Antibiotic use could be reduced by testing for specific bacteria when children present with acute sinusitis, a study shows. For those without nasopharyngeal bacterial pathogens on presentation, antibiotics were of little benefit, and discoloration of nasal discharge was not predictive of antibiotic effects.
In primary care practices affiliated with 6 U.S. institutions from Feb. 2016 through Apr. 2022, children aged 2 to 11 years presenting with acute sinusitis were evaluated for symptom burden, colored nasal discharge, and presence of nasopharyngeal Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis. Participants were randomized to oral amoxicillin 90 mg/kg/d and clavulanate 6.4 mg/kg/d or placebo for 10 days.
With a primary outcome of symptom burden based on daily symptom scores on a validated scale (range, 0-40) during the 10 days after diagnosis, the study showed: “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 colored nasal discharge was present (the between-group difference was −1.62 [95% CI, −2.09 to −1.16] for colored 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 colored nasal discharge).”
Editorial: “The current randomized clinical trial is an opportunity to reflect on the importance of providing clear anticipatory guidance around acute bacterial sinusitis management, such as typical symptom burden, expected duration of illness, and the insignificance of nasal secretion color,” editorialists write. “Overall, the current study suggests that antibiotics may provide mild relief in symptom burden in children with acute bacterial sinusitis, especially in those with common respiratory bacteria. However, given the limitations of nasopharyngeal bacterial pathogen testing, widespread adoption of a test-based treatment approach is not there yet.”
Editorial (JAMA Otolaryngology–Head and Neck Surgery): “[The study authors note their results could be applied for] presumptive treatment without testing, treatment while awaiting pathogenic test results, up-front testing to direct therapeutic management, or watchful waiting,” editorialists write. “With these potential management avenues in mind, as well as some uncertainty within the data regarding discharge coloration, an opportunity for shared decision-making with patients and families is presented. Shared decision-making is particularly apt in circumstances where multiple management options exist. For instance, the data suggest that antibiotic management may be associated with a higher incidence of adverse effects such as diarrhea, while observation, and thus watchful waiting, would result in symptom resolution by day 9 in 50% of patients. Even when practical, timely, and cost-effective testing is widely available to accurately differentiate acute bacterial rhinosinusitis from viral respiratory illnesses, it remains the collaboration between medical professionals and patients and their families that primarily guides the management of pediatric acute bacterial rhinosinusitis.”