Antibiotics for persistent nasal discharge (rhinosinusitis) in children

Nasal discharge (rhinosinusitis) is the result of inflammation of the mucosa of the upper respiratory tract, and is usually due to either infection or allergy.

To determine the effectiveness of antibiotics versus placebo or standard therapy in treating children with persistent nasal discharge (>10 days).

The Cochrane Controlled Trials Register, MEDLINE, EMBASE, and bibliographies of relevant articles were searched. Authors and pharmaceutical companies were contacted. Date of most recent searches: March 2000.

All randomized controlled trials that compared antibiotics versus placebo or standard therapy (decongestants or nasal saline drops). Trials which included the use of other medications were included if all participants were allowed equal access to such medications or if the additional or alternative therapies were regarded as ineffective. Trials that only combined or compared antibiotics with surgery, or sinus puncture and lavage, were not included in the review.

Data were extracted by a single reviewer for the following outcomes: clinical failure, failure to improve, clinical improvement, time to resolution, complications, side-effects and bacteriologic failure. For the dichotomous outcome variables of each individual study, proportional and absolute risk reductions were calculated using a modified intention-to-treat analysis. The summary weighted risk ratio and 95% confidence interval (fixed effects model) were calculated using the inverse of the variance of each study result for weighting (Cochrane statistical package, REVMAN version 4.3).

A total of five studies involving 401 children compared antibiotics with placebo or standard therapy. Only one of the seven outcomes (clinical failure) was reported in all studies. Around 45% of children did not have a clinical success documented when reviewed 2-6 weeks after randomization. The control event rate varied from to 47-71% (mean 56%). The risk ratio estimated using a fixed effects model was 0.72 (95% CI 0.59, 0.89). The estimated effect size was consistent in four of the five studies.

For children with persistent nasal discharge or older children with radiographically confirmed sinusitis, the available evidence suggests that antibiotics given for 10 days will reduce the probability of persistence in the short to medium-term. The benefits appear to be modest and around six children must be treated in order to achieve one additional cure. No long term benefits have been documented. These conclusions are based on a small number of small randomized controlled trials and additional larger well-designed studies are indicated.