About 5 million antibiotic prescriptions are written each year to treat kids for acute sinusitis, according to new research from UPMC that finds roughly half those scripts are useless and could be doing more harm than good.
Acute sinusitis is a complication of a regular cold that inflames the sinuses, causing a running nose, congestion, and facial pain. When cold-like symptoms last longer than what would be expected, it could be a stubborn virus but it might be a bacterial infection. If a child’s symptoms last for at least 11 days, a doctor might suspect the latter and prescribe an antibiotic.
That diagnosis is an educated guess. Unlike COVID-19 or strep throat, there isn’t a test for bacterial sinusitis. And because almost every patient with sinusitis will recover, there’s no way to know if antibiotics have helped a patient or were an unnecessary addition that can sometimes cause side effects, such as diarrhea.
This method of diagnosing patients annoyed UPMC pediatrician Dr. Nader Shaikh, who wanted a more precise way to identify bacterial sinusitis other than counting the number of days a child has had a runny nose. So, he and his team at UPMC devised a study: They swabbed the noses of some 500 kids, ages two to 11, who had acute sinusitis for at least 11 days to test for bacteria. Then half those kids were prescribed antibiotics and half got a placebo, regardless of a nasal swab's results.
Kids who took antibiotics after testing positive for bacteria felt better two days faster. In contrast, those without bacteria didn’t do any better on the antibiotics than the placebo.
“If we follow this approach, that would change the paradigm for treatment,” said Shaikh, whose team is now considering how to best roll out nasal testing in clinics so that providers can identify bacterial sinusitis the same way they test for strep throat or COVID-19.
An additional test may not be a good thing, according to Dr. Jesse Hackell, a member of the Committee on Practice and Ambulatory Medicine for the American Academy of Pediatrics. He said that implementation could create additional costs for an illness that resolves itself.
“I don’t want to put the kids through the trauma of testing or the expensive testing if it’s not going to have an immediate difference,” said Hackell.
It makes more sense, argued Hackell, to wait longer before writing a script for an antibiotic and to only do so if symptoms worsen, regardless of whether the persistent symptoms are caused by bacterial infection. After all, the kids with bacterial infections who got antibiotics only felt better a couple days sooner than those who received the placebo.
Two days of additional illnesses mean two additional days where kids are absent from school and missed work for parents who may be living paycheck-to-paycheck, said Dr. Jennifer Preiss, a pediatrician at Allegheny Health Network. A test for bacterial sinusitis might even allow Preiss to start patients on an antibiotic sooner than the 11-day mark: "I would use it in a second. It just makes sense."
The study has implications for antibiotic stewardship: Overuse causes bacteria to mutate faster and weakens the effectiveness of the medications.
"Anything that helps us figure out how to use antibiotics better is good," said Dr. Kris Bryant, a pediatric infectious disease physician at Norton Children's Hospital in Louisville. "This study suggests some ways that we can figure [that] out."
