Antibiotics for Acute Purulent Rhinitis? 'S not a Good Idea
Abstract & Commentary
By Allan J. Wilke, MD, Residency Program Director, Associate Professor of Family Medicine, University of Alabama at Birmingham School of Medicine—Huntsville Regional Medical Campus. Dr. Wilke reports no financial relationship to this field of study.
Synopsis: Antibiotics may improve acute purulent rhinitis at the cost of gastrointestinal upset and rash.
Source: Arroll B, Kenealy T. Are antibiotics effective for acute purulent rhinitis? Systematic review and meta-analysis of placebo controlled randomised trials. BMJ. 2006;333:279-282.
Purulent nasal discharge is a common sign in the common cold and acute sinusitis. It is also a key trigger for prescription of antibiotics.1,2 Arroll and Kenealy report their systemic review and meta-analysis of studies of the use of antibiotics in acute purulent rhinitis. They searched Medline, EMBASE, and the Cochrane controlled trials register and included controlled trials that studied purulent rhinitis, nasopharyngitis, common cold, and sinusitis where the study groups received an antibiotic and the control groups received a placebo. "Acute" was defined as less than 10 days. They found 5 papers which examined purulent rhinitis and 2 that examined rhinitis, but did not specify whether it was clear or cloudy. Several different antibiotics were studied: demethylchlortetracycline (demeclocycline, Declomycin® and others), amoxicillin (Amoxil® and others), co-trimoxazole (trimethoprim/ sulfamethoxazole, Bactrim® and others), and cephalexin (Keflex® and others).
Pooling the data, there was a significant benefit from antibiotics with a relative risk of 1.21 (95% confidence interval, 1.09-1.34, number-needed-to-treat [NNT] 8.) Looking at adverse effects (primarily vomiting, diarrhea, abdominal pain, and rash), the pooled relative risk was 1.46 (95% CI, 1.10-1.94). The number-needed-to-harm was seven.
Eight guys walk into a physician's office with green-yellow gunk coming out of their noses. We could treat all of them and, statistically, one of them might get better. On the other hand, at least one might suffer from an adverse side effect. What's a prudent physician to do?
Last year these authors published a systemic review of antibiotics for the common cold and acute purulent rhinitis.3 In it they concluded that the evidence of benefit with use of antibiotics for upper respiratory tract infections is too weak to recommend it, but the evidence in acute rhinitis, purulent or clear, was stronger. Since antibiotics can cause significant adverse effects, they did not recommend their routine use. A Cochrane Review of chronic (10 days or greater) purulent nasal discharge in children4 concluded that when there was radiographic evidence of sinusitis, antibiotics provided modest short-term help. NNT was eight.
Back to our prudent physician. The first step should be a discussion with the patient about the probable efficacy and the probable harm associated with use of antibiotics. Watchful waiting is appropriate. If "something" must be done, consideration should be given to nasal hypertonic saline irrigation. It is effective in acute sinusitis5 and well tolerated.6
1. Dosh SA, et al. Predictors of antibiotic prescribing for nonspecific upper respiratory infections, acute bronchitis, and acute sinusitis. An UPRNet study. Upper Peninsula Research Network. J Fam Pract. 2000;49:407-414.
2. Gonzales R, et al. The relation between purulent manifestations and antibiotic treatment of upper respiratory tract infections. J Gen Intern Med. 1999;14:151-156.
3. Arroll B, Kenealy T. Antibiotics for the common cold and acute purulent rhinitis. Cochrane Database Syst Rev. 2005;(3):CD000247. Review.
4. Morris P, Leach A. Antibiotics for persistent nasal discharge (rhinosinusitis) in children. Cochrane Database Syst Rev. 2002;(4):CD001094. Review.
5. Rabago D, et al. Efficacy of daily hypertonic saline nasal irrigation among patients with sinusitis: a randomized controlled trial. J Fam Pract. 2002;51:1049-1055.
6. Rabago D, et al. Qualitative aspects of nasal irrigation use by patients with chronic sinus disease in a multimethod study. Ann Fam Med. 2006;4:295-301.