Aggregate evidence quality: B; randomized controlled trials with limitations.
BenefitAntibiotics increase the chance of improvement or cure at 10 to 14 days (number needed to treat, 3–5); additional observation may avoid the use of antibiotics with attendant cost and adverse effects.
HarmAntibiotics have adverse effects (number needed to harm, 3) and may increase bacterial resistance. Observation may prolong illness and delay start of needed antibiotic therapy.
CostDirect cost of antibiotics as well as cost of adverse reactions; indirect costs of delayed recovery when observation is used.
Benefits-harm assessmentPreponderance of benefit (because both antibiotic therapy and additional observation with rescue antibiotic, if needed, are appropriate management).
Value judgmentsRole for additional brief observation period for selected children with persistent illness sinusitis, similar to what is recommended for acute otitis media, despite the lack of randomized trials specifically comparing additional observation with immediate antibiotic therapy and longer duration of illness before presentation.
Role of patient preferenceSubstantial role in shared decision-making that should incorporate illness severity, child’s quality of life, and caregiver values and concerns.
Intentional vaguenessNone.
ExclusionsChildren who are excluded from randomized clinical trials of acute bacterial sinusitis, as defined in the text.