Does my child need antibiotics for sinusitis?

Your child has yellow or green mucus coming from their nose. They must need antibiotics to get rid of a nasty sinus infection, right?

Probably not. It likely won’t help, plus it could give them diarrhea and contribute to the alarming problem of antibiotics becoming ineffective because of overuse.

A recent study published in JAMA (Journal of the American Medical Association) looked at data gathered over seven years from 510 children ages 2 to 11 diagnosed with acute sinusitis at six sites in the United States. Half were given a placebo and half were treated with a combination of the antibiotic amoxicillin and clavulanate for 10 days after diagnosis. The researchers compared severity and duration of illness between 28 percent of the children who showed presence of any of three common disease-causing bacteria in their nasal passages and the majority who did not, and the effect of treatment with the antibiotic or placebo.

• Those who got the antibiotic did have somewhat reduced symptoms and illness resolved about two days sooner (seven vs. nine days). The effects were more noticeable among those with nasal cultures that showed the presence of pathogenic bacteria.
• Colored nasal discharge wasn’t a reliable indicator of whether antibiotics would help.
• The authors wrote that antibiotic treatment “had minimal benefit” for the children that did not show the presence of pathogenic bacteria and suggested nasopharyngeal testing might be useful to limit overuse of antibiotics for sinusitis in children.

South Yarmouth pediatrician Kenneth P. Colmer, MD of Bass River Pediatric Associates said the study supports the recommended practice of not routinely prescribing antibiotics for sinus infections, since most are viral and antibiotics are ineffective against viruses.

“I think it’s helpful. It’s a little more information I can pass on to parents,” he said of the study. “There’s a few parents that just won’t take no for an answer. In general, we try to keep parents happy.”

An accompanying JAMA editorial said millions of upper respiratory infections occur annually in American children and while most are caused by viruses, about half result in an antibiotic being prescribed. An estimated 7.5 percent of pediatric upper respiratory infections get diagnosed as acute bacterial sinusitis – a diagnosis based on criteria such as length and severity of symptoms, not usually from testing for presence of bacteria.

The editorial noted that testing cannot readily differentiate whether pathogenic bacteria are causing an infection or are simply present in nasal passages.

Dr. Colmer agreed with the editorial that many parents see colored nasal discharge as a sign their child has a bacterial infection. The study shows that to be a myth, he said.

Overuse of Antibiotics and Infection Resistance

In addition to being ineffective against most childhood sinus infections, antibiotics used indiscriminately contribute to a growing problem of bacteria and fungi becoming resistant to these drugs, making treatment of some infections difficult or impossible. The federal Centers for Disease Control and Prevention call antimicrobial resistance “an urgent global health threat” responsible for 2.8 million resistant infections and more than 35,000 deaths in 2019 in the United States.

The standard treatment for bacterial sinus infections is amoxicillin, which may be given by itself or combined with clavulanate, according to the American Academy of Pediatrics. Dr. Colmer said amoxicillin is also the “go-to drug” to combat strep throat, a potentially dangerous infection if untreated.

“It’s a concern,” he said of the potential loss of amoxicillin’s effectiveness because of overuse. “We see kids with sore throats and strep. We want to use it (amoxicillin) for the kids who really need it.”

Dr. Colmer recommended treating younger children who are suffering from sinusitis by flushing their nasal passages with saline solution using a bulb syringe. Teens can do the flushing themselves with a neti pot or a squirt bottle. To help relieve nasal congestion, children can take a steamy shower or a parent could bring a very young child into a shower with them, he added. Tylenol (acetaminophen) or Motrin (ibuprofen) can be given for discomfort, especially at bedtime.

What About Acute Sinusitis Cases?

The American Academy of Pediatrics’ clinical guidelines base a diagnosis of acute bacterial sinusitis in children 1 to 18 on one of three situations:

• Illness with cough and/or nasal discharge lasting over 10 days without getting better.
• Daytime cough, nasal discharge or fever getting worse after first improving.
• Fever of 102.2 or higher and “purulent” nasal discharge for three or more days.

Treatment with antibiotics is recommended for worsening cases or those with high fever. Antibiotics may be prescribed in cases that have lasted 10 days without improvement; however, the guidelines also suggest waiting another 3 days to see if the illness clears up without antibiotics.

“I usually try to get 10 days as a cutoff” before prescribing antibiotics,” Dr. Colmer said.

The AAP guidelines date from 2013 and the JAMA editorial said the new study supports not changing them.

Dr. Colmer noted the study and the JAMA editorial referenced the risk of antibiotic-caused diarrhea in children already sick with sinusitis.

“There’s even a chance of making things worse,” he said.