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. 2017 Jul;15(4):347-354.
doi: 10.1370/afm.2060.

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

Mark H Ebell  1 , Jens Georg Hansen  2
Affiliations

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

Mark H Ebell et al. Ann Fam Med. 2017 Jul.

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.

Results: The 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.

Conclusions: We 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.

Keywords: clinical decision making; clinical decision rule; point score; primary care; respiratory tract infections; rhinosinusitis; sinusitis.

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Conflict of interest statement

Conflicts of interest: authors report none.

Figures

Figure 1
Figure 1
Receiver operating characteristic (ROC) curves for logistic regression models using (A) abnormal bacterial culture, (B) abnormal finding on computed tomography, and (C) antral puncture revealing purulent fluid as reference standards.
Figure 2
Figure 2
Classification and regression tree model for positive bacterial culture as the reference standard.
See this image and copyright information in PMC

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