Not Every Child With Acute Sinusitis Needs Antibiotics

Testing children with acute sinusitis symptoms for specific bacteria may dramatically decrease unnecessary antibiotic use, new research suggests.

The study, published in JAMA, found that children with positive nasopharyngeal tests for one or more of Haemophilus influenzae, Streptococcus pneumoniae, or Moraxella catarrhalis had better resolution of symptoms with antibiotics than those without these bacteria.

If antibiotic use was limited to children with H influenzae or S pneumoniae in their nasopharynx at the time of diagnosis, antibiotic use would decrease by 53%, according to the study authors.

Sinusitis is common in children, and symptoms are similar with uncomplicated viral upper respiratory infections.

Dr Nader Shaikh

“We have not had a good way to predict which children will benefit from antibiotics,” said Nader Shaikh, MD, MPH, professor of pediatrics and clinical and translational science at the University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, and the lead study author. “When a child comes in with a sore throat, we test for strep. If the test is positive, we prescribe antibiotics.”

Shaikh and his colleagues found that the same approach — swabbing the nose and testing for various bacteria — worked for children with sinusitis.

“Children who tested negative for bacteria did not benefit from antibiotics,” Shaikh said.

In the double-blind clinical trial, Shaikh and his colleagues randomized 510 children between ages 2 and 11 with acute sinusitis at six academic primary care offices over a 6-year period. Almost two thirds of participants were between ages 2 and 5, around half were male, and around half were White. All participants had an initial score of nine or higher on the validated Pediatric Rhinosinusitis Symptom Scale (PRSS).

For 10 days, 254 children received oral amoxicillin (90mg/kg/day) and clavulanate (6.4mg/kg/day) and 256 received placebo.

In children receiving antibiotics, symptoms resolved over a median of 7 days compared with 9 days for those given placebo (P = .003).

Children without detected nasopharyngeal pathogens did not benefit from antibiotics as much as those with the pathogens, the researchers found. Among those with pathogens, the mean symptom burden score was 1.95 points lower in the group that received antibiotics compared with the group that received placebo. For those without pathogens, there was a 0.88-point difference between the antibiotic and placebo groups (P = .02).

The researchers also took nasal swabs at the first and final study visits and tested for S pneumoniae, H influenzae, and M catarrhalis. During that time, parents or caregivers used the PRSS to assess their child’s symptoms, and they recorded the nasal discharge color. Nasal discharge color, Shaikh and his colleagues found, was not linked with antibiotic effect.

Welcome Findings

Pediatricians and primary care providers face a significant clinical dilemma when they consider using antibiotics with upper respiratory tract infections (URTIs), according to John H. Greinwald, Jr, MD, professor in the Department of Pediatrics at Cincinnati Children’s Hospital Medical Center.

Dr John H. Greinwald, Jr

“These findings certainly make sense because most respiratory infections in children are viral,” Greinwald said. “The investigators follow the appropriate clinical guidelines for considering antibiotic use in patients with URTIs, which include URTI symptoms lasting longer than 10 days or symptoms initially getting better, then worsening again day 6 through 10.”

Not only is antibiotic resistance a major public health concern, but the drugs can have side effects such as diarrhea, and their long-term effects on the microbiome are unknown.

Dr Eelam A. Adil

“Differentiating who has acute sinusitis from who has a viral infection is difficult for primary care providers,” said Eelam A. Adil, MD, MBA, assistant professor of otolaryngology at Harvard Medical School in Boston, Massachusetts.

The findings may help clinicians be more selective with antibiotic prescriptions, according to Jacob G. Eide, MD, a head and neck surgeon at Henry Ford Health in Detroit, Michigan.

“However, we do not want to deny antibiotics when they are beneficial,” Eide said. “And the difficulty and costs involved in developing the tests need to be considered.”

Dr Jacob G. Eide

Shaikh and his team are studying ways to bring nasal testing into clinical practice, potentially utilizing commercially available molecular testing and rapid antigen tests that work like COVID-19 at-home tests. They are also exploring if other biomarkers in nasal discharge may indicate the presence of bacteria.

All study and editorial authors as well as outside experts report no relevant financial relationships. The study was supported by the National Institute of Allergy and Infectious Diseases.

Lorraine L. Janeczko, MPH, is a medical science writer and journalist in Atlanta.

JAMA. Published July 25, 2023. Full text.          

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