Bacterial Testing in Kids with Sinusitis May Reduce Antibiotic Use

According to a new JAMA study by researchers at the University of Pittsburgh and UPMC, in children with suspected sinusitis, a nasal swab to screen for three types of bacteria can determine whether drugs are likely to be beneficial or not.

“Five million kids in the U.S. get prescribed antibiotics for sinusitis each year,” said lead author Nader Shaikh, M.D., pediatrician at UPMC Children’s Hospital of Pittsburgh and professor of pediatrics and clinical and translational science at Pitt. “Our study suggests that only half of these kids see an improvement in symptoms with antibiotic use, so by identifying who they are, we could greatly reduce unnecessary antibiotic use.”

Sinusitis, or sinus inflammation or swelling, can cause congestion, a runny nose, discomfort, and difficulty breathing. Doctors frequently prescribe antibiotics to treat the disease, despite the fact that it may be caused by viruses.

“Sinusitis is one of the most common diseases we see in children, but it’s difficult to diagnose because it’s based on the duration of symptoms: If the child has a runny nose or congestion for more than 10 days, we suspect sinusitis,” said Shaikh. “For an ear infection, we can look inside the ear; for pneumonia, we listen to the lungs. But for sinusitis, we have nothing to go on from a physical exam. That was very unsatisfying to me.”

Shaikh and his colleagues enrolled around 500 children with sinusitis symptoms from six locations across the United States and randomly allocated them to receive either a course of antibiotics or a placebo. The researchers then obtained swabs from each child’s nose, similar to a COVID-19 test, and tested for the three primary types of bacteria involved in sinusitis.

When compared to those who did not have germs, children who tested positive for the bacteria had improved symptom relief with antibiotic treatment. These findings imply that checking for bacteria could be a straightforward and effective technique to identify children who will benefit from antibiotics while avoiding providing antibiotics to those who will not.

“If antibiotics aren’t necessary, then why use them?” said Shaikh. “These medications can have side effects, such as diarrhea, and alter the microbiome, which we still don’t understand the long-term implications of. Overuse of antibiotics can also encourage antibiotic resistance, which is an important public health threat.”

A prevalent misconception among parents and doctors, according to Shaikh, is that yellow or green snot indicates a bacterial infection. Although several minor studies have suggested that nasal discharge color is unimportant, Shaikh and his colleagues fully evaluated this hypothesis by asking parents to identify the color of their child’s snot on a color card.

“If kids with green or yellow discharge benefitted more from antibiotics than those with clear-colored discharge, we would know that color is relevant for bacterial infection,” explained Shaikh. “But we found no difference, which means that color should not be used to guide medical decisions.”

The researchers are now investigating how to effectively implement nasal testing in the clinic. One significant problem is that the bacterial culture-based tests utilized in the study are difficult for most family doctors to order and often take several days to complete. According to Shaikh, a more realistic approach could be commercially available molecular testing, which could provide results overnight.

Another potential is the creation of fast antigen assays that function similarly to COVID-19 at-home testing kits. The researchers also intend to go deeper into the data from this study to discover if there is another type of biomarker in nasal discharge that indicates the presence of bacteria that is easier to detect.

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