Giving clinicians the option to wait up to 3 days before treating the most common presentation of acute bacterial sinusitis is among the changes to the American Academy of Pediatrics’ updated clinical practice guidelines for treating these infections.
About 5%-10% of upper respiratory tract infections in children develop into acute bacterial sinusitis, according to the new guidelines, published in Pediatrics.
Other changes include a new presentation, and discouraging the use of x-rays to confirm diagnosis. The guidelines published online were written by Dr. Ellen R. Wald, chair of pediatrics at the University of Wisconsin, Madison, and her associates (Pediatrics 2013 June 24 [doi:10.1542/peds.2013-1071]). The guidelines incorporated data from an accompanying systematic review of the research published since the last guidelines were issued in 2001.
The added presentation is a worsening course, defined as "worsening or new onset of nasal discharge, daytime cough, or fever after initial improvement." This presentation joins the existing severe onset (a fever of at least 39° C [102.2° F] with at least 3 days of a purulent nasal discharge) and, most common, persistent illness lasting more than 10 days without improvement.
For those with symptoms of nasal discharge, daytime cough, or fever lasting more than 10 days, clinicians may discuss with the parent whether to treat right away or wait a few days. For severe onset and worsening symptoms, clinicians should prescribe antibiotic therapy right away. First-line treatment is amoxicillin with or without clavulanate, followed by a reassessment of initial management if the symptoms worsen or do not improve within 72 hours.
The guidelines do not recommend adjuvant therapies, including intranasal corticosteroids, saline nasal irrigation or lavage, topical or oral decongestants, mucolytics, and topical or oral antihistamines.
Among the four major changes to the guidelines, including the updated evidence, the option for delayed treatment in nonsevere cases and the recommendation not to use imaging are especially relevant for clinical practice, according to Dr. Wald, a pediatric infectious disease specialist.
"When the AAP writes about this, they’re talking about it as joint decision making," Dr. Wald said in an interview. "If the parent really wants treatment at that time, I think the doctor’s going to want to do it. It’s being a little bit more permissive in tolerating the symptoms for a few more days. The clinician is given the option to treat immediately or, with the parents’ consent, they can wait a few days to see if the child gets better spontaneously."
Dr. Wald noted that the decision to treat can involve a trade-off, so these guidelines offer the clinicians more latitude in making the cost-benefit analysis with the parent, taking into account the illness severity, the child’s quality of life, and the parents’ values and concerns.
"The reason we like to treat it is that kids get better faster," Dr. Wald said. "On the one hand, we want the kid to get better faster, but on the other hand, we don’t want to use the antibiotic if we don’t have to because we want to avoid side effects or, from a public health perspective, the increased antibiotic resistance for the population." The most common side effect of antibiotics is diarrhea, she said; fewer patients may experience a rash.
The guideline discouraging imaging stems from findings that imaging offers little clinical benefit. "In the past, a diagnostician would get a set of x-rays to see if the sinuses were cloudy and confirm the diagnosis if they found cloudy sinuses," Dr. Wald said. "However, x-rays are frequently abnormal even in children with uncomplicated colds, so the x-rays are not a help. Therefore, we’re encouraging people to make the diagnosis only on clinical grounds."
However, the guidelines do encourage clinicians to get a "contrast-enhanced CT scan of the paranasal sinuses and/or an MRI with contrast whenever a child is suspected of having orbital or central nervous system complications of acute bacterial sinusitis" because discovered abscesses may require surgical intervention.
The systematic review, conducted by Dr. Michael J. Smith, a pediatric infectious disease specialist at the University of Louisville (Ky.), included evidence from 17 randomized controlled trials in the treatment of sinusitis in children (Pediatrics 2013 June 24 [doi:10.1542/peds.2013-1072]. All published since 2001, these trials add to the evidence base from the 21 studies published between 1966 and 1999 that were used in the previous guidelines.
Among the 17 new trials, 4 were randomized, double-blind, placebo-controlled trials of antimicrobial therapy used on a combined 392 children, but they were too heterogenous in criteria and results (2 favored treatment and 2 found no significant difference between treatment and control) to use in conducting a formal meta-analysis. Comparisons were further complicated by the long time span over which they were conducted, the introduction of universal conjugate pneumococcal vaccination, the increase in prevalence of other bacterial infections, and the variance in placebo group clinical improvement, ranging from 14% to 79% across the studies.