Nasal discharge colour a poor guide for antibiotic use in acute sinusitis

Antibiotics have little to no impact on acute sinus in children in relation to the color of nasal discharge. Yet they are commonly prescribed. “To our knowledge, the current study is the first randomized clinical trial to confirm that the colour of the nasal discharge should not influence therapeutic decisions,” said researchers in a study in JAMA. A multicentre, double-blind, placebo-controlled, randomized clinical trial was launched comparing the effects of treatment with antibiotics to placebo in children with acute sinusitis. Conducted between February 2016 and April 2022, it enrolled children aged two to 11 years with acute sinusitis. Cases of severe acute sinusitis, or a history of asthma or allergic rhinitis were excluded. Participants were stratified according to the presence or absence of colored nasal discharge (yellow or green), then randomly assigned to a 10-day course of either oral amoxicillin (90 mg/kg/d) and clavulanate (6.4 mg/kg/d), or placebo. Nasopharyngeal specimens were obtained for bacterial culture at baseline and at the end of the study. Data were analyzed for 496 children. Overall, 71% had bacterial pathogens of interest (S pneumoniae, H influenzae, and M catarrhalis) in their nasopharynx, and 67% had colored nasal discharge. “The correlation between the presence of colored nasal discharge and bacterial pathogens was weak.” the study said. The median length of time to symptom resolution was 7.0 days for children given antibiotics compared to 9.0 days for placebo, a statistically significant difference. Children in the amoxicillin and clavulanate groups were significantly less likely to experience treatment failure, develop acute otitis media, or receive additional systemic antibiotics than those given placebo. However, those taking antibiotics had higher rates of clinically significant diarrhea than the placebo group: 11.4% vs 4.7%, respectively. Generally, those who tested positive for bacterial pathogens had greater benefits from antibiotics than those with negative tests. Yet, “in contrast, the effect of antibiotics did not differ significantly between subgroups defined by the presence or absence of colored nasal discharge.” The authors suggested limiting antibiotics to patients with positive nasopharynx pathogen tests. Here, such an approach would have resulted in a 28% reduction in antibiotic use. Plus, if antibiotic use had been restricted to children with H influenzae or S pneumoniae “antibiotic use would decrease by 53%.” A rapid antigen test for S pneumoniae is commercially available, though similar bedside tests for H influenzae and M catarrhalis are not. Or, testing could be accomplished within hours “using commercially available multiplex polymerase chain reaction tests,” researchers said.

Nasal discharge colour a poor guide for antibiotic use in acute sinusitis

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