Acute sinusitis in children: Bacterial testing may inhibit antibiotic use Latest news for doctors, nurses and pharmacists

Antibiotics have little effect in the absence of bacterial pathogens in the nasopharynx of children with acute sinusitis, a study suggests, suggesting that testing for specific bacteria present at presentation may help prevent unnecessary antibiotic use.

510 children (2 to 11 years) with acute sinusitis were randomly assigned to receive amoxicillin (90 mg/kg/day) plus clavulanic acid (6.4 mg/kg/day; n=254) or placebo Antibiotics alone (n=256) for 10 days, antibiotic treatment did not reduce symptom burden in those without antibiotics Streptococcus pneumoniae, Haemophilus influenzaeor
Moraxella catarrhalis Dr. Nader Shaikh, University of Pittsburgh School of Medicine, Children’s Hospital of the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA, reports that the nasopharynx was tested at the index diagnosis.

Amoxicillin plus clavulanic acid was only slightly better than placebo at reducing sinusitis symptoms in children who tested negative for pathogens. The difference in Pediatric Sinusitis Symptom Scale (PRSS) scores between the two treatment groups was only –0.88 points (95% confidence interval (CI), -1.63 to -0.12). (Journal of the American Medical Association 2023;330:349-358)

In contrast, antibiotics relieved symptoms better than placebo in children who tested positive for pathogens, with a between-group difference in PRSS scores of –1.95 points (95% CI, -2.40 to -1.51).

“This finding is biologically plausible because the pathogens that cause sinusitis originate in the nasopharynx,” Sheikh noted. “If the nasopharynx is pathogen-free, the likelihood of bacterial sinusitis is low.” Similar results have been reported in placebo-controlled studies in adults. ” (Journal of Pediatric Infectious Diseases

2013;32:805-809;
Journal of Pediatric Infectious Diseases 2006;25:1032-1036; European Journal of Clinical Microbiology and Infectious Diseases 2001;20:445-451;
lancet 1996;347:1507-1510)

The color of your snot doesn’t matter

Sheikh said many parents and doctors believe the color of the mucus could be an indicator of infection, with yellow or green mucus meaning a child has a bacterial infection.

In fact, European and Canadian sinusitis guidelines recommend using purulent nasal discharge to select children for antimicrobial therapy. Additionally, a 2007 US survey showed that 86% of pediatricians considered the presence of colored nasal discharge to be “very important” or “moderately important” in their decision to diagnose acute sinusitis. (Otolaryngology-Head and Neck Surgery 2011;40:S99-S193;
Rhinology 2020;58:1-464; Pediatrics 2009;123:e193-e198)

However, current data suggest that antibiotics are not more beneficial in children with green or yellow nasal discharge than in children with clear discharge. The difference in PRSS scores between antibiotics and placebo was –1.62 points (95% CI, -2.09 to -1.16) in the subgroup of children with colored nasal discharge and –1.70 points (95% CI, -2.09 to -1.16) in the subgroup of children with colored nasal discharge CI, -2.38 to -1.03). Subgroup with clear nasal discharge.

Sheikh emphasized that ultimately, the color of mucus has nothing to do with bacterial infection and therefore should not influence treatment decisions.

“If children with green or yellow discharge benefited more from antibiotics than children with clear-colored discharge, we would know that color is associated with bacterial infection,” he said. “But we found no difference, which means color It should not be used to guide medical decisions.”

New approach to treating acute sinusitis

In current practice, many clinicians immediately prescribe antibiotics to treat acute sinusitis in children, although American Academy of Pediatrics guidelines recommend that clinicians consider observation as a treatment option. Sheikh found this blanket prescription of antibiotics problematic. (Pediatrics 2013;132:e262-e280;
JAMA Network Open 2022;5:e2214153; Pediatrics 2023;151:151)

“Five million children in the U.S. take antibiotics for sinusitis each year. Our research shows that only half of the children improve their symptoms with antibiotics, so by identifying who they are, we can significantly reduce unnecessary antibiotic use,” He said.

In the study cohort, if antibiotic use was limited to children with bacteria in their nasopharyngeal secretions at diagnosis, antibiotic use would have fallen by 28%.Interestingly, previous research has shown that although
Moraxella catarrhalis It is a common colonizer of the nasopharynx but rarely causes infection.In fact, exploratory analyzes confirmed that most of the therapeutic benefits observed with antibiotics were due to the presence
Haemophilus influenzae and Streptococcus pneumoniae. (European Journal of Clinical Microbiology and Infectious Diseases 2022;41:37-44;
Journal of Infection 2017;75:26-34; Public Library One 2016;11:e0150949)

Therefore, as long as Haemophilus influenzae and Streptococcus pneumoniae are considered pathogens, and antibiotics are only given to children whose nasal swab samples test positive for such pathogens, antibiotic use would be reduced by 53%. These findings remained consistent whether the pathogen was identified by culture or molecular testing.

Shaikh and colleagues are convinced that testing children with suspected sinusitis for bacterial pathogens will represent a paradigm shift.

“Sinusitis is one of the most common conditions we see in children, but it’s difficult to diagnose because it depends on the duration of symptoms: If a child has a runny or stuffy nose for more than 10 days, we suspect sinusitis,” Shaikh said. “With ear infections, we can look inside the ears; with pneumonia, we listen to the lungs. But with sinusitis, there’s nothing we can do with a physical exam. “That makes me very unsatisfied. “

Jumping through hoops

Sheikh acknowledges that there are barriers to a potential paradigm shift in the treatment of acute sinusitis in children.

He noted that in most cases, getting bacterial test results can take time. For bacterial culture testing, results are usually available within 2 to 3 days.However, fairly accurate rapid antigen tests
Streptococcus pneumoniae (90% sensitivity, 95% specificity) is commercially available and can be administered at the point of care.Similar bedside tests
Haemophilus influenzae and Moraxella catarrhalis Can be developed. Alternatively, pathogen testing can be performed in a few hours using commercially available multiplex polymerase chain reaction tests. (Journal of Clinical Microbiology 2002;40:4748-4749;
European Journal of Clinical Microbiology and Infectious Diseases 2012;31:703-706)

Bacterial testing also requires taking a nasopharyngeal swab, which may be considered invasive by some families. Shaikh said this method of sample collection is another potential obstacle to bacterial detection. But the COVID-19 pandemic has led to the routine collection of nasopharyngeal swab samples, so this concern may be lower than before the pandemic.

Finally, the cost of care increases due to the need for bacterial testing, which may make it difficult for some families to afford the care their children need.

Watchful waiting without antibiotics

Shaikh said observation is also a reasonable treatment option in the absence of testing.

Results from the current study indicate that although children in the placebo group had worse overall symptom outcomes than those in the antibiotic group, the incidence of clinically significant diarrhea was lower in the placebo group (11.4% vs 4.7%). In addition, children who received placebo never experienced serious adverse events and rarely developed acute otitis media, with 50% experiencing resolution of symptoms by day 9.

“Being patient without antibiotics depends on the willingness of the child’s family to accept the increased symptom burden of the child (the child has been unwell for at least 6 days) and to accept daily monitoring for worsening symptoms,” Shaikh said.

Sheikh concluded by emphasizing the need for parents and health care providers to work together to make informed decisions about the best treatment options for acute sinusitis in children.