Acute Bacterial Rhinosinusitis Clinical Pathway – Primary Care, Emergency Department and Inpatient

Clinical Pathways Home Emergency ICU Inpatient Outpatient Specialty Care Primary Care

Related Pathway
- Cellulitis, Preseptal or Orbital, All Settings

Diagnostic Criteria Any of the following
Persistent	Symptoms lasting more than 10 days without improvement
Worsening	Symptoms worsen more than 5-6 days into viral URI; “double sickening”
Severe	Temperature ≥ 39°C and purulent nasal drainage for ≥ 3 days

Child with Suspected Acute Bacterial Rhinosinusitis (ABRS)

ED Triage

Team Assessment

History and Physical
- Assess for symptoms of ABRS
  - Nasal drainage, any quality
  - Daytime cough
  - Fever
It is difficult to distinguish between ABRS and viral or allergic rhinitis
Differential Diagnosis
Imaging is not indicated for the diagnosis of ABRS

Concern for intracranial extension or orbital complications
- Severe persistent headache
- Eye/lid swelling
Imaging and treatment as clinically indicated

Not Acute Bacterial Rhinosinusitis

Non-Severe
Acute Bacterial Rhinosinusitis

Severe
Acute Bacterial Rhinosinusitis

Consider alternate diagnosis
- Viral/allergic rhinitis
Re-evaluate if symptoms worsen

Persistent

Worsening

Antibiotic Recommendations

≥ 30 days

< 30 days

Symptom Management
Most resolve without antibiotics
Shared Decision-Making
Observe for 3 days (preferred) vs. consider antibiotics

Chronic rhinosinusitis
Symptom Management
Consider ENT referral
Consider antibiotics

Subspecialty Referral Considerations

Posted: March 2025

Authors:
- R. Same, MD;
- M. Rizzi, MD;
- D. Elliott, MD;
- C. Foley, CPNP-PC;
- A. Buzi, MD;
- B. Guttadauria, MD;
- G. Sharer, ACCNS-P;
- J. Kimmes, CRNP;
- L. Rodriguez, PharmD;
- G. Murray, MD;
- M. Ingley, MD;
- A. Mendelson, MD;
- J. Hayes, MD;
- B. Ku, MD

Evidence

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.

Primary Care, Emergency Department and Inpatient Clinical Pathway for Diagnosis and Treatment of Acute Bacterial Rhinosinusitis

Evidence