Review: antibiotics are effective for acute purulent rhinitis but are associated with increased gastrointestinal side effects
Medline, EMBASE/Excerpta Medica, Cochrane Register of Controlled Trials (up to November 2005), bibliographies of published reviews, and authors.
Study selection and assessment:
randomised controlled trials (RCTs) that compared antibiotics with placebo in patients of any age with acute purulent rhinitis (duration <10 d). Studies of patients with sinusitis were excluded. 7 RCTs met the selection criteria; 6 RCTs (n = 1647, age >2 mo) were included in the quantitative analysis; 2 RCTs included only children. Quality assessment of individual studies was based on the Jadad scale. All 6 RCTs had Jadad scores of 5 out of 5.
clearance (v persistence) of purulent rhinitis and adverse events.
Meta-analysis showed that overall, antibiotics (amoxicillin, co-trimoxazole, and cefalexin) were more effective than placebo for clearing purulent rhinitis, with significant benefit at 5–8 days (table); amoxicillin was more effective than placebo (table). The antibiotic group had more adverse events (eg, vomiting, diarrhoea, abdominal pain, rash, and hyperactivity) than the placebo group (table).
Antibiotics are effective for clearing acute purulent rhinitis but have more associated side effects (primarily gastrointestinal).
- Caroline Dorsen, MSN, APRN, BC, FNP
In response to the worldwide trend of increased frequency and severity of bacterial resistance, recent large scale public health campaigns have urged prudent use of antibiotics. However, these campaigns have had mixed results. For example, although current guidelines recommend against antibiotic use for common viral illnesses, they are still prescribed much more frequently than the target set forth by Healthy People 2010.1 Although several factors are at play in providers’ decisions to prescribe or not prescribe antibiotics for acute rhinitis, presence of purulent nasal discharge has often been cited as one of the major determining factors.
The systematic review and meta-analysis by Arroll and Kenealy examined 7 randomised placebo controlled trials for evidence of benefit or harm with use of antibiotics in patients with acute purulent rhinitis. Patients of all ages in general practice settings were included in the review, and those with evidence of sinusitis, including symptoms lasting >10 days, were excluded. The authors concluded that antibiotics may decrease duration of symptoms in acute purulent rhinitis. However, because of possible individual adverse effects and societal costs, they continue to recommend “watchful waiting” as the initial preferred treatment.
The review underscores the importance of provider-patient communication in the treatment of common health problems. The adage that “antibiotics won’t do anything” to treat viral illnesses such as acute rhinitis may not be technical correct. Instead, the message to patients may be more complicated. Antibiotics are not without risks, and their use must be weighed against their potential harm at both individual and societal levels. More than ever, we must depend on our patients to follow our prescribed non-pharmacological advice and return for further evaluation if symptoms persist or worsen.
For correspondence: Professor B Arroll, Department of General Practice and Primary Health Care, University of Auckland, Auckland, New Zealand.
Source of funding: no external funding.