Assignment Details

Applying Current Evidence-Based Practice Guidelines for the Diagnosis and Treatment of Acute Bacterial Sinusitis in Pediatric Patients 

This assignment will demonstrate your ability to apply current evidence-based practice guidelines to the management of a pediatric patient diagnosed with acute bacterial sinusitis. Using the Purdue Global Library, you are to locate the following article and use the evidence based recommended guidelines to complete this assignment.

Hauk, L. (2014). AAP releases guideline on diagnosis and management of acute bacterial sinusitis in children one to 18 years of age. American Family Physician, 89(8), 676–681.

This assignment has a template that you will use to fill in the requested information.                 Article information:                                      Practice Guidelines

AAP Releases Guideline on Diagnosis and Management of Acute Bacterial Sinusitis in Children One to 18 Years of Age

 Guideline source: American Academy of Pediatrics

Evidence rating system used? Yes

Literature search described? Yes

Guideline developed by participants without relevant financial ties to industry? No

Published source: Pediatrics, July 2013

Available at: http://pediatrics.aappublications.org/content/132/ 1/e262.full

Coverage of guidelines from other organizations does not imply endorse- ment by AFP or the AAFP.

A collection of Practice Guidelines published in AFP is available at http:// www.aafp.org/afp/ practguide.

Approximately 6% to 7% of children pre- senting with respiratory symptoms have acute sinusitis. This practice guideline from the American Academy of Pediatrics (AAP), which updates the 2001 guideline, discusses diagnosis and management of acute bacterial sinusitis in children one to 18 years of age.

Recommendations

Acute bacterial sinusitis can be diagnosed in children with an acute upper respiratory infection that persists (nasal discharge or daytime cough for more than 10 days with no improvement), that gets worse (worsening or new nasal discharge, daytime cough, or fever after improving at first), or that is severe (concomitant fever of at least 102.2 ̊F [39 ̊C] and purulent nasal discharge for at least three consecutive days).

Plain radiography, contrast-enhanced computed tomography, magnetic resonance imaging, and ultrasonography should not be performed to differentiate acute bacterial sinusitis from viral upper respiratory infec- tion. However, contrast-enhanced computed tomography of the paranasal sinuses or magnetic resonance imaging with contrast media should be performed in children thought to have orbital or central nervous

system complications. The most common orbital complications of acute bacterial sinusitis involve children younger than five years who have ethmoid sinusitis. These complications should be suspected in a child with a swollen eye, especially if there is also proptosis or if extraocular muscle function is impaired. Intracranial complications (e.g., subdural and epidural empyema, venous thrombosis, brain abscess, meningitis) are less common, but more serious, and have higher morbidity and mortality rates than orbital complications. These complications should be suspected in a child with a severe headache, photophobia, seizures, or other focal neurologic findings.

Antibiotics should be prescribed in chil- dren with severe, worsening, or persistent acute bacterial sinusitis. Outpatient obser- vation for three days is also an option in children with persistent illness. Amoxicillin alone or in combination with clavulanate is the first-line antibiotic choice. Intravenous or intramuscular ceftriaxone (Rocephin), 50 mg per kg once, can be given to children who are vomiting, who cannot take oral medications, or who are not likely to take the initial antibiotic doses as prescribed. After clinical improvement, the treatment can be changed to oral therapy. Children with hypersensitivity to amoxicillin (type 1 and non–type 1) can be treated with cefdinir (Omnicef), cefuroxime (Ceftin), or cefpodoxime. Surveillance studies have shown resistance of pneumococcus and Haemophilus influenzae to trimethoprim/ sulfamethoxazole and azithromycin (Zith- romax), indicating that they should not be used to treat acute bacterial sinusitis in persons with penicillin hypersensitiv- ity. Recommendations regarding the

 D6o7w6nloAadmederfriocmanthFeaAmielryicPanhyFasimcilay nPhysician website at www.aafp.owrgw/awfp..aCaofpy.orirgght/a©fp2014 American Academy ofVFoalmuimlyePh8y9s,icNiaunsm. Fboerrt8he prAivpatrei,l n1o5n,c2o0m1-4 mercial use of one individual user of the website. All other rights reserved. Contact copyrig[email protected] for copyright questions and/or permission requests.

optimal duration of treatment vary from 10 to 28 days. Alternatively, it has been recom- mended that patients be treated for seven days after symptoms subside, which pro- vides for individualized treatment, at least 10 days of treatment, and avoiding contin- ued treatment in asymptomatic patients.

If acute bacterial sinusitis is confirmed in a child whose symptoms are getting worse or who is not improving after 72 hours, the antibiotic may be changed (if the child is already taking an antibiotic) or started (if the child is being observed). If a parent indicates that the child’s illness is getting worse (initial signs or symptoms progress- ing, or new signs or symptoms occurring) or not improving (signs and symptoms persist) after 72 hours of treatment, management decisions should be reevaluated.

There are no recommendations regarding adjuvant therapy for acute bacterial sinusitis, although intranasal corticosteroids, saline nasal irrigation or lavage, topical or oral decongestants, mucolytics, and topical or oral antihistamines may be options. One Cochrane review found no appropriately designed studies to establish the effectiveness of decongestants, antihistamines, and nasal irrigation for acute sinusitis in children.

Only a few high-quality studies on the diagnosis and treatment of acute bacterial sinusitis in children have been published since the 2001 guideline was released. There- fore, evidence on which to base recommen- dations is limited, and further research is needed in many areas.

LISA HAUK, Senior Associate Editor, AFP Online ■

Practice Guidelines

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676 American Family Physician www.aafp.org/afp Volume 89, Number 8 ◆ April 15, 2014

Approximately 6% to 7% of children pre-
senting with respiratory symptoms have
acute sinusitis. This practice guideline from
the American Academy of Pediatrics (AAP),
which updates the 2001 guideline, discusses
diagnosis and management of acute bacterial
sinusitis in children one to 18 years of age.

Recommendations
Acute bacterial sinusitis can be diagnosed
in children with an acute upper respiratory
infection that persists (nasal discharge or
daytime cough for more than 10 days with no
improvement), that gets worse (worsening or
new nasal discharge, daytime cough, or fever
after improving at first), or that is severe
(concomitant fever of at least 102.2˚F [39˚C]
and purulent nasal discharge for at least three
consecutive days).

Plain radiography, contrast-enhanced
computed tomography, magnetic resonance
imaging, and ultrasonography should not
be performed to differentiate acute bacterial
sinusitis from viral upper respiratory infec-
tion. However, contrast-enhanced computed
tomography of the paranasal sinuses or
magnetic resonance imaging with contrast
media should be performed in children
thought to have orbital or central nervous

system complications. The most common
orbital complications of acute bacterial
sinusitis involve children younger than five
years who have ethmoid sinusitis. These
complications should be suspected in a child
with a swollen eye, especially if there is also
proptosis or if extraocular muscle function
is impaired. Intracranial complications (e.g.,
subdural and epidural empyema, venous
thrombosis, brain abscess, meningitis) are
less common, but more serious, and have
higher morbidity and mortality rates than
orbital complications. These complications
should be suspected in a child with a severe
headache, photophobia, seizures, or other
focal neurologic findings.

Antibiotics should be prescribed in chil-
dren with severe, worsening, or persistent
acute bacterial sinusitis. Outpatient obser-
vation for three days is also an option in
children with persistent illness. Amoxicillin
alone or in combination with clavulanate is
the first-line antibiotic choice. Intravenous
or intramuscular ceftriaxone (Rocephin),
50 mg per kg once, can be given to children
who are vomiting, who cannot take oral
medications, or who are not likely to take
the initial antibiotic doses as prescribed.
After clinical improvement, the treatment
can be changed to oral therapy. Children
with hypersensitivity to amoxicillin (type
1 and non–type 1) can be treated with
cefdinir (Omnicef), cefuroxime (Ceftin),
or cefpodoxime. Surveillance studies have
shown resistance of pneumococcus and
Haemophilus inf luenzae to trimethoprim/
sulfamethoxazole and azithromycin (Zith-
romax), indicating that they should not
be used to treat acute bacterial