Editorial <\/p>\n\n\n\n
July 25, 2023<\/p>\n\n\n\n
The diagnosis of acute bacterial rhinosinusitis in children is clinically challenging due to symptom overlap with acute viral upper respiratory illnesses. To help address this frequent conundrum, Shaikh and colleagues designed a study to identify children who are likely to benefit from antibiotics for acute rhinosinusitis.1<\/a><\/sup> The investigators included 510 children (2-11 years old) who met inclusion criteria to receive amoxicillin, 90 mg\/kg\/d, and clavulanate, 6.4 mg\/kg\/d, or placebo, then further stratified the patients based on nasopharyngeal culture for Streptococcus pneumoniae<\/em>, nontypeable Haemophilus influenzae<\/em>, or Moraxella catarrhalis<\/em>, as well as the presence of colored nasal discharge. Across 6 institutions, symptoms were assessed by parents and\/or caregivers for 10 days via the validated Pediatric Rhinosinusitis Symptom Scale. Overall, 71% of included children had a positive nasopharyngeal culture, and 67% had colored nasal discharge at time of presentation. The authors reported that children in the antibiotic group, when compared with the placebo group, experienced faster symptom resolution (median 7 vs 9 days). Children with positive nasopharyngeal cultures had lower symptom burden when treated with antibiotics (mean difference, \u22121.95; 95% CI, \u22122.40 to \u22121.51). Additional exploratory analyses suggested that treatment efficacy was primarily due to the presence of H influenzae<\/em> and S pneumoniae<\/em> in the nasopharynx and not M catarrhalis<\/em>. The effect of antibiotics did not differ according to the presence or absence of colored nasal discharge.<\/a><\/p>\n\n\n\n With regard to these data about colored discharge, the authors suggested that therapeutic decision-making should not rely on this factor.1<\/a><\/sup> Physical examination has classically focused on attempts to distinguish between acute bacterial rhinosinusitis and viral upper respiratory tract infections. Both are commonly present with rhinorrhea, nasal mucosa edema, and turbinate swelling. Furthermore, the color and viscosity of nasal drainage can also change during the natural course of viral illnesses without the use of antimicrobial agents.2<\/a><\/sup> In light of these challenges, the 2013 American Academy of Pediatrics clinic practice guideline has supported a presumptive diagnosis of acute bacterial sinusitis based on duration of symptoms (>10 days), \u201cdouble sickening\u201d (worsening after initial improvement), or presence of severe symptoms (purulent nasal discharge and fever \u226539 \u00b0C for at least 3 consecutive days).2<\/a><\/sup> Shaikh et al, however, have suggested that nasal drainage coloration is not substantially associated with antibiotic treatment effect.1<\/a><\/sup> Their data arose in the context of patients presenting with colored nasal discharge, and they reported a priori calculations suggesting that with an anticipated 6% attrition rate, 344 enrolled children per treatment group were needed to achieve 80% power to detect an interaction between either of the 2 subgroup variables. It is unknown whether enrolling more patients would uncover a difference between the colored and noncolored nasal discharge groups in future studies.<\/a><\/p>\n\n\n\n The authors additionally described that patients with positive nasopharyngeal cultures for S pneumoniae<\/em>, H influenzae<\/em>, and M catarrhalis<\/em> had a significant reduction in symptoms when treated with antibiotics.1<\/a><\/sup> They also noted that using nasopharyngeal culture data to guide therapeutic management would have reduced antibiotic use by 28%. They furthermore commented that if M catarrhalis<\/em> is a frequent nasopharyngeal colonizer, antibiotic prescriptions could decrease by 53% when using positive S pneumoniae<\/em> and H influenzae<\/em> nasopharyngeal culture information to support decisions. A cross-sectional study of the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey from 2006 to 2010 found that broad-spectrum antibiotics were more likely to be prescribed for diagnoses of acute sinusitis compared with acute pharyngitis (adjusted odds ratio, 2.77; 95% CI, 1.65-4.63), with a larger effect size observed in children younger than 2 years (adjusted odds ratio, 3.55; 95% CI, 1.26-9.98).3<\/a><\/sup> Akin to rapid antigen detection testing as the standard of care for group A streptococcal (GAS) pharyngitis, the use of culture-directed decision-making for acute bacterial sinusitis could notably decrease antibiotic prescriptions in the setting of acute rhinosinusitis.4<\/a><\/sup> Clinical practice guidelines have established the use of rapid antigen detection testing for GAS with or without throat culture to accurately diagnose GAS pharyngitis, arising from the need to treat GAS pharyngitis for the prevention of rheumatic fever.5<\/a><\/sup><\/a><\/p>\n\n\n\n Development of a similarly practical point-of-care test option for acute bacterial rhinosinusitis could invoke a paradigm shift for ambulatory care professionals assessing patients whose presentation raises uncertainty in the diagnosis of viral or bacterial acute rhinosinusitis. Point-of-care multiplex polymerase chain reaction testing with same-day results could potentially be leveraged to reduce antibiotic prescriptions. While this approach requires nasopharyngeal swabs, which have traditionally been viewed as invasive by patients and families, as the authors note,1<\/a><\/sup> in the setting and needs of the COVID-19 pandemic, such swabs have become more frequently accepted. In this setting, swabbing amid acute rhinosinusitis could be a more feasible proposition.<\/a><\/p>\n\n\n\n The current study by Shaikh et al uses metatranscriptomics tests.1<\/a><\/sup> Compared with polymerase chain reaction testing, which sequences the whole profile of the microbiome (metagenomics), metatranscriptomics testing uses RNA expression to provide a functional \u201csnapshot\u201d of the bacterial pathogenic activity.6<\/a><\/sup> By providing a function-focused result, metatranscriptomics testing is more likely to identify bacterial pathogens, which are more active in the setting of an infection.<\/a><\/p>\n\n\n\n The authors also note that their results could be applied in multiple different ways in clinical practice: presumptive treatment without testing, treatment while awaiting pathogenic test results, up-front testing to direct therapeutic management, or watchful waiting.1<\/a><\/sup> With these potential management avenues in mind, as well as some uncertainty within the data regarding discharge coloration, an opportunity for shared decision-making with patients and families is presented.7<\/a><\/sup> Shared decision-making is particularly apt in circumstances where multiple management options exist. For instance, the data suggest that antibiotic management may be associated with a higher incidence of adverse effects such as diarrhea, while observation, and thus watchful waiting, would result in symptom resolution by day 9 in 50% of patients.1<\/a><\/sup> Even when practical, timely, and cost-effective testing is widely available to accurately differentiate acute bacterial rhinosinusitis from viral respiratory illnesses, it remains the collaboration between medical professionals and patients and their families that primarily guides the management of pediatric acute bacterial rhinosinusitis.<\/p>\n","protected":false},"excerpt":{"rendered":" Editorial July 25, 2023 Time for Acute […]<\/p>\n","protected":false},"author":3,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":[],"categories":[24,23],"tags":[],"_links":{"self":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/24467"}],"collection":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=24467"}],"version-history":[{"count":1,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/24467\/revisions"}],"predecessor-version":[{"id":24468,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/24467\/revisions\/24468"}],"wp:attachment":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=24467"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=24467"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=24467"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}