• Posted July 26, 2023

Nasal Swab for Bacteria Might Slash Antibiotic Prescribing in Kids

Testing children with a suspected sinus infection for three common bacteria might cut unnecessary antibiotic prescribing, a new study suggests.

Only half of kids with sinusitis -- inflammation or swelling of the sinuses -- show any improvement with antibiotics, which target bacterial infections, not viral infections, the researchers note.

"When a child comes in with a sore throat, we test for strep [a bacteria]. If the test is negative, we do not prescribe antibiotics," said lead researcher Dr. Nader Shaikh, a professor of pediatrics and clinical and translational science at the University of Pittsburgh School of Medicine.

"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," he said.

Sinus infections are common in children, but there isn't a good way of predicting which kids will benefit from antibiotics, so these drugs may be prescribed unnecessarily, Shaikh said. The condition causes congestion, runny nose, discomfort and difficulty breathing, but often clears up without treatment.

"Reducing unnecessary antibiotic use is an important goal because antibiotic resistance is a major public health issue," Shaikh said. "These medications can also have side effects, such as diarrhea, and we still don't understand the long-term effects of antibiotics on the microbiome, so they can potentially do more harm than good if a child's symptoms are not caused by a bacterial infection."

For the study, the researchers enrolled 515 children with sinusitis who randomly received either antibiotics or a placebo. The researchers also took nasal swabs and tested for the three main types of bacteria involved in sinus infections.

Children whose tests were positive for bacteria did better with antibiotics than those who did not have bacteria, the researchers found. The findings suggest that testing for bacteria might be a simple and effective way to identify kids who will benefit from antibiotics and avoid prescribing antibiotics to those who won't.

Doctors commonly believe that yellow or green snot is a sign of a bacterial infection, Shaikh said. Several studies, however, have suggested that the color of nasal discharge is not meaningful. In this study, Shaikh's group found it was not indicative of the type of infection and thus should not be used to make a decision about using antibiotics.

The researchers would like to see a test developed to test quickly for sinus bacteria using nasal swabs.

"Our study supports the implementation of bacterial testing into patient care for children with sinusitis symptoms to improve diagnoses and reduce antibiotic use," Shaikh said. The report was published July 25 in the Journal of the American Medical Association.

One expert doesn't think such a test is practical or necessary.

"There really aren't widely available tests like that that can be rolled out cheaply and widely to help inform that decision by parents and providers about whether antibiotics would be beneficial," said Dr. Aaron Milstone, a professor of pediatrics at Johns Hopkins University and co-author of an accompanying journal editorial.

Not all bacteria in the nose are a sign of serious infection, he added. "Just swabbing the nose and finding bacteria doesn't mean that it would benefit from antibiotics. You could imagine if there was a rapid test that could be used to swab the nose of a child, it might be used more often than necessary, and that might actually lead to an increase in antibiotic use as opposed to a decrease in antibiotic use," Milstone said.

Such a test could also lead to added costs that aren't justified by the small benefit, he said.

In most cases, sinusitis goes away by itself, Milstone said. Moreover, the side effects of an antibiotic, like diarrhea, can be harder for parents and children to deal with than sinusitis, he added.

"Sinusitis is very common," Milstone said. "And even where antibiotics benefit, that benefit is modest. So I think parents should understand that if their child has sinusitis, they're going to have to be patient and expect that their child will get better, but it will take time."

More information

The American College of Allergies, Asthma & Immunology has more on sinusitis.

SOURCES: Nader Shaikh, MD, MPH, professor, pediatrics and clinical and translational science, University of Pittsburgh School of Medicine; Aaron Milstone, MD, professor, pediatrics, Johns Hopkins University, Baltimore; Journal of the American Medical Association, July 25, 2023