• Cincinnati Children's Hospital Medical Center. Evidence-based care guideline for management of acute bacterial sinusitis in children 1-18 years of age. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2006 Jul 7. 17 p. [107 references]

This is the current release of the guideline.

This guideline updates a previous version: Cincinnati Children's Hospital Medical Center. Evidence based clinical practice guideline for children with acute bacterial sinusitis in children 1 to 18 years of age. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2001 Apr 27. 17 p.

The guideline was reviewed for currency in August 2006 using updated literature searches, and was determined to be current.

Each recommendation is followed by evidence classification (A-X) identifying the type of supporting evidence. Definitions for the types of evidence are presented at the end of the "Major Recommendations" field.

Assessment and Diagnosis

See Table 1 of the original guideline document for clinical signs and symptoms consistent with a diagnosis of acute bacterial sinusitis (ABS).

Clinical Assessment

1. It is recommended that the diagnosis of ABS be made clinically in the presence of a constellation of signs and symptoms of at least 10 days duration without improvement (Wald et al., 1984 [B], Wald et al., 1981 [B], Aitken & Taylor, 1998 [C], Wald, Guerra, & Byers, 1991 [C]). No single symptom or sign is specific for the diagnosis of ABS. See Appendix 1 of the original guideline document for likelihood ratios for clinical signs and symptoms.
   • Note 1: The 10-day duration is suggested because it has been shown that, in most children with uncomplicated upper respiratory infections (URI), improvement is seen on average by 10 days (Wald et al., 1984 [B], Wald et al., 1981 [B], Wald, Guerra, & Byers, 1991 [C]).
   • Note 2: A less common presentation, acute severe bacterial sinusitis, represents a more toxic form of ABS in which severity of symptoms, rather than persistence of symptoms, is consistent with the diagnosis (Wald, 1994 [S], Fireman, 1992 [S]).  See Table 1 of the original guideline document.
2. It is recommended that the character of the nasal discharge not be used to make a diagnosis or as an indication for antibiotic treatment. The quantity, quality, and color of nasal discharge are not helpful in differentiating ABS from other upper respiratory illnesses (e.g., common cold, allergic rhinitis) (Wald et al., 1981 [B], Aitken & Taylor, 1998 [C], McLean, 1970 [D], Gungor & Corey, 1997 [S], Wald 1994 [S]).
   • Note: Physical exam is likely to reveal purulent nasal discharge and/or posterior oropharyngeal drainage. These findings, however, are non-specific and of little diagnostic usefulness (Wald, et al., 1981 [B], McLean, 1970 [D], Williams & Simel, 1993 [S], Fireman, 1992 [S]).

Radiologic Assessment

3. It is recommended that radiologic studies not be routinely obtained in the initial management of patients with suspected uncomplicated ABS (Engels et al., 2000 [M], Schwartz, Pitkaranta, & Winther, 2001 [C], American Academy of Pediatrics [AAP] 2001 [S], McAlister et al., 2000 [E], Diament 1992 [E]). See Appendix 1 of the original guideline document for likelihood ratios for radiologic studies.
   • Note 1: Abnormalities of the paranasal sinuses are found frequently on conventional radiographs and computed tomography (CT) scans in children without clinical evidence of sinusitis (see Table 3 in the original guideline document) (Rak et al., 1991 [C], Glasier, Mallory, & Steele, 1989 [C], Diament et al., 1987 [C], Glasier, Ascher, & Williams, 1986 [C], Odita et al., 1986 [C], Shopfner & Rossi, 1973 [C], Maresh 1940 [D]).
   • Note 2: The presence of a URI alone (without sinusitis) can result in mucosal thickening and abnormal findings in the paranasal sinuses on plain radiographs and CT scans (Glasier, Mallory, & Steele, 1989 [C], Glasier, Ascher, & Williams, 1986 [C], Shopfner & Rossi, 1973 [C], Gwaltney et al., 1994 [D]).
   • Note 3: Imaging findings may persist well after symptoms improve. CT abnormalities with the common cold may last up to two weeks after symptomatic improvement (Gwaltney et al., 1994 [D]). Magnetic resonance imaging (MRI) changes in patients with symptoms of ABS may last more than eight weeks (Leopold, 1994 [C]).
   • Note 4: "Limited" sinus CT lacks sensitivity in identifying air-fluid levels (Gross, 1991 [C]), suboptimally visualizes the osteomeatal complex 30% of the time, and misses 20 to 30% of the findings found on full CT (Wippold et al., 1995 [C]).
4. It is recommended, for older children with persistent clinical findings after unsuccessful therapy, or for children with clinical evidence of orbital or intracranial complications of ABS, that the decision to perform radiologic studies be made in collaboration with the consulting ophthalmologist or otolaryngologist (Oxford & McClay, 2005 [D], Vazquez et al., 2004 [D], AAP, 2001 [S], Local Expert Consensus [E]). See tables below titled "Radiologic Modalities for Suspected Complications of Acute Bacterial Sinusitis" for radiologic modalities and "Complications of Pediatric Acute Bacterial Sinusitis" for description of complications.
   • Note 1: An otolaryngology or ophthalmology consultation prior to obtaining radiologic studies in this patient population may reduce the need for an early study and limit repeat radiation exposure (Local Expert Consensus [E]).
   • Note 2: A clear or normal Water's view (occipitomental) may be helpful in ruling out significant maxillary sinus disease (Ros, Herman & Azar-Kia, 1995 [D], Lau et al., 1999 [S], Wald, 1988 [E]).

Table: Radiologic Modalities for Suspected Complications of Acute Bacterial Sinusitis

(Vazquez et al., 2004 [D], AAP 2001 [S], McAlister et al., 2000 [E], Local Expert Consensus [E])

Laboratory Assessment

5. It is recommended that routine laboratory testing such as a complete blood count (CBC) or nasopharyngeal culture not be obtained in the initial evaluation in children with uncomplicated ABS (Clement et al., 1998 [E]). See Appendix 1 in the original guideline document for likelihood ratios for laboratory studies
   • Note: Organisms recovered from nasopharyngeal washings and throat culture do not reflect the organisms found in sinus aspirate (Wald et al., 1981 [B]).
6. It is recommended that sinus aspiration and bacterial culture not be obtained for use in the initial evaluation and management of the child with uncomplicated ABS. They are recognized as the "gold standard" for definitive diagnosis of bacterial sinusitis and may need to be considered under the following situations (Wald et al., 1981 [B]):
   • Severe illness or toxic-looking child
   • Immunocompromised child
   • Presence of suppurative or intracranial complications

Management

General

The treatment of pediatric ABS is best considered in light of the duration and severity of symptoms and the increasing prevalence of resistant strains of a common sinus pathogen, Streptococcus pneumoniae. The treatment recommendations for this guideline were developed with a focus on antimicrobial activity against S. pneumoniae in an era of increasing penicillin resistance. It is prudent for clinicians to consider use of the most narrow-spectrum agent that is active against the likely pathogens for the initial antimicrobial treatment of ABS in children (Dowell, Schwartz, & Phillips, 1998 [E]).

See Appendix 2 in the original guideline document for antibiotic dosages.

Antibiotic Treatment

7. It is recommended that high-dose amoxicillin (80 to 90 mg/kg/day) or amoxicillin-clavulanate (with high-dose amoxicillin component) be first-line therapy for most patients with pediatric ABS (Wald, Chiponis & Ledesma-Medina, 1986 [B], AAP 2001 [S], Nash & Wald, 2001 [S], Dowell et al, 1999 [E], Friedland & McCracken, 1994 [E], Local Expert Consensus [E]). Treatment duration is 10 to 14 days to minimize the development of bacterial resistance (Morris & Leach, 2002 [M], Local Expert Consensus [E]). See Appendix 2 in the original guideline document.
   • Note 1: Approximately 65% of the S. pneumoniae isolated from non-sterile sites of children in Cincinnati in outpatient settings are resistant to penicillin (Cincinnati Children's Hospital Medical Center, 2005 [O]).
   • Note 2: It is recognized that the rates of S. pneumoniae resistance to penicillin are increasing nationally and locally (Butler et al., 1996 [C], Breiman et al., 1994 [C]) and failure with amoxicillin is likely to be due to resistant S. pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis (Whitney et al., 2000 [D]). Resistance of S. pneumoniae to penicillin (including amoxicillin) is mediated through alterations in the penicillin-binding proteins. Using high doses of amoxicillin saturates the penicillin-binding proteins, and is therefore considered a reasonable antibiotic option (Schrag et al., 2001 [A], Dagan et al., 2001 [C], Dowell et al., 1999 [E]). The clavulanic acid component of amoxicillin-clavulanate is active against resistant H. influenzae and M. catarrhalis (beta-lactamase enzyme) (Dagan et al., 2000 [A],  Wald, Chiponis, & Ledesma-Medina, 1986 [B]).
   • Note 3: Toxic-appearing children who demonstrate poor tolerance of oral intake may require initial parenteral therapy either as an outpatient or a short inpatient stay. Reassessment after initial stabilization may avoid unnecessary imaging and referral early in the course of therapy (Local Expert Consensus [E]).
8. It is recommended that cefuroxime, cefpodoxime, and cefdinir be second-line therapy for pediatric ABS (Pichichero et al., 1997 [C], Felmingham et al., 2005 [D], Jacobs et al., 2003 [D], Jacobs et al., 1999 [D], Anon et al., 2004 [S,E], Dowell et al., 1999 [E]). Treatment duration is 10 to 14 days to minimize the development of bacterial resistance (Morris & Leach, 2002 [M], Local Expert Consensus [E]). See Appendix 2 of the original guideline document.
9. It is recommended, if clinical failure with a second-line agent occurs, that alternative agents or combination therapy be considered:
   • Intramuscular (IM) ceftriaxone (5 days)
   • Combination therapy with adequate gram-positive and -negative coverage, such as clindamycin plus cefixime

   (Anon et al., 2004 [S,E], AAP 2001 [S], Local Expert Consensus [E]). See Appendix 2 of the original guideline document.

10. It is recommended, in the penicillin-allergic patient, that the following be used:
    • Non-type I¹: cefdinir, cefuroxime, or cefpodoxime
    • Type I²: clarithromycin or azithromycin

    (AAP 2001 [S], Local Expert Consensus [E]). See Appendix 2 in the original guideline document.

    • Note: Macrolides, azalides, and sulfa containing agents are not considered standard therapeutic agents due to either a lack of efficacy data, increasingly resistant S. pneumoniae, or both (Dagan et al., 2000 [A], Nelson, Mason & Kaplan, 1994 [C], Wu et al., 2004 [D], Gay et al., 2000 [D], AAP 2001 [S]).

    ¹ Non-type I penicillin allergy: more common; characterized by symptoms such as maculopapular, polymorphous rash, arthralgia, or emesis.

    ² Type I penicillin allergy: IgE-mediated; rare; anaphylactic reactions result in urticaria, pruritis, laryngeal edema, bronchospasm, cardiovascular collapse, and, potentially, death.

Symptomatic Treatment

11. It is recommended that common agents for symptomatic treatment of cough or congestion (i.e., reduction in frequency or severity), not be used in the routine management of patients with ABS (Schroeder & Fahey, 2004 [M], Bernard et al., 1999 [B], Davies et al.,1999 [B], Chang et al., 1998 [B], McCormick et al., 1996 [B], Taylor et al.,1993 [B], Gadomski & Horton, 1992 [O], Local Expert Consensus [E]).
    • Note 1: Studies measuring a decrease in frequency, severity, and time to resolution of cough or congestion in children with symptoms from URI found no significant difference between any of the therapeutic interventions and placebo. The therapies evaluated were antitussives, mucolytics, inhaled steroids, inhaled and oral beta₂-agonists, antihistamines/decongestants (brompheniramine, phenylephrine, phenylpropanolamine, dextromethorphan/guaifenesin, oxymetolazine or "afrin"), and morphine derivatives (codeine) (Schroeder& Fahey, 2004 [M], Paul et al., 2004 [A], Bernard et al., 1999 [B], Davies et al., 1999 [B], Chang et al., 1998 [B], McCormick et al., 1996 [B], Taylor et al., 1993 [B], Gadomski& Horton, 1992 [O]).
    • Note 2: One previously common ingredient (phenylpropanolamine) of symptomatic treatment preparations has been associated with stroke, and most antihistamines, decongestants, and antitussives have not been Food and Drug Administration (FDA) approved in children (Kernan et al., 2000 [D], AAP 1997 [S,E]).
    • Note 3: Although hypertonic and normal saline and balanced physiological saline nasal washes are commonly used in postoperative patients and in children with chronic sinusitis (Shoseyov et al., 1998 [B], Pigret & Janowski, 1996 [B], Nuutinen et al., 1986 [C]) there is no evidence for their effectiveness in pediatric ABS.

Follow Up

12. It is recommended that follow-up assessment for expected clinical response occur by 72 hours of antimicrobial therapy. A lack of expected clinical improvement may indicate that a change of antibiotic is necessary (Wald, Chiponis, & Ledesma-Medina, 1986 [B], Dowell et al., 1999 [E], Local Expert Consensus [E]).

Consults and Referrals

Although children with the complications discussed below (see Table below titled "Complications of Pediatric Acute Bacterial Sinusitis") are listed as exclusions to this guideline, recommendations are included here to assist the practitioner in decisions regarding consultation to specialists for these key complications.

13. It is recommended that an otolaryngology and/or ophthalmology consultation be sought when signs of impending suppurative complications of ABS are present (AAP, 2001 [S], Local Expert Consensus [E]). Such complications are rare but very serious and often result from orbital or intracranial spread of infection (Oxford & McClay, 2005 [D], Rosenfeld & Rowlay, 1994 [D]).
    • Note 1: Preseptal cellulitis, involving only tissue anterior to the orbital septum, manifests as lid edema/erythema, conjunctivitis, and fever. It may be treated with oral antibiotics and close follow up except where toxicity or specific symptoms preclude adequate antimicrobial effectiveness by mouth (AAP, 2001 [S]).
    • Note 2: Consultation prior to imaging limits repeat radiation exposure (Local Expert Consensus [E]).
14. It is recommended that otolaryngology consultation be considered in cases of a moderately to severely ill child with suspected acute frontal or sphenoid sinusitis because of the potential for intracranial spread. Infection arising in either site will generally occur in a relatively older age group (>6 years), and based on the developmental anatomy of these sinuses, the clinical presentation is likely to be more severe (Oxford & McClay, 2005 [D], Herrmann & Forsen, 2004 [D], Wolf, Anderhuber, & Kuhn, 1993 [F]).
    • Note 1: Acute frontal sinusitis manifests as an intense frontal headache with tenderness over the sinus itself. Spread of infection anteriorly produces periosteal edema and osteomyelitis and may manifest as doughiness of the forehead skin, known as Pott's puffy tumor. Spread of infection to the cranial vault results in meningitis or intracranial abscess (Oxford & McClay, 2005 [D]).
    • Note 2: Acute isolated sphenoid sinusitis is rare, with an estimated incidence of <1% of all sinusitis cases (Hnatuk, Macdonald, & Papsin, 1994 [S], Fearon, Edmonds, & Bird, 1979 [S], Wyllie, Kern, & Djalilian, 1973 [S]). Acute sphenoid sinusitis represents an elusive diagnosis (Myer et al., 1982 [S], Sellars, Goldberg, & Seid, 1975 [S], Postma, Chole, & Nemzek, 1995 [E]), as signs and symptoms are more variable and non-specific than those of frontal sinus disease. Nasal symptoms may be absent. Headache is severe, deep-seated and worse at night, with the pain radiating to any craniofacial region (Myer et al., 1982 [S], Sellars, Goldberg, & Seid, 1975 [S]). Suppurative complications may involve any of the vital juxtaposing structures, including the cavernous sinus, intracranial cavity, orbit, pituitary gland, or abducens nerve.

Table: Complications of Pediatric Acute Bacterial Sinusitis

(Oxford & McClay, 2005 [D], Vazquez 2004 [D], AAP, 2001 [S])

Parental Expectations and Education

15. It is recommended that, for a child with ABS, physicians explore parental expectations concerning the office visit, parental knowledge regarding respiratory infections, and preventive behavior (Mangione-Smith et al., 1999 [C], Barden et al., 1998 [C], Macfarlane et al., 1997 [C], Varonen & Sainio, 2004 [O], Local Expert Consensus [E]). Topics for discussion may include:
    • The natural history of URIs/ABS (Roberts et al.,1983 [A], Hamm, Hicks, & Bemben 1996 [C])
    • Diagnostic uncertainty (Varonen & Sainio, 2004 [O])
    • Viral and bacterial sources of ABS
    • Role of antibiotics (Hamm, Hicks, & Bemben, 1996 [C])
      • Appropriate use of antibiotics (Mangione-Smith et al., 1999 [C], Barden et al., 1998 [C], Macfarlane et al., 1997 [C])
      • Persistent or severe infections (Garbutt et al., 2001 [B], Wald, Chiponis, & Ledesma-Medina, 1986 [B])
    • Bacterial resistance (Trepka et al., 2001 [C])
    • Lack of proven efficacy for over-the-counter medications for symptom relief (Schroeder & Fahey, 2004 [M])
      • Managing cough symptoms
    • Observation for complications of ABS
    • Prevention of URIs may decrease risk of ABS
      • Handwashing (Morton & Schultz, 2004 [A], Roberts et al., 2000 [A])
      • Annual influenza vaccination (Loughlin et al., 2003 [D]).

Definitions:

Evidence Grading Scale

M: Meta-analysis or systematic review
A: Randomized controlled trial: large sample
B: Randomized controlled trial: small sample
C: Prospective trial or large case series
D: Retrospective analysis
O: Other evidence
S: Review article
E: Expert opinion or consensus
F: Basic laboratory research
L: Legal requirement
Q: Decision analysis
X: No evidence

An algorithm for the treatment of acute bacterial sinusitis is provided in the original guideline document.

The type of evidence is identified and graded for each recommendation (see "Major Recommendations").

Evidence Grading Scale

M: Meta-analysis
A: Randomized controlled trial: large sample
B: Randomized controlled trial: small sample
C: Prospective trial or large case series
D: Retrospective analysis
O: Other evidence
S: Review article
E: Expert opinion or consensus
F: Basic laboratory research
L: Legal requirement
Q: Decision analysis
X: No evidence

• Cincinnati Children's Hospital Medical Center. Evidence-based care guideline for management of acute bacterial sinusitis in children 1-18 years of age. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2006 Jul 7. 17 p. [107 references]

Not applicable: The guideline was not adapted from another source.

2001 (revised 2006 Jul 7; reviewed 2006 Aug)

Cincinnati Children's Hospital Medical Center - Hospital/Medical Center

Cincinnati Children's Hospital Medical Center

Acute Bacterial Sinusitis Team 2005-2006

Community Physician: *Stephen Bird, MD, Chair, Pediatrics

Cincinnati Children's Hospital Medical Center Physicians and Practitioners: *Amal Assa'ad, MD, Allergy/Immunology; Michael Gerber, MD, Infectious Diseases; *Bernadette Koch, MD, Radiology; *Paul Willging, MD, Otolaryngology; *Constance West, MD, Ophthalmology; Tiffany Raynor, MD, Otolaryngology; Patrick Brady, MD, Resident

Patient Services: *Dawn Butler, PharmD, Pharmacy; *Donna Hillman, RN, Emergency Dept

Division of Health Policy & Clinical Effectiveness Support: Eloise Clark, MPH, Facilitator; *Kieran Phelan, MD, Methodologist, General Pediatrics; Edward Donovan, MD, Medical Director, Clinical Effectiveness; Eduardo Mendez, RN, MPH, Dir. Evidence-Based Care; Danette Lopp-Stanko, MA, MPH, Epidemiologist; Carol Tierney, RN, MSN, Education Specialist; *Kate Rich, Lead Decision Support Analyst; Deborah Hacker, RN, Medical Reviewer

All Team Members and Clinical Effectiveness support staff listed above have signed a conflict of interest declaration.

Ad Hoc Advisors: *Uma Kotagal, MBBS, MSc, VP, Division Director; *Alan Brody, MD, Radiology; *Thomas DeWitt, MD, General & Community Pediatrics; *Richard Ruddy, MD, Emergency Medicine; *Michael Farrell, MD, Chief of Staff; *Beverly Connelly, MD, Director Infectious Diseases; Cheryl Hoying, RN, PhD, Sr. VP, Patient Services; *Barbarie Hill, Pratt Library

*Member of previous Acute Bacterial Sinusitis guideline development Team

The guideline was developed without external funding. All Team Members and Clinical Effectiveness support staff listed have declared whether they have any conflict of interest and none were identified.

This is the current release of the guideline.

This guideline updates a previous version: Cincinnati Children's Hospital Medical Center. Evidence based clinical practice guideline for children with acute bacterial sinusitis in children 1 to 18 years of age. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2001 Apr 27. 17 p.

The guideline was reviewed for currency in August 2006 using updated literature searches, and was determined to be current.

None available

This summary was completed by ECRI on March 28, 2002. The information was verified by the guideline developer on May 7, 2002. This NGC summary was updated by ECRI on September 29, 2006. The updated information was verified by the guideline developer on October 6, 2006. This summary was updated by ECRI Institute on October 3, 2007 following the U.S. Food and Drug Administration (FDA) advisory on Rocephin (ceftriaxone sodium).