Reducing unnecessary antibiotics use in children with acute sinusitis through bacterial testing

11 Sep 2023

A recent randomized clinical trial suggests that undergoing testing for specific nasopharyngeal bacteria in children with acute sinusitis could identify those who will benefit most from antibiotic treatment.1 Consequently, this could in turn substantially reduce antibiotic use among pediatric patients who are unlikely to benefit from this course of treatment.1 The notable findings of this study could potentially lead to a paradigm shift in the management of pediatric acute sinusitis, resulting in more targeted antibiotic prescription practices.1

Acute sinusitis is characterized by inflammation of the mucosal membranes lining the sinuses, leading to symptoms such as cough, nasal congestion and discharge.2 This condition is commonly seen in outpatient care and is a frequent reason for antibiotic use in children.1,3 Although acute sinusitis can be caused by viral or bacterial infections, the signs and symptoms overlap considerably, hence many clinicians continue to prescribe immediate antibiotics upon diagnosis.1 However, patients with uncomplicated viral upper respiratory tract infections (URTIs) are unlikely to benefit from antibiotics and may also develop antibiotic resistance.1,3 A study, published in JAMA and led by investigators from the University of Pittsburg, found that children without nasopharyngeal colonization of Streptococcus pneumoniae (S. pneumoniae), Haemophilus influenzae (H. influenzae), or Moraxella catarrhalis (M. catarrhalis) indeed benefited significantly less from antibiotic treatment than those with these pathogens.1

In this multicenter, double-blind, placebo-controlled, randomized clinical trial, 510 children aged 2-11 who had acute sinusitis symptoms for >10 days without a history of allergic rhinitis or asthma were recruited from 6 primary care offices.1 Only patients with a score of >9 on the validated Pediatric Rhinosinusitis Symptom Scale (PRSS) were included.1 Participants were then randomized 1:1 to receive either a 10-day course of oral amoxicillin (90mg/kg/d) and clavulanate (6.4mg/kg/d) (n=254) or a matching placebo (n=256).1  Overall, the children who received antibiotics experienced significantly lower symptom burden and a shorter median symptom resolution time of 7 days compared to 9 days for those who received the placebo.1 

In addition, nasopharyngeal swabs (NPS) were performed at the start and end of the study, then cultured for S. pneumoniae, H. influenzae, and M. catarrhalis.1 These bacterial pathogens were found in 71% of participants at the time of enrollment.1 Among these children, those treated with antibiotics had a lower mean score for symptom burden (8.90; 95% CI: 8.50-9.30) compared to the placebo group (10.89; 95% CI:10.50-11.27), leading to a between-group difference of -1.95 (95% CI: -2.40 to -1.51).1 In comparison, the between-group difference in mean symptom scores for children without these pathogens was significantly smaller (-0.88; 95% CI: -1.63 to -0.12; p=0.02), suggesting that these children did not benefit as much from antibiotic treatment.1 On the other hand, the researchers also investigated the efficacy of antibiotics among children with or without colored nasal discharge but no significant difference was observed (p=0.52).1

Overall, the findings from this study suggest that antibiotic use in children with acute sinusitis should be limited to those with pathogens detected in the nasopharynx at the time of diagnosis.1 This approach would have led to a 28% reduction in antibiotic use in this study population.1 However, the implementation of nasopharyngeal screening in clinical practice poses challenges, including the time-consuming nature of bacterial culture-based tests, as well as the use of nasal swabs which may be viewed as invasive by families.1 Nonetheless, future development of rapid antigen tests for these pathogens and increased acceptance of nasopharyngeal swabs after the coronavirus disease 2019 (COVID-19) pandemic could overcome such barriers.1 Ultimately, testing for specific bacteria on presentation in children with acute sinusitis may be an effective strategy to reduce antibiotic use in this condition.1

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