BMJ  2006;333:395-396 (19 August), doi:10.1136/bmj.333.7564.395-b

Letter

Antibiotics and acute purulent rhinitis

Are antibiotics effective for acute purulent rhinitis?

EDITOR—Arroll and Kenealy conclude that antibiotics are probably effective for acute purulent rhinitis but suggest that most patients will get better without them and hence advocate a "no antibiotics as first line" treatment plan.¹ Their systematic review looked at seven studies comparing placebo with antibiotic treatment for "acute purulent rhinitis" and defined acute as "less than 10 days with this symptom." They considered all papers in the Cochrane reviews addressing the use of antibiotics for "the common cold and acute purulent rhinitis and for acute maxillary sinusitis."

They do not mention the evidence base used for the above definitions. The currently accepted definition of acute rhinosinusitis classifies an acute episode as lasting for "up to four weeks with total resolution of symptoms."² The authors have also grouped three different conditions together under the general heading of acute purulent rhinitis— namely, the common cold, acute purulent rhinitis, and acute maxillary sinusitis. In doing so, their statement that this is not a serious condition is misleading. Although the first two conditions may not have, acute maxillary sinusitis has several uncommon but potentially serious complications. Periorbital cellulitis is the most common and carries a risk of permanent blindness. Rarer, but potentially fatal, are the intracerebral complications of meningitis, intracranial abscess, and cavernous sinus thrombosis.

Although treating a simple cold, or indeed acute purulent rhinitis, with conservative measures in the first instance is reasonable, patients with classic symptoms of acute maxillary sinusitis should be treated with antibiotics as well as a short-term nasal decongestant to minimise the risk of such complications.

A Cochrane review of antibiotics for persistent rhinosinusitis in children noted that most begin to improve spontaneously within 10 days of onset.³ The authors' suggestion that antibiotics should be introduced when "symptoms have persisted long enough to concern parents or patients" is not evidence based and harks back to the days of "prescribing on demand" that we have tried so hard to move away from.

West Middlesex University Hospital, Isleworth, Middlesex TW7 6AF jrimmer{at}doctors.org.uk

West Middlesex University Hospital, Isleworth, Middlesex TW7 6AF

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Competing interests: None declared.

References

1. Arroll B, Kenealy T. Are antibiotics effective for acute purulent rhinitis? Systematic review and meta-analysis of placebo-controlled randomised trials. BMJ 2006;333: 279-81. (5 August.)[Abstract/Free Full Text]
2. European Academy of Allergology and Clinical Immunology. European position paper on rhinosinusitis and nasal polyps. Rhinol Suppl 2005;18: 1-87.
3. Morris P, Leach A. Antibiotics for persistent nasal discharge (rhinosinusitis) in children. Cochrane Database Syst Rev 2002;4:CD001094.

Related Article

Are antibiotics effective for acute purulent rhinitis? Systematic review and meta-analysis of placebo controlled randomised trials

B Arroll and T Kenealy
BMJ 2006 333: 279. [Abstract] [Full Text] [PDF]