosinusitis. Ann Allergy AsthmaImmunol. 2002;89(3):271–278

85. Williamson IG, Rumsby K, Benge S, et al.Antibiotics and topical nasal steroid fortreatment of acute maxillary sinusitis:a randomized controlled trial. JAMA. 2007;298(21):2487–2496

86. Zalmanovici A, Yaphe J. Intranasal ste-roids for acute sinusitis. Cochrane Data-base Syst Rev. 2009;(4):CD005149

87. Yilmaz G, Varan B, Yilmaz T, Gurakan B.Intranasal budesonide spray as an ad-junct to oral antibiotic therapy for acutesinusitis in children. Eur Arch Oto-rhinolaryngol. 2000;257(5):256–259

88. Barlan IB, Erkan E, Bakir M, Berrak S,Basaran MM. Intranasal budesonide sprayas an adjunct to oral antibiotic therapyfor acute sinusitis in children. Ann AllergyAsthma Immunol. 1997;78(6):598–601

89. Bruni FM, De Luca G, Venturoli V, Boner AL.Intranasal corticosteroids and adrenal sup-pression. Neuroimmunomodulation. 2009;16(5):353–362

90. Kim KT, Rabinovitch N, Uryniak T, SimpsonB, O’Dowd L, Casty F. Effect of budesonideaqueous nasal spray on hypothalamic-pituitary-adrenal axis function in chil-dren with allergic rhinitis. Ann AllergyAsthma Immunol. 2004;93(1):61–67

91. Meltzer EO, Tripathy I, Maspero JF, Wu W,Philpot E. Safety and tolerability of flutica-sone furoate nasal spray once daily in pae-diatric patients aged 6-11 years with allergicrhinitis: subanalysis of three randomized,double-blind, placebo-controlled, multicentrestudies. Clin Drug Investig. 2009;29(2):79–86

92. Murphy K, Uryniak T, Simpson B, O’Dowd L.Growth velocity in children with perennialallergic rhinitis treated with budesonideaqueous nasal spray. Ann Allergy AsthmaImmunol. 2006;96(5):723–730

93. Ratner PH, Meltzer EO, Teper A. Mometa-sone furoate nasal spray is safe and ef-fective for 1-year treatment of children withperennial allergic rhinitis. Int J PediatrOtorhinolaryngol. 2009;73(5):651–657

94. Skoner DP, Gentile DA, Doyle WJ. Effect ongrowth of long-term treatment with in-tranasal triamcinolone acetonide aque-ous in children with allergic rhinitis. Ann

Allergy Asthma Immunol. 2008;101(4):431–436

95. Weinstein S, Qaqundah P, Georges G,Nayak A. Efficacy and safety of tri-amcinolone acetonide aqueous nasalspray in children aged 2 to 5 years withperennial allergic rhinitis: a randomized,double-blind, placebo-controlled studywith an open-label extension. Ann AllergyAsthma Immunol. 2009;102(4):339–347

96. Zitt M, Kosoglou T, Hubbell J. Mometasonefuroate nasal spray: a review of safetyand systemic effects. Drug Saf. 2007;30(4):317–326

97. Adam P, Stiffman M, Blake RL Jr. A clinicaltrial of hypertonic saline nasal spray insubjects with the common cold or rhino-sinusitis. Arch Fam Med. 1998;7(1):39–43

98. Wang YH, Yang CP, Ku MS, Sun HL, Lue KH.Efficacy of nasal irrigation in the treat-ment of acute sinusitis in children. Int JPediatr Otorhinolaryngol. 2009;73(12):1696–1701

99. Harvey R, Hannan SA, Badia L, Scadding G.Nasal saline irrigations for the symptomsof chronic rhinosinusitis. Cochrane Data-base Syst Rev. 2007;(3):CD006394

100. Kassel JC, King D, Spurling GK. Saline na-sal irrigation for acute upper respiratorytract infections. Cochrane Database SystRev. 2010;(3):CD006821

101. Shapiro GG, Virant FS, Furukawa CT, Pier-son WE, Bierman CW. Immunologic defectsin patients with refractory sinusitis. Pe-diatrics. 1991;87(3):311–316

102. Wood AJ, Douglas RG. Pathogenesis andtreatment of chronic rhinosinusitis. Post-grad Med J. 2010;86(1016):359–364

103. Liao S, Durand ML, Cunningham MJ.Sinogenic orbital and subperiosteal ab-scesses: microbiology and methicillin-resistant Staphylococcus aureus in-cidence. Otolaryngol Head Neck Surg.2010;143(3):392–396

104. Oxford LE, McClay J. Medical and surgicalmanagement of subperiosteal orbital ab-scess secondary to acute sinusitis inchildren. Int J Pediatr Otorhinolaryngol.2006;70(11):1853–1861

e280 FROM THE AMERICAN ACADEMY OF PEDIATRICS by guest on March 10, 2019www.aappublications.org/newsDownloaded from

Page 20: CLINICAL PRACTICE GUIDELINE Clinical Practice Guideline ... · CLINICAL PRACTICE GUIDELINE Clinical Practice Guideline for the Diagnosis and Management of Acute Bacterial Sinusitis

originally published online June 24, 2013; Pediatrics Michael J. Smith, Paul V. Williams and Stuart T. Weinberg

Glode, S. Michael Marcy, Carrie E. Nelson, Richard M. Rosenfeld, Nader Shaikh, Ellen R. Wald, Kimberly E. Applegate, Clay Bordley, David H. Darrow, Mary P.

Sinusitis in Children Aged 1 to 18 YearsClinical Practice Guideline for the Diagnosis and Management of Acute Bacterial

ServicesUpdated Information &

013-1071http://pediatrics.aappublications.org/content/early/2013/06/19/peds.2including high resolution figures, can be found at:

Permissions & Licensing

http://www.aappublications.org/site/misc/Permissions.xhtmlin its entirety can be found online at: Information about reproducing this article in parts (figures, tables) or

Reprintshttp://www.aappublications.org/site/misc/reprints.xhtmlInformation about ordering reprints can be found online:

by guest on March 10, 2019www.aappublications.org/newsDownloaded from

Page 21: CLINICAL PRACTICE GUIDELINE Clinical Practice Guideline ... · CLINICAL PRACTICE GUIDELINE Clinical Practice Guideline for the Diagnosis and Management of Acute Bacterial Sinusitis

originally published online June 24, 2013; Pediatrics Michael J. Smith, Paul V. Williams and Stuart T. Weinberg

Glode, S. Michael Marcy, Carrie E. Nelson, Richard M. Rosenfeld, Nader Shaikh, Ellen R. Wald, Kimberly E. Applegate, Clay Bordley, David H. Darrow, Mary P.

Sinusitis in Children Aged 1 to 18 YearsClinical Practice Guideline for the Diagnosis and Management of Acute Bacterial

http://pediatrics.aappublications.org/content/early/2013/06/19/peds.2013-1071located on the World Wide Web at:

The online version of this article, along with updated information and services, is

http://pediatrics.aappublications.org/content/suppl/2018/12/28/peds.2013-1071.DC1Data Supplement at:

ISSN: 1073-0397. 60007. Copyright © 2013 by the American Academy of Pediatrics. All rights reserved. Print the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois,has been published continuously since 1948. Pediatrics is owned, published, and trademarked by Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it

by guest on March 10, 2019www.aappublications.org/newsDownloaded from