HealthDay News — The American Academy of Pediatrics (AAP) has issued it’s first update to guidelines for diagnosing acute bacterial sinusitis in children since 2001. The new recommendations include persistent illness, worsening cough and severe onset of symptoms as diagnostic criteria.
Previous recommendations for imaging as a diagnostic tool have been downgraded, and the update emphasizes the importance of reserving antibiotics for only the worst cases, Ellen Wald, MD, chair of the AAP subcommittee on acute sinusitis and colleagues reported in Pediatrics.
When revising the guidelines, the committee reviewed medical literature published as far back as 1966, but focused on studies that have come out since 2001. Those performed as recently as November 2012 were included.
Clinicians should use the following key criterion when diagnosing children with acute upper respiratory infection (URI):
- Any nasal discharge, daytime cough or both lasting more than 10 days without improvement
- A worsening course, new nasal discharge, daytime cough or fever after initial improvement
- Severe onset of fever of 39° C/102.2°F or higher with purulent nasal discharge for at least three consecutive days
Clinicians should not use plain films, contrast-enhanced CT, MRI, or ultrasonography “to distinguish acute bacterial sinusitis from viral URI,” they stated. However, if a child is suspected of having orbital or central nervous system complications, a contrast-enhanced CT scan of the paranasal sinuses and/or an MRI is appropriate.
In cases of severe onset, or if symptoms worsen after seeming to improve, or fail to improve after 72 hours, antibiotic therapy for acute bacterial sinusitis in children is recommended. First-line treatment is amoxicillin with or without clavulanate, the guidelines state.
This contrasts with the 2001 guidelines, which called for antibiotic therapy for all children diagnosed with acute bacterial sinusitis, the authors noted. The recommendation to observe children who present with persistent illness for more than 10 days for 72 hours is based on study results that show similar outcomes among children treated with antibiotics and those who were not, or received nonpharmaceutical treatment.
Antibiotic associated adverse events included diarrhea (20%-22%; P=0.97 in three studies) and abdominal pain (29% for amoxicillin, 15% for amoxicillin/clavulanate, 9% for placebo; P=0.02).
Other treatments included steroids, decongestants and antihistamines and nasal spray, the researchers wrote. Corticosteroid treatment may speed up symptom resolution, they noted. Decongestants and nasal sprays had similar efficacy at 14 days, but those treated with saline nasal spray had less discharge at seven days than those treated with xylometazoline (P=0.0163). Mucolytic agents were no more effective than placebo.
A total of 17 randomized studies of sinusitis in children aged 1 to 18 years were included in the analysis. The updated recommendations do not apply to children with sub-acute or chronic sinusitis, the AAP stated.
by Walker Harrison, an undergraduate student at Columbia University and editorial intern with Clinical Advisor.