Antimicrobial prescribing for acute purulent rhinitis in children: a survey of pediatricians and family practitioners

Abstract

Background. The tenet that children with acute purulent rhinitis need not be treated with antibiotics unless drainage persists for 7 to 10 days is taught to medical students and residents in primary care specialties but may not be adhered to in actual clinical practice. Because of the global increase in bacterial resistance stemming largely from the overuse of antibiotics, we sought to determine how acute purulent rhinitis is managed in the primary care setting. Methods. We surveyed all 450 pediatricians (PD) and family practitioners (FP) in northern Virginia who were in active practice in 1994. The survey instrument was a questionnaire containing two clinical vignettes followed by a series of multiple choice or fill-in-the-blanks questions. Initial nonresponders received up to three additional mailings of the same questionnaire. Results. There were 346 (77%) evaluable responses. Seventy-one percent of FP and 53% of PD (P = 0.001) immediately prescribed antibiotics for infants with scant, green nasal mucopurulent secretions of 1 day duration; fewer treated an older child immediately (50% FP vs. 24% PD, P < 0.00001). Only 15% of FP vs. 23% of PD (P = 0.07) waited for 7 to 10 days of persistent purulent nasal drainage in infants before prescribing antibiotics. Ninety-four percent of FP and 95% of PD (P = 0.8) indicated that they would prescribe antibiotics immediately for infants with acute purulent rhinitis who attended day care. For otitis-prone children who were not in day care, 86% of FP and 78% of PD (P = 0.02) would also treat without delay. The reasons given for prompt antibiotic therapy were (1) the belief that many untreated patients would develop persistent purulent nasal drainage, (2) concern that acute otitis media would develop, (3) pressure from mothers to prescribe an antibiotic and/or (4) the desire to allow employed parents to return to work earlier. Amoxicillin was the initial choice for 89% of FP vs. 76% of PD (P = 0.003). Most FP (89%) and PD (97%) were concerned about the increase in bacterial resistance rates arising from unnecessary antibiotic prescribing (P = 0.01). Conclusions. Most infants and children with acute purulent rhinitis of short duration were treated with antibiotics despite professed concerns over the spread of bacterial resistance; the practice was more prevalent among FP.