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RESEARCH: B Arroll and T Kenealy Are antibiotics effective for acute purulent rhinitis? Systematic review and meta-analysis of placebo controlled randomised trials BMJ 2006; 333: 279 [Abstract] [Full text]

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There is no significant difference between antibiotics

Christopher J Cates   (4 August 2006)

We agree with Chris Cates but add a practical perspective

Bruce Arroll, Tim Kenealy   (8 August 2006)

Are antibiotics effective for acute purulent rhinitis?

Joanne Rimmer, John Almeyda (Consultant Otolaryngologist)   (9 August 2006)

'Snot Always Easy to Decide

Mark W. Heffington   (25 November 2006)

There is no significant difference between antibiotics 4 August 2006
Christopher J Cates, GP Manor View Practice, Bushey Health Centre, London Road, Bushey WD23 2NN Send response to journal: Re: There is no significant difference between antibiotics	Editor, Arroll and Kenealy suggest that amoxicillin may be the preferred antibiotic for purulent rhinitis. The pooled effect of the two studies using amoxicillin was statistically significant (Relative Risk 1.26, 95% CI 1.11 to 1.45), whilst cefalexin did not achieve significance in one study (Relative Risk 0.62, 95% 0.26 to 1.47). Altman and Bland[1] have pointed out that reporting the P values of subgroups is not the correct method to compare the treatments, as it is confounded by the number of subjects in each group. When the method suggested by Altman and Bland is used to compare the studies using amoxicillin directly to the study using cefalexin the Relative Risk Reduction is 0.49 (95% CI 0.20 to 1.18, P = 0.11). This does not confirm a significant difference between the two antibiotics. Moreover, as the authors point out, half of the participants in De Sutter had unilateral facial pain, and this may also further confound this comparison. The data presented do not justify a preference in choice of antibiotic. [1] Altman DG, Bland JM. Statistics Notes: Interaction revisited: the difference between two estimates. BMJ 2003;326(7382):219. Competing interests: None declared
We agree with Chris Cates but add a practical perspective 8 August 2006
Bruce Arroll, Professor Dept of General Practice and Primary Health Care University of Auckland, Tim Kenealy Send response to journal: Re: We agree with Chris Cates but add a practical perspective	We have reproduced the calculations of Chris Cates and he is correct in his assertion. From the practical clinical point of view if one wished to treat purulent rhinitis (and we do not recommend that routinely) amoxycillin would be a good choice as it is probably safer than co- trimoxazole and the only study that was statistically significant in our review was one which compared amoxycillin versus placebo. It is an antibiotic frequently used in general practice and would be our choice. Competing interests: Is intranasal zinc effective for the common cold? A systematic review and meta-analysis
Are antibiotics effective for acute purulent rhinitis? 9 August 2006
Joanne Rimmer, Specialist Registrar in Otolaryngology West Middlesex University Hospital, Isleworth, Middlesex. TW7 6AF, John Almeyda (Consultant Otolaryngologist) Send response to journal: Re: 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 plan1. Their systematic review looked at seven studies comparing placebo with antibiotic treatment for "acute purulent rhinitis", and defined "acute" as "less than ten 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". The authors make no mention of the evidence base used for the above definitions. The currently accepted definition of acute rhinosinusitis, from the European Position Paper on Rhinosinusitis and Nasal Polyps, classifies and 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 atatement that "this is not a serious condition" is misleading. Whilst the first two conditions may not be, acute maxillary sinusitis has several uncommon but potentially serious complications. periorbital cellulitis is the most common of these, and whilst treatable does carry a rick of permanent blindess. Rarer, but potentially fatal, are the intracerebral complications of meningitis, intracranial abscess and acvernous sinus thrombosis. Whilst it is reasonable to treat a simple cold, or indeed acute purulent rhinitis, with conservative measures in the first instance, if a patient presents with classical symptoms of acute maxillary sinusitis they should be treated with antibiotics as well as a short-term nasal decongestant to minimise the risk of such complications. A 2002 Cochrane review of antibiotics for persistent rhinosinusitis in children noted that most begin to improve spontaneously within ten days of onset3. 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. 1. Arroll B, Kenealy T. Are antibiotics effective for acute purulent rhinitis? Systematic review and meta-analysis of placebo-controlled randomised trials. BMJ 2006;333:279-281 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 Competing interests: None declared
'Snot Always Easy to Decide 25 November 2006
Mark W. Heffington, Private Practice, Family Medicine Cashiers, N.C. 28717 Send response to journal: Re: 'Snot Always Easy to Decide	This article does not specify the method by which the diagnosis of purulent rhinitis was made, or how it varied from study to study. I suspect that restricting the criteria to include only those with opaque yellow or green nasal secretions visualized by the physician (rather than allowing the always-questionable patient-reported description) would have made a significant difference in the outcomes, at least in the number needed to treat. My chief concern with this article, however, is the final paragraph, in which the authors would make all of the preceding science moot by suggesting that "antibiotics should be used only when symptoms have persisted for long enough to concern parents or patients." In my experience, patients ONLY decide to come to my office (and to pay me) when symptoms have persisted long enought to concern them or their parents. So this advice would lead me to treat them all with antibiotics, while the final sentence would lead me to treat very few. Competing interests: None declared