With 5m American children being prescribed antibiotics for sinusitis every year – and only half seeing a drop in symptoms afterwards – researchers suggest a nasal swab for three types of bacteria for those youngsters suspected of having the condition might determine whether the meds would be effective or not.
The study, led by researchers at the University of Pittsburgh and published in JAMA Network, said that by identifying the 50% who did see an improvement after taking the drugs would lead to a reduction in unnecessary antibiotic use.
Sinusitis, an inflammation or swelling of the sinuses, can cause congestion, runny nose, discomfort and difficulty breathing. Doctors often prescribe antibiotics – which target only bacterial infections – to treat the condition, even though it may be caused by viruses.
“Sinusitis is one of the most common diseases we see in children, but it's difficult to diagnose because it’s based on the duration of symptoms: If the child has a runny nose or congestion for more than 10 days, we suspect sinusitis,” said lead author Dr Nader Shaikh, paediatrician at UPMC Children’s Hospital of Pittsburgh and professor of paediatrics and clinical and translational science.
“For an ear infection, we can look inside the ear; for pneumonia, we listen to the lungs. But for sinusitis, we have nothing to go on from a physical exam. That was very unsatisfying to me.”
With the goal of developing a better tool to diagnose bacterial sinusitis, Shaikh and his team enrolled about 500 children with sinusitis symptoms from six centres across the US and randomly assigned them to receive either a course of antibiotics or placebo.
The researchers also took swabs from inside the nose – much like a Covid-19 test – from each child and tested for the three main types of bacteria involved in sinusitis.
Children who tested positive for the bacteria had better resolution of symptoms with antibiotic treatment compared with those who did not have bacteria. These findings suggest that testing for bacteria could be a simple and effective way to detect children who are likely to benefit from antibiotics and avoid prescribing antibiotics to those who wouldn’t.
“If antibiotics aren’t necessary, then why use them?” said Shaikh. “These medications can have side effects, like diarrhoea, and alter the microbiome, which we still don’t understand the long-term implications of. Overuse of antibiotics can also encourage antibiotic resistance, which is an important public health threat.”
Shaikh said a common belief among parents and doctors is that yellow or green snot signals a bacterial infection. Although several small studies have suggested that nasal discharge colour is not meaningful, Shaikh and his team formally tested this idea by asking parents to identify the hue of their child’s snot on a colour card.
“If those with green or yellow discharge benefitted more from antibiotics than those with clear-coloured discharge, we would know that colour is relevant for bacterial infection,” he said. Shaikh. “But we found no difference, which means that colour should not be used to guide medical decisions.”
The researchers are now looking at how to best roll out nasal testing in the clinic. A major challenge is that bacterial culture-based tests used in the study are not easy for most family doctors to order and can take several days to get results. A more practical approach could be commercially available molecular testing, which could return results overnight, said Shaikh.
Another possibility could be development of rapid antigen tests that work like Covid-19 at-home testing kits. The researchers also plan to delve deeper into the data from this study to see whether there could be another type of biomarker in nasal discharge indicating the presence of bacteria that would be easier to test for.
Study details
Identifying children likely to benefit from antibiotics for acute sinusitis
Nader Shaikh, Alejandro Hoberman, Timothy Shope, Jong-Hyeon Jeong, Marcia Kurs-Lasky, Judith Martin, Sonika Bhatnagar, Gysella Muniz, Stan Block, Melissa Andrasko, Matthew Lee, Kumaravel Rajakumar, Ellen Wald.
Published in JAMA Network on 25 July 2023.
Key Points
Question In children aged 2 to 11 years with acute sinusitis, does the efficacy of antibiotic treatment differ based on nasopharyngeal colonisation with a bacterial pathogen or by the colour of the nasal discharge?
Findings Children without nasopharyngeal bacterial colonisation (28% of all enrolled) benefited significantly less from antibiotic treatment than children colonized with pathogens. The effect of antibiotics did not differ based on the colour of the nasal discharge.
Meaning In children with acute sinusitis, antibiotic treatment had minimal benefit for those without nasopharyngeal bacterial pathogens. The antibiotic effect did not depend on the colour of nasal discharge.
Abstract
Importance
The large overlap between symptoms of acute sinusitis and viral upper respiratory tract infection suggests that certain subgroups of children being diagnosed with acute sinusitis, and subsequently treated with antibiotics, derive little benefit from antibiotic use.
Objective
To assess if antibiotic therapy could be appropriately withheld in prespecified subgroups.
Design, Setting, and Participants
Randomised clinical trial including 515 children aged 2 to 11 years diagnosed with acute sinusitis based on clinical criteria. The trial was conducted between February 2016 and April 2022 at primary care offices affiliated with 6 US institutions and was designed to evaluate whether symptom burden differed in subgroups defined by nasopharyngeal Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis on bacterial culture and by the presence of coloured nasal discharge.
Interventions
Oral amoxicillin (90 mg/kg/d) and clavulanate (6.4 mg/kg/d) (n = 254) or placebo (n = 256) for 10 days.
Main Outcomes and Measures
The primary outcome was symptom burden based on daily symptom scores on a validated scale (range, 0-40) during the 10 days after diagnosis. Secondary outcomes included treatment failure, adverse events including clinically significant diarrhoea, and resource use by families.
Results
Most of the 510 included children were aged 2 to 5 years (64%), male (54%), white (52%), and not Hispanic (89%). The mean symptom scores were significantly lower in children in the amoxicillin and clavulanate group (9.04 [95% CI, 8.71 to 9.37]) compared with those in the placebo group (10.60 [95% CI, 10.27 to 10.93]) (between-group difference, −1.69 [95% CI, −2.07 to −1.31]). The length of time to symptom resolution was significantly lower for children in the antibiotic group (7.0 days) than in the placebo group (9.0 days) (P = .003). Children without nasopharyngeal pathogens detected did not benefit from antibiotic treatment as much as those with pathogens detected; the between-group difference in mean symptom scores was −0.88 (95% CI, −1.63 to −0.12) in those without pathogens detected compared with −1.95 (95% CI, −2.40 to −1.51) in those with pathogens detected. Efficacy did not differ significantly according to whether coloured nasal discharge was present (the between-group difference was −1.62 [95% CI, −2.09 to −1.16] for coloured nasal discharge vs −1.70 [95% CI, −2.38 to −1.03] for clear nasal discharge; P = .52 for the interaction between treatment group and the presence of coloured nasal discharge).
Conclusions
In children with acute sinusitis, antibiotic treatment had minimal benefit for those without nasopharyngeal bacterial pathogens on presentation, and its effects did not depend on the colour of nasal discharge. Testing for specific bacteria on presentation may represent a strategy to reduce antibiotic use in this condition.
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Over-prescribed antibiotics cause significant harm – large US analysis
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No benefit from high-dose vs standard-dose amoxicillin for acute sinusitis