Discharge With Pus (Rhinosinusitis)
It has been assumed that a pussy discharge
would always be bacterial and a more watery nasal discharge viral.
Studies have shown a different picture. Many times
severe acute rhinitis that obviously is infectious, is actually viral when evidence
based medical studies are done. Ref. 3 give an overview from a group of emergency
medicine physicians who have reviewed the evidence based literature.
they found that isolated rhinitis and sinusitis does not exist. Any upper respiratory
infection starts in the nose and simultaneously affects the sinuses as well, but
the sinuses are only really sympotomatic in the moderate and more severe forms
of the rhinosinusitis (that's the name they used in
rhinitis or rhinosinusitis is one of the 10 most common diagnoses in the
office setting. 25 million Americans in the U.S. see their physician at he office
every year. Patients call any nose infection that leads to facial fullness and
a plugged up feeling "sinusitis". Physicians call "sinusitis"
the condition that leads to an accumulation of secretions ("purulent effusion")
in the sinus cavity with upper toothache on one side only or extreme one-sided
facial pain with a high fever.
This latter more narrow definition of sinusitis
has a higher likelihood of being the bacterial sinusitis as dealt with under sinusitis.
All other cases of pussy nasal discharge from both nostrils, particularly
within the first 7 days of a cold or rhinosinusitis is usually
viral when the appropriate viral studies are done and sinus punctures with cultures
were done in evidence based trials (reviewed in Ref. 3).
Only less than
2% of all viral upper respiratory tract infections are complicated by bacterial
rhinosinusitis! As most people do not see their physician about every cold, only
15% are seen in doctors' offices or walk-in-clinics. According to Ref.3, if all
patients with bacterial infections were seeing their physicians only about 13%
of patients seen by the physician should receive antibiotic treatment. However,
close to 100% of those patients receive antibiotic therapy. This has created the
problem of resistant bacterial strains as bacteria learn how to chew up antibiotics,
if they are exposed long enough.
should get antibiotics? Only those how have a high probability of having true
bacterial rhinosinusitis. I have summarized the answer to this question from data
provided in Ref.3 for you in this table.
|Who should get antibiotics?
discharge from only one nostril||viral
infection mostly in both nostrils|
|gnawing pain in cheek bone on one side||usually
associated with pus in maxillary sinus cavity|
|upper toothache on one side||irritation
of nerve root from sinusitis infection|
|one sided facial pain present more than 10 days into cold||most
viral infections heal within 10 to 14 days|
|CT scan, ultrasound or plain X-rays show sinus fluid level
||infection accumulates secretions in sinuses,
but viruses can cause this too |
fever restarts after a period of normal temperature||the
second fever usually indicates the start of the bacterial superinfection|
|poor response to decongestants
(Sinutab etc.)||bacterial superinfection leads
to swelling of mucous membranes and blockage|
know from controlled studies, where sinus cavity punctures were done as part of
the studies, that in bacterial infections there were at least 100,000 bacteria
per milliliter in the pus sample and at least one ot the typical bacteria that
was cultured: Streptococcus pneumoniae or Haemophilus influenzae.
Occasionally there was also Streptococcus pyogenes or Moraxella catarrhalis
that was isolated.
Many studies in the last 30 years have established these
bacteria to be part of bacterial rhinosinusitis and sinusitis.
In Ref. 3 the evidence is very clear that a reliable diagnosis
cannot be made in the beginning. To do sinus punctures routinely would be absurd
However, if three of the symptoms listed in the table
above are positive at 7days, there is a probability of 80 to 90% that the diagnosis
of bacterial rhinosinusitis is correct. For this condition antibiotic therapy
is reasonable. However, as mentioned above, this would only be for about 2% of
the total cold population (about 13 to 15% of the population seen by the physician).
If in doubt at 7 days into the cold, a nasal swab could be taken to see if pathogenic
bacteria can be isolated in the laboratory.
The vast majority of patients
who do not fulfil the criteria above would simply inhale with hot steam as described
under sinusitis to moisturize the
airways and facilitate a spontaneous recovery from the illness.
is also a useful measure to keep the nasal passages open (comes as nasal solution).
The other 2 to 3% of the total cold population would need amoxicillin, or if the
bactrium is resistant in the region where the patient lives (or proven by culture
& sensitivity) another antibiotic would be prescribed by the physician. Placebo
studies have shown that those who do not get antibiotics have a recovery rate
of about 56%, whereas those on amoxicillin for 10 days had a response rate of
about 89%, only a 35% advantage. This is due to a dilution factor, because a large
portion of the study was likely still viral in origin (Ref.3), hence the good
response in the placebo group.