Proposed Clinical Decision Rules to Diagnose Acute Rhinosinusitis Among Adults in Primary Care

Abstract

PURPOSE To reduce inappropriate antibiotic prescribing, we sought to develop a clinical decision rule for the diagnosis of acute rhinosinusitis and acute bacterial rhinosinusitis.METHODS Multivariate analysis and classification and regression tree (CART) analysis were used to develop clinical decision rules for the diagnosis of acute rhinosinusitis, defined using 3 different reference standards (purulent antral puncture fluid or abnormal finding on a computed tomographic (CT) scan; for acute bacterial rhinosinusitis, we used a positive bacterial culture of antral fluid). Signs, symptoms, C-reactive protein (CRP), and reference standard tests were prospectively recorded in 175 Danish patients aged 18 to 65 years seeking care for suspected acute rhinosinusitis. For each reference standard, we developed 2 clinical decision rules: a point score based on a logistic regression model and an algorithm based on a CART model. We identified low-, moderate-, and high-risk groups for acute rhinosinusitis or acute bacterial rhinosinusitis for each clinical decision rule. RESULTSThe point scores each had between 5 and 6 predictors, and an area under the receiver operating characteristic curve (AUROCC) between 0.721 and 0.767. For positive bacterial culture as the reference standard, low-, moderate-, and high-risk groups had a 16%, 49%, and 73% likelihood of acute bacterial rhinosinusitis, respectively. CART models had an AUROCC ranging from 0.783 to 0.827. For positive bacterial culture as the reference standard, low-, moderate-, and high-risk groups had a likelihood of acute bacterial rhinosinusitis of 6%, 31%, and 59% respectively. CONCLUSIONSWe have developed a series of clinical decision rules integrating signs, symptoms, and CRP to diagnose acute rhinosinusitis and acute bacterial rhinosinusitis with good accuracy. They now require prospective validation and an assessment of their effect on clinical and process outcomes. Ann Fam Med 2017;15:347-354. https://doi.org/10.1370/afm.2060. INTRODUCTIONP ractice guidelines recommend the use of antibiotics only for patients with prolonged, severe, or worsening symptoms of acute rhinosinusitis, when the likelihood of a bacterial cause is thought to be higher.1,2 It is common practice, however, for patients with a diagnosis of acute rhinosinusitis to be prescribed an antibiotic regardless of the duration of symptoms or their severity.3 One strategy to reduce inappropriate prescribing is to give physicians tools that can help them more confidently diagnose or rule out acute bacterial rhinosinusitis.Previous studies have shown that individual signs and symptoms are of limited value for the diagnosis of acute bacterial rhinosinusitis.4,5 Point-ofcare tests, such as C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) are promising, but by themselves they are not adequate to diagnose or rule out acute bacterial rhinosinusitis. 6,7 Clinical decision rules have been proposed but have not been prospectively validated. 12 Although a CT scan is highly sensitive for the d...

Accuracy of Signs and Symptoms for the Diagnosis of Acute Rhinosinusitis and Acute Bacterial Rhinosinusitis

“…Two studies reported the accuracy of combinations of signs and symptoms for the diagnosis of ABRS (Table 5). 25,36 Berg proposed a 4-item score using a reference standard of purulent antral puncture fluid. The score discriminated well: those with a score or 3 or 4 findings present had a LR of 7 for ABRS, while those with ≤1 findings present had a LR of 0.06.…”

“…25 The most recently reported clinical decision rule used 5 signs or symptoms plus C-reactive protein (see Table 5 for scoring details) to identify patients at low risk (n = 77, 16%), moderate risk (n = 75, 49%), or high risk (n = 23, 73%) for ABRS using positive bacterial culture of antral puncture fluid as the reference standard. 36 Unfortunately, none of the above scores have been prospectively validated.…”

C-reactive protein: guiding antibiotic prescribing decisions at the point of care

“…15 However, both rules still require prospective validation in different populations, and an assessment of their impact on prescribing. Held and colleagues developed a simple CDR to rule out pneumonia in Swiss outpatients with acute cough, which was then validated in a separate Swiss population.…”

Limiting Antibiotic Use in Acute Sinusitis: Partly a Matter of Vocabulary?

“…13 In addition to offering symptomatic relief, previous strategies to reduce antibiotic prescription in acute sinusitis have included patient, prescriber, and public education (including in-office posters); enhancing communication between clinician and patient regarding withholding of antibiotics; implementation of clinical pathways; prescribing of delayed/reserved antibiotic prescriptions; and efforts to improve differentiation of bacterial versus viral sinusitis at the time of patient visit. 2,8,[14][15][16][17][18] These efforts include clinical decision rules, 16 C-reactive protein point-of-care testing, 17 and the potential for procalcitonin point-of-care testing. 18 The latter two actions, along with clinical shared decision-making, were noted in a Cochrane review as exhibiting moderate-quality evidence, suggesting efficacy in reducing antibiotic prescriptions for upper respiratory tract infections (URI).…”