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798
BACKGROUND
METHODS
To develop the clinical practice guideline on the management
of acute bacterial sinusitis, the American Academy of Pediatrics
subcommittee partnered with the Agency for Healthcare Research
and Quality and colleague organizations from family practice and
otolaryngology. The Agency for Healthcare Research and Quality
worked with the New England Medical Center Evidence-based
Practice Center, as one of several centers that focus on conducting
systematic reviews of the literature. A full report was produced by
the New England Medical Center on the diagnosis and management of acute sinusitis.15 However, because there were only 5
randomized studies in children, a supplemental analysis was conducted that included nonrandomized pediatric trials. The subcommittee used both reports to form the practice guideline recommendations but relied heavily on the pediatric supplement.16
For the pediatric supplement, the major research questions to
be analyzed through the literature on acute bacterial sinusitis in
childhood were 1) evidence for the efficacy of various antibiotics
in children; 2) evidence for the efficacy of various ancillary, nonantibiotic regimens; and 3) the diagnostic accuracy and concordance of clinical symptoms, radiography (and other imaging
methods), and sinus aspiration.
The literature was searched in Medline, complemented by Excerpta Medica, from 1966 through March 1999, using the word
sinusitis. Search criteria were limited to human studies and
English language and appropriate pediatric terms. More than 1800
citations were reviewed. One hundred thirty-eight articles were
fully examined, resulting in 21 qualifying studies. These studies
included 5 controlled randomized trials and 8 case series on
antimicrobial therapy, 3 controlled randomized trials on ancillary
treatments, and 8 studies with information on diagnostic tests. The
heterogeneity and paucity of the data did not allow for formal
meta-analysis. When possible, rates were pooled across different
studies and heterogeneity assessed.
The draft clinical practice guideline underwent extensive peer
review by committees and sections within the American Academy
of Pediatrics and by numerous outside organizations. Liaisons to
the committee also distributed the draft within their organizations. Comments were compiled and reviewed by the subcommittee and relevant changes incorporated into the guideline.
The recommendations contained in this practice guideline are
based on the best available data. Where data are lacking, a combination of evidence and expert opinion was used. Strong recommendations were based on high-quality scientific evidence or,
when such was unavailable, strong expert consensus. Fair and
weak recommendations are based on lesser-quality or limited data
and expert consensus. Clinical options are identified as interventions for which the subcommittee could not find compelling positive or negative evidence. These clinical options are interventions
that a reasonable health care professional may or may not wish to
consider.
RECOMMENDATIONS
Methods of Diagnosis
799
consecutive days that helps to define the severe presentation of acute bacterial sinusitis.23 Children with
severe onset of acute bacterial sinusitis may have an
intense headache that is above or behind the eye; in
general, they seem to be moderately ill.
Unfortunately, the physical examination does not
generally contribute substantially to the diagnosis of
acute bacterial sinusitis. This is explained by the
similarity of physical findings in the patient with an
uncomplicated viral rhinosinusitis and the patient
with acute bacterial sinusitis.2 In both instances, examination of the nasal mucosa may show mild erythema and swelling of the nasal turbinates with
mucopurulent discharge. Facial pain is an unusual
complaint in children. Facial tenderness is a rare
finding in small children and may be unreliable as an
indicator of acute bacterial sinusitis in older children
and adolescents. Reproducible unilateral pain,
present on percussion or direct pressure over the
body of the frontal and maxillary sinuses, may indicate a diagnosis of acute bacterial sinusitis.27 Likewise, observed or reported periorbital swelling is
suggestive of ethmoid sinusitis. Examination of the
tympanic membranes, pharynx, and cervical lymph
nodes does not usually contribute to the diagnosis of
acute bacterial sinusitis.
The value of the performance of transillumination
of the sinuses to assess whether fluid is present in the
maxillary and frontal paranasal sinuses is controversial. The technique is performed in a completely
darkened room (after the examiners eyes are
adapted to the dark) by placing a transilluminator
(high-intensity light beam) either in the mouth or
against the cheek (for the maxillary sinuses) or under
the medial aspect of the supraorbital ridge area (for
the frontal sinuses) to assess the transmission of light
through the sinus cavity.27 Transillumination is difficult to perform correctly and has been shown to be
unreliable in children younger than 10 years.22,28 In
the older child it may be helpful at the extremes of
interpretation; if transillumination is normal, sinusitis is unlikely; if the transmission of light is absent,
the maxillary or frontal sinus is likely to be filled
with fluid.18
Subacute sinusitis is defined by the persistence of
mild to moderate and often intermittent respiratory
symptoms (nasal discharge, daytime cough, or both)
for between 30 and 90 days. The nasal discharge may
be of any quality, and cough is often worse at night.
Low-grade fever may be periodic but is usually not
prominent. The microbiology of subacute sinusitis is
the same as that observed in patients with acute
bacterial sinusitis.29
Patients with recurrent acute bacterial sinusitis are
defined as having had 3 episodes of acute bacterial
sinusitis in 6 months or 4 episodes in 12 months. The
response to antibiotics is usually brisk and the patient is completely free of symptoms between episodes.
The most common cause of recurrent sinusitis is
recurrent viral upper respiratory infection, often a
consequence of attendance at day care or the presence of an older school-age sibling in the household.
Other predisposing conditions include allergic and
nonallergic rhinitis, cystic fibrosis, an immunodeficiency disorder (insufficient or dysfunctional immunoglobulins), ciliary dyskinesia, or an anatomic
problem.23
Recommendation 2a
801
Recommendation 3
Antibiotics are recommended for the management of acute bacterial sinusitis to achieve a more
rapid clinical cure (strong recommendation based
on good evidence and strong panel consensus).
To promote the judicious use of antibiotics, it is
essential that children diagnosed as having acute
bacterial sinusitis meet the defining clinical presentations of persistent or severe disease as described previously.41 This will minimize the number
of children with uncomplicated viral upper respiratory tract infections who are treated with antimicrobials.
In a study comparing antimicrobial therapy with
placebo in the treatment of children with the clinical
and radiographic diagnosis of acute bacterial sinusitis, children receiving antimicrobial therapy recovered more quickly and more often than those
receiving placebo.31 On the third day of treatment,
83% of children receiving an antimicrobial were
cured or improved compared with 51% of the children in the placebo group. (Forty-five percent of
children receiving antimicrobial therapy were cured
[complete resolution of respiratory symptoms] compared with 11% receiving placebo.) On the 10th day
of treatment, 79% of children receiving an antimicrobial were cured or improved compared with 60% of
children receiving placebo. Approximately 50% to
60% of children will improve gradually without the
use of antimicrobials; however, the recovery of an
additional 20% to 30% is delayed substantially compared with children who receive appropriate antibiotics.
A recent study by Garbutt et al42 has challenged
the notion that children identified as having acute
sinusitis on clinical grounds alone (without the performance of images) will benefit from antimicrobial
therapy. When children randomized to low-dose antibiotic therapy were compared with those receiving
placebo there were no differences observed in outcome, either in the timing or frequency of recovery.
The discrepancy in results between this investigation
and the Wald31 study may be attributable to the
inclusion in this study of a larger cohort of older
children (who may not have had sinusitis) and the
exclusion of more seriously ill children with a temperature 39C or facial pain. Current recommendations for antibiotic management of uncomplicated
sinusitis vary depending on a previous history of
antibiotic exposure (in the previous 13 months),
attendance at day care, and age. Some of the children
in the Garbutt study might have qualified for highdose amoxicillin-clavulanate to overcome antimicrobial resistant pathogens.
Comparative bacteriologic cure rates in studies of
adults with acute sinusitis indicate the efficacy of
antimicrobial treatment.11,43 The findings of these
studies indicate that antimicrobials in adequate
doses with appropriate antibacterial spectra are
highly effective in eradicating or substantially reducing bacteria in the sinus cavity, whereas those with
inadequate spectrum or given in inadequate doses
are not (Table 1).
802
TABLE 1.
Comparative Bacteriologic Cure Rates (as Determined by Sinus Puncture) Among Adult Patients With Acute
Community-Acquired Bacterial Sinusitis*
Comment Regarding
Treatment
Antibiotic concentration was
MIC of causative bacteria
Antibiotic concentration was
MIC of causative bacteria
Appropriate antimicrobial and
dose given
Suboptimal dose given
Number (%) of
Bacteriologic Cures
19/21 (90)
15/33 (45)
278/300 (93)
53/76 (70)
TABLE 2.
Calculation of the Likelihood that a Child With Acute Bacterial Sinusitis Will Fail
Treatment With Standard Doses of Amoxicillin*
Bacterial Species
Prevalence
Spontaneous
Cure Rate
(%)
Prevalence of
Resistance
(%)
Failure to
Amoxicillin
(%)
Streptococcus pneumoniae
Haemophilus influenzae
Moraxella catarrhalis
30
20
20
15
50
5075
25
50
100
3
5
510
* This table is based on data obtained from treatment of acute otitis media.
Consider that 50% of resistant strains are highly resistant to penicillin and only highly resistant
isolates will fail to respond to standard doses of amoxicillin (45 mg/kg/day); Minimum inhibitory
concentration (MIC) of susceptible S pneumoniae 0.1 g/mL; MIC of moderately resistant S pneumoniae 0.11.0 g/mL; MIC of highly resistant S pneumoniae 2.0 g/mL.
The desire to continue to use amoxicillin as firstline therapy in patients suspected of having acute
bacterial sinusitis relates to its general effectiveness,
safety, and tolerability; low cost; and narrow spectrum. For children younger than 2 years of age with
uncomplicated acute bacterial sinusitis that is mild to
moderate in degree of severity, who do not attend
day care, and have not recently been treated with an
antimicrobial, amoxicillin is recommended at either a
usual dose of 45 mg/kg/d in 2 divided doses or a
high dose of 90 mg/kg/d in 2 divided doses (Fig 1).
If the patient is allergic to amoxicillin, either cefdinir
(14 mg/kg/d in 1 or 2 doses), cefuroxime (30 mg/
kg/d in 2 divided doses), or cefpodoxime (10 mg/
kg/d once daily) can be used (only if the allergic
reaction was not a type 1 hypersensitivity reaction).
In cases of serious allergic reactions, clarithromycin
(15 mg/kg/d in 2 divided doses) or azithromycin (10
mg/kg/d on day 1, 5 mg/kg/d 4 days as a single
daily dose) can be used in an effort to select an
antimicrobial of an entirely different class. The Food
and Drug Administration has not approved azithromycin for use in patients with sinusitis. Alternative
therapy in the penicillin-allergic patient who is
known to be infected with a penicillin-resistant S
pneumoniae is clindamycin at 30 to 40 mg/kg/d in 3
divided doses.
Most patients with acute bacterial sinusitis who
are treated with an appropriate antimicrobial agent
respond promptly (within 48 72 hours) with a diminution of respiratory symptoms (reduction of nasal
discharge and cough) and an improvement in general well-being.11,23,31 If a patient fails to improve,
either the antimicrobial is ineffective or the diagnosis
of sinusitis is not correct.
If patients do not improve while receiving the
usual dose of amoxicillin (45 mg/kg/d), have recently been treated with an antimicrobial, have an
illness that is moderate or more severe, or attend day
care, therapy should be initiated with high-dose
amoxicillin-clavulanate (80 90 mg/kg/d of amoxicillin component, with 6.4 mg/kg/d of clavulanate
in 2 divided doses). This dose of amoxicillin will
yield sinus fluid levels that exceed the minimum
inhibitory concentration of all S pneumoniae that are
intermediate in resistance to penicillin and most, but
not all, highly resistant S pneumoniae. There is sufficient potassium clavulanate to inhibit all -lactamase
producing H influenzae and M catarrhalis. Alternative
therapies include cefdinir, cefuroxime, or cefpo-
803
study in which children with presumed acute bacterial sinusitis were randomized to receive either decongestant-antihistamine or placebo in addition to
amoxicillin. The active treatment group received
topical oxymetazoline and oral decongestant-antihistamine syrup (brompheniramine and phenylpropanolamine). No difference in clinical or radiographic
resolution was noted between groups.56
There has been a single study of intranasal steroids
as an adjunct to antibiotics in young children with
presumed acute bacterial sinusitis. Intranasal budesonide spray had a modest effect on symptoms only
during the second week of therapy.57 A multicenter,
double-blind, randomized, parallel trial evaluating
flunisolide spray as an adjunct to oral antibiotic therapy was reported in patients at least 14 years of
age.58 The benefit of flunisolide was marginal and of
minimal clinical importance. There is little reason to
expect a substantial benefit from intranasal steroids
in patients with acute bacterial sinusitis when antibiotics work effectively in the first 3 to 4 days of
treatment.
No clinical trials of mucolytics have been reported
in nonatopic children or adults with acute bacterial
sinusitis.59 Neither saline nose drops nor nasal spray
have been studied in patients with acute bacterial
sinusitis. However, by preventing crust formation
and liquefying secretions, they may be helpful. In
addition, saline also may act as a mild vasoconstrictor of nasal blood flow.59 A method for performing a
nasal saline flush was reported anecdotally by
Schwartz.60
Antibiotic Prophylaxis
805
The extensive Medline searches to review the literature for the diagnosis and treatment of acute bacterial sinusitis in children uncovered the fact that
there are scant data on which to base recommendations. Accordingly, areas for future research include
the following:
1. Conduct more and larger studies correlating the
clinical findings of acute bacterial sinusitis with
findings of sinus aspiration, imaging, and treatment outcome.
2. Develop noninvasive strategies to accurately diagnose acute bacterial sinusitis in children.
a. Correlate cultures obtained from the middle
meatus of the maxillary sinus of infected individuals with cultures obtained from the
maxillary sinus by puncture of the antrum.
b. Develop imaging technology that differentiates bacterial infection from viral infection or
allergic inflammation.
c. Develop rapid diagnostic methods to image
the sinuses without radiation.
3. Determine the optimal duration of antimicrobial
therapy for children with acute bacterial sinusitis.
4. Determine the causes and treatment of subacute
and recurrent acute bacterial sinusitis.
5. Determine the efficacy of prophylaxis with antimicrobials to prevent recurrent acute bacterial
sinusitis.
6. Determine the impact of bacterial resistance
among S pneumoniae, H influenzae, and M catarrhalis on outcome of treatment with antibiotics
by the performance of randomized, doubleblind, placebo-controlled studies in well-defined
populations of patients.
7. Determine the role of adjuvant therapies (mucolytics, decongestants, antihistamines, etc) in
patients with acute bacterial sinusitis by the performance of prospective, randomized, clinical
trials.
8. Determine the role of complementary and alternative medicine strategies in patients with acute
bacterial sinusitis by performing systematic, prospective, randomized clinical trials.
9. Assess the effect of the pneumococcal conjugate
vaccine on the epidemiology of acute bacterial
sinusitis.
10. Develop new bacterial and viral vaccines to reduce the incidence of acute bacterial sinusitis.
CONCLUSION
This clinical practice guideline provides evidencebased recommendations for the management of bacterial rhinosinusitis in children ages 1 to 21 years.
The guideline emphasizes 1) appropriate diagnosis
in children who present with persistent or severe
upper respiratory symptoms; 2) the utility of imaging studies to confirm a diagnosis; 3) treatment therapies such as antibiotic use including prophylaxis,
adjuvant treatment, and alternative interventions;
and 4) management of complications. The guideline
provides decision-making strategies for managing
sinusitis to assist primary care providers in diagnosing and treating children with this common health
problem.
ACKNOWLEDGMENTS
The subcommittee wishes to acknowledge the Agency for
Healthcare Research and Quality and the New England Medical
Center Evidence-based Practice Center for their work in developing the evidence report. We especially thank John P. A. Ioannidis,
MD, and Joseph Lau, MD, for their work on the technical report.
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ERRATUM
A24
Downloaded from pediatrics.aappublications.org by guest on May 27, 2012
ERRATUM
The following is the correct clinical algorithm that accompanies Clinical Practice Guideline: Management of
Sinusitis (Pediatrics. 2001;108:798 808). Errors in the spelling and names of antimicrobial agents have been
corrected.
A40
Downloaded from pediatrics.aappublications.org by guest on May 27, 2012
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