Antibiotics for acute purulent rhinitis-wait and watchBMJ 2006; 333 doi: https://doi.org/10.1136/bmj.333.7562.0 (Published 03 August 2006) Cite this as: BMJ 2006;333:0
All rapid responses
Rhinitis is defined as inflammation of the nasal membranes and is
characterized by a symptom complex that consists of any combination of
sneezing, nasal congestion, nasal itching, and rhinorrhea. The whole upper
respiratory tract may be involved.
Rhinitis may have many reasons (e.g. airborn irritants, allergens,
medication or infection). The finding of purulent secretion indicates a
Rhinitis is an extremely common condition, affecting nearly the whole
population at least once a year. Rhinitis is not a life-threatening
condition, but complications can occur and the condition can significantly
impair quality of life.
Rhinitis usually involves inflammation of the mucous membranes of the
nose, eyes, eustachian tubes, middle ear, sinuses, and pharynx. The nose
invariably is involved, and the other organs are affected in certain
individuals. The mediators that are immediately released include
histamine, tryptase, chymase, kinins, and heparin. These mediators, via
various interactions, ultimately lead to the symptoms of rhinorrhea (ie,
nasal congestion, sneezing, itching, redness, tearing, swelling, ear
pressure, postnasal drip). Mucous glands are stimulated, leading to
increased secretions. Vascular permeability is increased, leading to
plasma exudation. Vasodilation occurs, leading to congestion and pressure.
Systemic effects, including fatigue, sleepiness, and malaise, can occur
from the inflammatory response. These symptoms often contribute to
impaired quality of life.
Rhinitis often coexists with other disorders, it may be associated with
asthma exacerbations. It is also associated with otitis media, eustachian
tube dysfunction and sinusitis. Rhinitis may also contribute to learning
difficulties, sleep disorders, and fatigue.
Therefore decongesting medication, topical or/and systemic should be
prescribed as a first line treatment, additionally a rinse with salty
water (NaCl 0,9%) helps mechanically to reduce the purulent discharge.
These measurements improve the condition of the most patients. Combining
this treatment with a “watchful waiting” - as mentioned in the article –
may reduce the need of antibiotics.
The second step is to define the cause of the rhinitis, as above quoted
many causes have to be excluded (a common reason in children suffering
from recurrent rhinitis may be due to enlarged adenoids – leading to a
dramatic improvement of the child’s health after removal of the adenoids).
The attitude to prescribe antibiotics for this condition may result
from different reasons. One reason may be a legal reason, in case of an
antibiotic treatment the chances to get sued for an insufficient treatment
are rather low, because the antibiotic would already be the treatment of
choice in case of a complication (e.g. otitis media) (not mentioning the
possible side effects of an antibiotic treatment).
Another reasons may be the lack of time of many physicians and patients.
Most people think taking an antibiotics is the safest way to handle any
This may result of the poor understanding of the action of antibiotics by
the patients. Most of them are still convinced that antibiotics work as a
disinfectant, and are rather astonished if they learn that antibiotics are
only supporting the bodies’ own immune system (leukocytes) to fight
After explaining this circumstance and the way how bacteria and
mediators can be reduced mechanically with decongestion and rinsing the
nose, most patients agree to a non antibiotic treatment, but they have to
be told to return to the physician in case of worsening of their condition
under the quoted treatment, which may be more time consuming for the
physician and the patient – this is something both of the have to learn
Competing interests: No competing interests
An excellent article on the state of medicine today. Journals today contain volumes on the mysticism of ethics, conditions affecting communities with underlying problems far greater than the scope of the article and a knowledge base of big severe illnesses. Unfortunately a paucity of knowledge on the most basic medical conditions.
None of the articles quoted gives any indication that the nose was ever examined. Was there any history of obvious causes of acute purulent rhinitis? Who is taught to examine a nose today? No mention in the article of the conditions far more common than bactarial infection causing acute discoloured secretions. No mention of the fact that discoloured secretion does not indicate infection - even eosinphils cause discolouration. The mention of Cochrane analysis of chronic purulent rhinitis almost implying that there is any similarity to acute purulent rhinitis.
No attempt was made to show that some of the side effects, diarrhoea, rash etc were part of the illness rather than antibiotic problems.
I think the article showing the effect of phenylephrine basically exposes the above weaknesses well.
Unfortunately in my opinion, the article has little merit other than to show the poor state of clinical capability of assessing the most basic and common conditions
Competing interests: No competing interests