Sinusitis is one of the most common reasons for children to receive antibiotics. But do they work? This week, Pediatrics is early releasing a meta-analysis of 6 randomized controlled trials for the treatment of acute sinusitis in children, by Shannon Conway, BS, Grace Mueller, BS, and Nader Shaikh, MD, from the University of Pittsburgh (10.1542/peds.2023-064244).
These 6 studies enrolled almost 1000 children. There was a lot of variability in the studies:
- Four studies used symptoms not improving for 10 days as a criterion for diagnosis. One study used purulent nasal drainage for >4 weeks. One study did not specify the duration of symptoms.
- Three studies required an abnormal imaging study; one required a maxillary x-ray, one a maxillary ultrasound, and one a sinus CT scan.
- Two studies used low-dose (40–45 mg/kg/day) amoxicillin +/- clavulanate, 1 used cefuroxime 250 mg/day, and 3 used high dose (90 mg/kg/day) amoxicillin-clavulanate.
The authors found that:
- Antibiotic treatment, compared to placebo, had a 41% lower likelihood of treatment failure. High-dose amoxicillin-clavulanate was always superior to placebo.
- However, nearly 60% of those who received placebo had improved symptoms.
- Those who received antibiotics had approximately 2 fewer days of symptoms.
- Those who received antibiotics were 60% more likely to experience diarrhea as a side effect.
What should we take away from this article? In a commentary entitled “Clarifying the Role of Antibiotics in Acute Sinusitis Treatment,” Timothy Savage, MD, from Harvard Medical School and Matthew Kronman, MD, from Seattle Children’s Hospital note that none of the 6 studies used high-dose amoxicillin, and that might be just as good as high-dose amoxicillin-clavulanate and result in less diarrhea (10.1542/peds.2024-065732). They also question the need to treat children with sinusitis, given that 60% will resolve without antibiotic treatment, and that antibiotic treatment only decreases symptoms by 2 days. They also note that, in one of the studies that used nasopharyngeal cultures, antibiotic use was only helpful in those who had positive bacterial cultures.
Take a look at the article and commentary. They will provide you with data that you can use when you talk with families and use shared decision-making after you make the diagnosis of sinusitis.
