Testing kids with suspected sinusitis for specific bacteria could curb antibiotic use

Source/Disclosures

Disclosures:
Shaikh reports owning stock in and serving as a consultant for Kaizen Bioscience. Please see the study for all authors’ relevant financial disclosures. Altillo, Caballero and Milstone report no relevant financial disclosures.

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Key takeaways:

• The symptoms of acute sinusitis and viral upper respiratory tract infection are similar.
• Testing children for three species of bacteria could help reduce unnecessary antibiotic use for suspected sinusitis.

Testing children with suspected sinusitis for three species of bacteria could help cut down on antibiotic use, the results of a randomized clinical trial suggest.

“About 5 million kids in the U.S. get prescribed antibiotics for sinusitis each year, but antibiotics are not effective for children whose symptoms are not caused by bacteria, so these medications can potentially do more harm than good,” Nader Shaikh, MD, MPH, a professor of pediatrics and clinical and translational science at the University of Pittsburgh School of Medicine, told Healio.

Bacterial testing in children with suspected sinusitis could help cut down on antibiotic use, a study in JAMA found. Image: Adobe Stock

“Antibiotics can have side effects such as diarrhea, and we still don’t understand the long-term effects of antibiotics on the microbiome,” Shaikh said. “Beyond the individual, antibiotic resistance is a major public health issue.”

Shaikh said health care professionals require “a good way of diagnosing bacterial sinusitis and predicting which children will benefit from sinusitis.”

“This problem motivated us to develop a better tool to diagnose and treat sinusitis,” Shaikh said.

Shaikh and colleagues recruited 510 children aged 2 to 11 years from primary care offices affiliated with six institutions in the United States who had symptoms of acute sinusitis for more than 10 days.

Each child was swabbed for Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis. The researchers randomly assigned the children to receive either a 10-day antibiotic regimen of amoxicillin and clavulanate, or a placebo.

“A sizable proportion of children who we currently treat for acute sinusitis do not benefit from antibiotics,” Shaikh said. “By doing a nasal swab at the time of presentation, we can narrow down treatment to those who might benefit from antibiotic treatment.”

Parents of patients in the study were also asked to identify the color of their child’s nasal discharge against a color card as a way of what Shaikh called “formally testing” a common belief among doctors that nasal discharge could indicate whether or not the child has a bacterial infection.

“If kids with yellow or green discharge benefited more from antibiotics than kids with clear-colored discharge, we would know that color is relevant for bacterial infection,” Shaikh said. “But we found no difference in antibiotic response between kids with different colored discharge. This tells us that color of discharge should not guide medical decisions.”

Ultimately, the researchers observed that length of time to symptom resolution was significantly lower for children in the antibiotic group than in the placebo group, 7 vs. 9 days. They noted, however, that children in whom the three nasopharyngeal pathogens were not detected — 28% of all children — did not benefit from antibiotic treatment as much as those who tested positive for the pathogens.

“It was not particularly surprising that children who tested negative for bacteria did not benefit from antibiotics, and it wasn’t surprising that nasal discharge color wasn’t associated with antibiotic response because this has been shown before in smaller studies,” Shaikh said.

“When a child comes in with a sore throat, we test for strep,” Shaikh continued. “If the test is negative, we do not prescribe antibiotics. We found that the same approach could work for children with sinusitis. We would swab the nose and test for bacteria associated with sinusitis. If these bacteria are not present, antibiotic treatment is much less likely to be beneficial.”

Shaikh said his team is examining a more “practical way” to roll out nasal testing in-clinic.

“One possibility is commercially available molecular testing, which could return results overnight, so that clinicians could call parents the morning after their appointment to tell them the results and whether or not they should pick up an antibiotic prescription,” Shaikh said.

“It could also be possible to develop rapid antigen tests that work like COVID-19 at-home testing kits. However, this would take considerable time and effort to develop and get FDA approval,” he said. “We are also investigating whether there may be other types of biomarkers in nasal discharge that could indicate the presence of bacteria and may be simpler to test for.”

The study was accompanied by two editorials, including one authored by Tania M. Caballero, MD, and Aaron M. Milstone, MD, MHS, both of the department of pediatrics at Johns Hopkins University’s School of Medicine, and Brandon S. A. Altillo, MD, MHS of the departments of pediatrics, internal medicine and population health at the Dell Medical School at the University of Texas, Austin.

“Given the ubiquity of COVID-19 testing, caregivers are familiar with and often expect nasopharyngeal diagnostic tests to be performed,” they wrote. “However, in the setting of COVID-19 testing, caregivers likely experienced or witnessed the discomfort experienced by their child during the collection of a nasopharyngeal culture. This discomfort, coupled with the increased rates of diarrhea in children taking antibiotics, may empower caregivers to opt out of exposing children to further discomfort if there is a possibility that good supportive care alone will lead to clinical improvement.

“Ultimately, the risk of causing further discomfort to an ill child may outweigh the potential benefit of a small reduction in duration and severity of symptoms among a subset of children with pathogens detected.”

References:

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