A strong recommendation means that a treatment’s benefits clearly exceed the harms-or that the harms clearly exceed the benefits in the case of a strong negative recommendation-and that the quality of the supporting evidence is excellent. Clinicians should follow a strong recommendation unless there is a clear and compelling reason for an alternative.
Explore this issue:November 2007
A recommendation means that the benefits exceed the harms-or the reverse for a negative recommendation-but the quality of evidence is not as strong. Clinicians should generally follow a recommendation but should remain alert to new information and be sensitive to patient preferences.
An option means that either the quality of the existing evidence is suspect or that well-done studies show little clear advantage of one approach over another. Clinicians should be flexible in decision making about appropriate practice. Although they may set bounds on alternatives, patient preference should have a substantial influencing role.
If no recommendation is made, it means that the committee found no pertinent evidence and an unclear balance between benefits and harms. Clinicians should feel little constraint in decision making and be alert to new published evidence that clarifies the balance of benefit and harm. Patient preference should have a substantial influencing role.
Guidelines in a Nutshell
The guidelines emphasize appropriate diagnosis, and provide management options that include observation, antibiotic therapy, and additional testing. The guidelines include:
- Distinguishing acute bacterial sinusitis from that caused by colds, viruses, and non-infectious conditions. Strong recommendation.
- Defining acute sinusitis as lasting up to four weeks with purulent nasal drainage accompanied by obstruction, facial pain, pressure, fullness, or all. Strong recommendation.
- Eschewing X-rays. Recommendation.
- Prescribing symptomatic relief for viral rhinositis. Optional because randomized trials had limited cohorts and an unclear balance of benefit and harm.
- Observing without antibiotics (but assuring follow-up) for selected patients who have mild illness. Optional because double-blind, randomized trials had heterogeneous populations based on diagnostic criteria and illness severity. Benefit and risk were about the same.
- Prescribing symptomatic relief for acute bacterial rhinosinusitis. Optional because randomized trials were conducted with heterogeneous populations and diagnostic criteria. Outcomes showed a balance of benefit and harm.
- Using amoxicillin as first-line therapy for seven days. Recommendation.
- Distinguishing between chronic sinusitis (lasting 12 weeks or longer) and recurrent acute sinusitis (four episodes per year with no symptoms in between) by means of CT scan, nasal endoscopy, and allergy assessment. Recommendation, although nasal endoscopy is an option, despite expert opinion of benefit over harm.
- Encouraging patients to stop smoking and to use saline nasal irrigation. Recommendation.