1. There is limited advantage in giving antibiotics to children with acute sinusitis who do not have nasopharyngeal bacterial pathogens at the time of initial diagnosis.
2. The color of nasal mucus in children with acute sinusitis has a weak correlation with bacterial infection and has nothing to do with the efficacy of antibiotics.
Evidence rating level: 1 (excellent)
Research outline: Acute sinusitis is often diagnosed based on clinical symptoms in children, leading to presumptive treatment with antibiotics without testing for pathogens. This clinical trial aims to determine whether specific factors, such as bacterial colonization of the nasopharynx and color of nasal secretions, can help determine which patient groups will most benefit from antibiotics to treat acute sinusitis. Study results indicate that children diagnosed with acute sinusitis but lacking detectable bacterial pathogens in their nasopharynx derive significantly less benefit from antibiotic treatment than children colonized by the pathogen. Of note, the color of nasal secretions has no effect on antibiotic efficacy. One limitation of the study is the exclusion of children with severe sinusitis due to strict diagnostic criteria, which limits the generalizability of the results. Nonetheless, the study showed that detecting specific bacterial pathogens (Streptococcus pneumoniae or Haemophilus influenzae) during diagnosis may be a valuable strategy to reduce unnecessary antibiotic use for childhood sinusitis while ensuring appropriate treatment for those who would benefit most. Additionally, the study highlighted a weak association between nasal discharge color and acute sinusitis, emphasizing its minimal impact on treatment decisions. These insights represent key advances in optimizing treatments for this common childhood disease, with potential benefits including improved resource utilization and reduced risk of antibiotic resistance. Future studies should focus on point-of-care detection of these pathogens and the actual implementation of such strategies in clinical practice.
Click to read the study in JAMA
Click to read the accompanying JAMA editorial
Related Reading: Predicting response to antimicrobial therapy in children with acute sinusitis
In depth (randomized clinical trial): This randomized clinical trial was conducted in U.S. primary care offices from February 2016 to April 2022. The study included 510 children aged 2 to 11 years who had a clinical diagnosis of acute sinusitis. Patients were randomly assigned to receive oral amoxicillin and clavulanic acid (antibiotics) or placebo for 10 days. They were then assessed daily using the validated Pediatric Sinusitis Symptom Scale (PRSS) to measure the primary outcome of symptom burden during the 10-day follow-up period. Children in the antibiotic group had a slightly lower symptom burden and were less likely to fail treatment, develop acute otitis media, or require additional antibiotics than those in the placebo group. However, among children who received antibiotics and had no bacterial pathogens (28% of participants), the difference in symptom burden compared with placebo was small (between-group difference -0.88, 95% CI -1.63 to -0.12, p =0.02). For nasal discharge, there were no significant between-group differences in symptom burden among children in the antibiotic and placebo groups.
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