Erythromycin therapy for otitis media with effusion in sinobronchial syndrome

Prospective evaluation of clarithromycin in recurrent chronic rhinosinusitis with nasal polyps

Introduction

The antiinflammatory effects of macrolides, especially clarithromycin, have been described in patients with chronic rhinosinusitis without polyps and also other chronic inflammatory airway diseases. There is no consensus in the literature regarding the effectiveness of clarithromycin in patients with chronic rhinosinusitis with sinonasal polyposis and the national literature does not report any prospective studies on the efficacy of clarithromycin in chronic rhinosinusitis in our population.

Objective

To evaluate the effect of clarithromycin in the adjunctive treatment of recurrent chronic rhinosinusitis with sinonasal polyposis refractory to clinical and surgical treatment.

Methods

Open prospective study with 52 patients with chronic rhinosinusitis and recurrent sinonasal polyposis. All subjects received nasal lavage with 20 mL 0.9% SS and fluticasone nasal spray, 200 mcg / day, 12/12 h for 12 weeks; and clarithromycin 250 mg 8/8 h for 2 weeks and, thereafter, 12/12 h for 10 weeks. The patients were assessed by SNOT 20, NOSE and Lund-Kennedy scales before, immediately after treatment and 12 weeks after treatment. The patients were also evaluated before treatment with paranasal cavity computed tomography (Lund-Mackay) and serum IgG, IgM, IgA, IgE and eosinophil levels. The outcomes evaluated were: SNOT-20, NOSE and Lund-Kennedy.

Results

Most patients were women, aged 47 (15) years (median / interquartile range), and 61.5% (32/52) had asthma. All patients completed the follow-up after 12 weeks and 42.3% (22/52) after 24 weeks. Treatment resulted in a quantitative decrease in the SNOT-20 [2.3 (1.6) vs. 1.4 (1.6); Δ = −0.9 (1.1); p < 0.01]; NOSE [65 (64) vs. 20 (63); Δ = −28 (38), p < 0.01] and Lund-Kennedy [11 (05) vs. 07 (05); Δ = −2 (05); p < 0.01] scores. SNOT-20 showed a qualitative improvement (>0.8) in 54% (28/52, p < 0.04) of patients, a group that showed lower IgE level [108 (147) vs. 289 (355), p < 0.01]. The group of patients who completed follow-up 12 weeks after the end of treatment (n = 22) showed no worsening of outcomes.

Conclusion

Long-term adjuvant use of low-dose clarithromycin for chronic rhinosinusitis patients with recurrent sinonasal polyposis refractory to clinical and surgical treatment has resulted in improved quality of life and nasal endoscopy findings, especially in patients with normal IgE levels. This improvement persisted in the patient group evaluated 12 weeks after the end of the treatment.

The anti-inflammatory effects of erythromycin, clarithromycin, azithromycin and roxithromycin on histamine-induced otitis media with effusion in guinea pigs

BACKGROUND

Otitis media with effusion is a clinical manifestation characterised by inflammation of middle-ear mucosa. This study investigated the therapeutic effect of erythromycin, clarithromycin, azithromycin and roxithromycin on a histamine-induced animal model of otitis media with effusion.

METHODS

The animals were divided into five groups, receiving erythromycin, clarithromycin, azithromycin, roxithromycin or saline solution. The guinea pigs in the study groups received erythromycin (40 mg/kg/day), clarithromycin (15 mg/kg/day), azithromycin (10 mg/kg/day) or roxithromycin (10 mg/kg/day) for 3 days by gastric tube. Four hours after the end of the administration, histamine solution was injected into the right middle ear.

RESULTS

The lowest neutrophil density value obtained using stereological techniques was in the azithromycin group (0.86 ± 0.25 × 10-5/μm3), while the highest value was observed in the control group (6.68 ± 3.12 × 10-5/μm3). The anti-inflammatory properties of clarithromycin, azithromycin and roxithromycin were similar to one another, but better than that of erythromycin.

CONCLUSION

The use of macrolide antibiotics is recommended, as they show antibacterial and anti-inflammatory efficacy in otitis media with effusion.

Past, present and future of macrolide therapy for chronic rhinosinusitis in Japan

In 1984, the effectiveness of low-dose, long-term erythromycin treatment (macrolide therapy) for diffuse panbronchiolitis (DPB) was first reported in Japan. The 5-year survival rate for DPB improved from 62.9 to 91.4% after implementation of macrolide therapy. The usefulness of this treatment has since been demonstrated in patients with other chronic airway diseases, such as chronic bronchitis, cystic fibrosis, bronchiectasis, bronchial asthma, and chronic rhinosinusitis (CRS). The new 14-membered macrolides clarithromycin and roxithromycin and the 15-membered macrolide azithromycin are also effective for treating these inflammatory diseases. The mechanism of action of the 14- and 15-membered macrolides may involve anti-inflammatory rather than anti-bacterial activities. Macrolide therapy is now widely used for the treatment of CRS in Japan; it is particularly effective for treating neutrophil-associated CRS and is useful for suppressing mucus hypersecretion. However, macrolide therapy is not effective for eosinophil-predominant CRS, which is characterized by serum and tissue eosinophilia, high serum IgE levels, multiple polyposis, and bronchial asthma. Recent reports have described the clinical efficacy of macrolides in treating other inflammatory diseases and new biological activities (e.g., anti-viral). New macrolide derivatives exhibiting anti-inflammatory but not anti-bacterial activity thus have therapeutic potential as immunomodulatory drugs. The history, current state, and future perspectives of macrolide therapy for treating CRS in Japan will be discussed in this review.

Prolonged antibiotics for non-cystic fibrosis bronchiectasis in children and adults

BACKGROUND

The vicious cycle hypothesis for bronchiectasis predicts that bacterial colonisation of the respiratory tract perpetuates inflammatory change. This damages the mucociliary escalator, preventing bacterial clearance and allowing persistence of pro-inflammatory mediators. Conventional treatment with physiotherapy and intermittent antibiotics is believed to improve the condition of people with bronchiectasis, although no conclusive data show that these interventions influence the natural history of the condition. Various strategies have been tried to interrupt this cycle of infection and inflammation, including prolonging antibiotic treatment with the goal of allowing the airway mucosa to heal.

OBJECTIVES

To determine the benefits of prolonged antibiotic therapy in the treatment of patients with bronchiectasis.

SEARCH METHODS

We searched the Cochrane Airways Group Trials Register and reference lists of identified articles. Searches were current as of February 2014.

SELECTION CRITERIA

Randomised trials examining the use of prolonged antibiotic therapy (for four or more weeks) in the treatment of bronchiectasis compared with placebo or usual care.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. We contacted study authors to ask for missing information.

MAIN RESULTS

Eighteen trials met the inclusion criteria, randomly assigning a total of 1157 participants. Antibiotics were given for between four weeks and 83 weeks. Limited meta-analysis was possible because of the diversity of outcomes reported in these trials. Based on the number of participants with at least one exacerbation, the meta-analysis showed significant effects in favour of the intervention (odds ratio (OR) 0.31, 95% confidence interval (CI) 0.19 to 0.52; P value < 0.00001), with events occurring in 271 per 1000 people in the intervention arm (95% CI 126 to 385) and in 546 per 1000 in the control population, based on evidence of moderate quality. A non-statistically significant reduction in hospitalisation favoured the use of prolonged antibiotics with a moderate quality grade of supporting evidence (37 per 1000 in the intervention arm (95% CI 13 to 96) and 87 per 1000 in control (OR 0.40, 95% CI 0.14 to 1.11; P value = 0.08). Drug resistance developed in 36 of 220 participants taking antibiotics compared with 10 of 211 participants given placebo or standard therapy (OR 3.48, 95% CI 1.20 to 10.07; P value = 0.02), translating to natural frequencies of 155 per 1000 in the intervention arm (95% CI 59 to 346) and 50 per 1000 in the control arm. The intervention was well tolerated with no overall significant difference in withdrawal between treatment and placebo groups (OR 0.91, 95% CI 0.56 to 1.49). Diarrhoea was commonly reported as an adverse event, particularly with an oral intervention.

AUTHORS' CONCLUSIONS

Available evidence shows benefit associated with use of prolonged antibiotics in the treatment of patients with bronchiectasis, at least halving the odds of exacerbation (with 275 fewer exacerbations per every 1000 people treated in the antibiotic arm compared with the control arm) and hospitalisation (50 fewer hospitalisations per 1000 people in the antibiotic arm compared with the control arm). However, the risk of emerging drug resistance is increased more than threefold. This review is limited by diversity of trials and by evidence of moderate to low quality. Further randomised controlled trials with adequate power and standardised end points are required.

Nasopharyngeal flora and drug susceptibility in children with macrolide therapy

OBJECTIVES/HYPOTHESIS

Low-dose, long-term administration of macrolides (macrolide therapy) has been used as an effective treatment for chronic respiratory tract diseases. The authors reported on the nasopharyngeal flora in children treated with macrolide therapy.

STUDY DESIGN

Prospective study.

METHODS

Nasopharyngeal cultures were obtained from 73 children with chronic rhinosinusitis and/or otitis media with effusion at the end of the low-dose administration of clarithromycin (macrolide group). As control subjects, 98 children with chronic rhinosinusitis and/or otitis media with effusion who were not given macrolides were also included in the study. The culture results were evaluated with respect to antimicrobial susceptibility patterns, risk factors for carriage of erythromycin-resistant Streptococcus pneumoniae, and the clinical efficacy of the therapy.

RESULTS

The macrolide therapy did not have a significant effect on the incidence or the susceptibility patterns of potential pathogens except for Moraxella catarrhalis. Most of children in the macrolide group possessed a normal flora compared with the control children. The risk factors for carriage of erythromycin-resistant S pneumoniae were male gender in the macrolide group and age under 6 years and use of antimicrobial drugs other than macrolides in the control group. The clinical efficacy of the therapy was independent of carriage of erythromycin-resistant S pneumoniae.

CONCLUSION

Macrolide therapy has little effect on carriage of drug-resistant pathogens, and the efficacy of the therapy depends on the anti-inflammatory effect of the drugs, which is independent of their antimicrobial effect.

Is there a role for inhaled corticosteroids and macrolide therapy in bronchiectasis?

Bronchiectasis is characterised by permanent dilatation of the bronchi that arises from chronic inflammation predominantly caused by bacterial infection. This condition remains a major cause of excess respiratory morbidity and treatment is generally only partly successful. There is an urgent need for improved anti-inflammatory medication to treat bronchiectasis. Two potentially useful therapies are inhaled corticosteroids (ICS) and macrolides. The clinical trials that have been performed in bronchiectasis with these two medications can be considered to be preliminary data. This article reviews the anti-inflammatory properties, clinical efficacy and adverse effects of ICS and macrolides.ICS have a large number of potent anti-inflammatory properties. ICS remain the first-line treatment in asthma, reduce exacerbations in chronic obstructive pulmonary disease, and may improve lung function and symptoms in cystic fibrosis (CF). Four small clinical trials have assessed the effect of high-dose ICS on bronchiectasis. The main reported effect of these trials was a reduction in sputum volume and this may be a marker of decreased airway inflammation. Other possible benefits included decreased cough and sputum inflammatory cells/biomarkers. ICS have a relatively high prevalence of local adverse effects, and may be associated with ocular complications and osteoporosis. These adverse effects can be minimised by prescribing low doses of the medication. Macrolides have both antibacterial and immunomodulatory properties. Macrolides have less marked immunosuppressive properties than corticosteroids, and effects include decreasing mucous production, inhibiting virulence factors and biofilm formation of Pseudomonas aeruginosa, decreasing leukocyte numbers and altering inflammatory mediator release. Macrolides have been shown to be extremely effective in the treatment of diffuse panbronchiolitis, improve lung function and symptoms in asthma and CF, and reduce nasal polyps and secretions in sinusitis. Five small clinical trials have assessed the effect of macrolides on bronchiectasis. Reported benefits include reduced sputum volume, improved lung function and better symptom control. Macrolides are generally well tolerated, although they do have a number of drug interactions. There are concerns about the development of resistance, especially to non-tuberculous mycobacteria, with prolonged macrolide use. The evidence available suggests that both medications have a role in the management of bronchiectasis. More definitive trials of ICS and macrolides in bronchiectasis will clarify the likely benefit of these therapies.

Prolonged antibiotics for purulent bronchiectasis in children and adults

BACKGROUND

The vicious cycle hypothesis for bronchiectasis predicts that bacterial colonisation of the respiratory tract perpetuates inflammatory change. This damages the mucociliary escalator preventing bacterial clearance and allowing the persistence of pro-inflammatory mediators. Conventional treatment with physiotherapy and intermittent antibiotics are felt to improve the condition of bronchiectasis patients although there are no conclusive data showing that these interventions influence the natural history of the condition. Various strategies have been tried to interrupt this cycle of infection and inflammation and one of these is to prolong antibiotic treatment in the hope of allowing the airway mucosa to heal.

OBJECTIVES

This systematic review brings together the evidence and where possible presents a meta-analysis of the data available to answer the question 'Does treatment with prolonged courses of antibiotics influence the outcome in purulent bronchiectasis?'

SEARCH STRATEGY

The Cochrane Airways Group trials register and reference lists of identified articles were searched. Searches were current as of January 2007.

SELECTION CRITERIA

Randomised trials looking at the use of prolonged antibiotic therapy in the treatment of bronchiectasis compared with either placebo or usual care.

DATA COLLECTION AND ANALYSIS

Trial quality was assessed and data extraction was carried out by the reviewers independently. Study authors were contacted for missing information.

MAIN RESULTS

Nine trials met the inclusion criteria, recruiting a total of 378 participants. Antibiotics were given for between 4 weeks and one year. Only limited meta-analysis was possible due to the diversity of outcomes in the trials. Response rates showed significant effects in favour of prolonged antibiotic treatment (Peto OR (95% CI), 3.37 (1.60 to 7.09)). Conversely for exacerbation rates there was no significant difference between prolonged antibiotics and placebo (Peto OR (95% CI), 0.96 (0.27 to 3.46)). For withdrawals there was no significant difference between treatment and placebo management (Peto OR (95% CI), 1.06 (0.42 to 2.65)). Data for lung function showed no significant benefit in favour of antibiotic treatment (% predicted FEV1 mean difference -1.05 % (95% CI -6.93 to 4.83)).

AUTHORS' CONCLUSIONS

The evidence available shows a small benefit for the use of prolonged antibiotics in the treatment of bronchiectasis. This review is limited by the diversity of the trials. Further randomised controlled trials with adequate power and standardised end points are required.

Importance of atopic cough, cough variant asthma and sinobronchial syndrome as causes of chronic cough in the Hokuriku area of Japan

OBJECTIVE

A prospective multicentre study was conducted to elucidate the causes of chronic cough in Japan.

METHODOLOGY

All consecutive and unselected patients complaining of cough lasting 8 weeks or more, who visited our clinics from 1 June to 31 December 2001, were registered. The causes of chronic cough were diagnosed based on the criteria for definite and probable causes of cough as recommended by the Japanese Cough Research Society.

RESULTS

Of the 248 patients enrolled, 72 patients (29.0%) were unavailable for follow up before their diagnostic assessment had been finalized. Among the 176 patients who were adequately assessed, a diagnosis was made in 165 patients (93.7%) either as single cause or as one of two causes: atopic cough in 48 (29.1%) and 11 patients (6.7%); cough variant asthma in 46 (27.9%) and nine patients (5.5%); cough predominant asthma in 14 (8.5%) and three patients (1.8%); and sinobronchial syndrome (SBS) in 28 (17.7%) and 14 patients (8.5%), respectively. A diagnosis of gastro-oesophageal reflux-associated cough was made in a total of four patients (2.4%).

CONCLUSION

Atopic cough, asthmatic cough consisting of cough variant asthma and cough predominant asthma, and SBS are major causes of chronic cough in Japan.

Treatment of chronic rhinosinusitis with low-dose, long-term macrolide antibiotics: an evolving paradigm

The 14-membered and 15-membered ring macrolide antibiotics express immunomodulatory effects in chronic respiratory disorders in humans that are distinct from their antimicrobial properties. These drugs downregulate the excessive immune and inflammatory responses observed in these conditions while promoting tissue repair. To this end, chronic rhinosinusitis is characterized by mucosal inflammation of nasal and sinus mucosa for more than 3 months and accounts for significant health care resource allocation due to difficulties in treatment. Clinical efficacy of macrolide antibiotics as biologic response modifiers in patients with chronic rhinosinusitis is suggested by compelling basic research and small, uncontrolled clinical studies. Hence, long-term, prospective double-blind placebo-controlled clinical studies are indicated to establish the utility of these drugs in the treatment of patients with chronic rhinosinusitis.

Macrolides in cystic fibrosis

Macrolide antibiotics have been licensed since the 1950s and have an important role in the treatment of a diverse range of infectious diseases. Macrolide antibiotics have antibacterial activity against gram-positive bacteria, some gram-negative bacteria and intracellular pathogens. The spectrum of antibacterial activity combined with excellent intracellular and tissue penetration has led to the extensive use of this class of drugs in respiratory disease. Macrolide antibiotics also have demonstrated anti-inflammatory properties in various in vitro and in vivo model systems. Novel antimicrobial and anti-inflammatory properties of macrolide may result in clinical benefits, particularly in conditions where the infectious agent is inherently resistant to macrolides. Three randomized control trials have demonstrated improved lung function in patients treated with the macrolide antibiotic, azithromycin. Azithromycin was generally well tolerated and resulted in reduction in the inflammatory response which may be due to an immunomodulatory role. Short term studies (three to six months) have not demonstrated the development of increased bacterial resistance or the emergence of new pathogens following azithromycin.

Clinical implications of the immunomodulatory effects of macrolides on sinusitis

This article reviews the treatment of chronic sinusitis with macrolides. Chronic sinusitis is often the result of bacterial infections that lead to chronic inflammation with thickening of the sinus mucosa and hypersecretion of mucus. In addition to their anti-infective properties, some macrolides possess immunomodulatory effects. These macrolides have been used successfully to treat diffuse panbronchiolitis, a progressive inflammatory lung disease, and may be useful for treatment of asthma, chronic bronchitis, chronic sinusitis, cystic fibrosis, and bronchiectasis. The clinical benefits of macrolides in patients with chronic sinusitis include decreased nasal secretions and postnasal drip, with improvement in nasal obstruction. In vivo and in vitro studies show that some macrolides affect neutrophil chemotaxis and infiltration, inflammatory cytokine production, mucus production, and the transportability of airway secretions. These findings indicate that macrolides are promising agents for treating chronic inflammation of the airways.

Macrolides for the treatment of chronic sinusitis, asthma, and COPD

In addition to their well-known antimicrobial activity, macrolides possess immunomodulatory properties that may confer beneficial effects to patients with respiratory diseases associated with chronic inflammation. These properties include attenuation of inflammatory responses in the lung, mucoregulatory properties, and effects on bronchial responsiveness. Macrolides increase mucociliary clearance, improve sinusitis symptoms, and decrease nasal secretions and polyp size in patients with sinusitis. They also have been shown to modify the inflammatory response associated with chronic sinusitis. In patients with asthma, macrolides have been reported to reduce airway hyperresponsiveness and improve pulmonary function, and have historically been selected for their "steroid-sparing" effect. Preliminary data from studies of patients with COPD have shown improvements in symptom scores and FEV(1) after macrolide treatment. As biological response modifiers, macrolides have the potential to improve the outcomes of patients with inflammatory airway diseases. Large scale, placebo-controlled clinical trials designed to assess long-term efficacy and safety in these diseases are warranted.

The role of nuclear factor-kappa B in interleukin-8 expression by human adenoidal fibroblasts

OBJECTIVES/HYPOTHESIS

The production of cytokines by adenoids is known to be associated with inflammation of nasopharynx and the pathogenesis of otitis media with effusion. However, the role of adenoids in producing inflammatory cytokines such as interleukin-8 (IL-8) is not yet clear. In the present study, expression of IL-8 in adenoidal fibroblasts was investigated at the level of transcription factors. Further, the effects of clarithromycin, a 14-member ring macrolide, on IL-8 gene expression and nuclear factor-kappa B (NF-kappa B) activation in adenoidal fibroblasts were evaluated.

STUDY DESIGN

In vitro study for the production of inflammatory cytokine from human adenoidal fibroblasts.

METHODS

Adenoidal fibroblasts were incubated with nontypeable Haemophilus influenzae endotoxin or interleukin-1 beta. Then the expression of IL-8 and the influence of NF-kappa B inhibitor and clarithromycin were evaluated. Interleukin-8 protein production was assessed by ELISA, and IL-8 messenger RNA production was measured by Northern blot analysis and reverse transcriptase-polymerase chain reaction. Activation of NF-kappa B and inhibition of its activation were determined by electrophoretic mobility shift assay.

RESULTS

The expression of both IL-8 protein and messenger RNA in adenoidal fibroblasts was enhanced by Haemophilus influenzae endotoxin and interleukin-1 beta and was positively correlated with increases in NF-kappa B activity. Treatment of cells with the NF-kappa B inhibitor N-tosyl-(L)-phenylalanine chloromethyl ketone, as well as with clarithromycin, reduced expression of IL-8 and NF-kappa B activity in a dose-dependent manner.

CONCLUSIONS

Results suggest that adenoidal fibroblasts produce IL-8 in response to endotoxin through NF-kappa B activation. The inhibitory effects of clarithromycin on NF-kappa B activation and IL-8 production in adenoidal fibroblasts might explain, in part, the mechanism of this drug in improving otitis media with effusion.

Prolonged antibiotics for purulent bronchiectasis

BACKGROUND

The vicious cycle hypothesis for bronchiectasis predicts that bacterial colonisation of the respiratory tract perpetuates inflammatory change. This damages the mucociliary escalator preventing bacterial clearance and allowing the persistence of pro-inflammatory mediators. Conventional treatment with physiotherapy and intermittent antibiotics are felt to improve the condition of bronchiectasis patients although there are no conclusive data showing that these interventions influence the natural history of the condition. Various strategies have been tried to interrupt this cycle of infection and inflammation and one of these is to prolong antibiotic treatment in the hope of allowing the airway mucosa to heal.

OBJECTIVES

This systematic review brings together the evidence and where possible presents a meta-analysis of the data available to answer the question 'Does treatment with prolonged courses of antibiotics influence the outcome in purulent bronchiectasis?'

SEARCH STRATEGY

The Cochrane Airways Group trials register and reference lists of identified articles were searched.

SELECTION CRITERIA

Randomised trials looking at the use of prolonged antibiotic therapy in the treatment of bronchiectasis.

DATA COLLECTION AND ANALYSIS

Trial quality was assessed and data extraction was carried out by the reviewers independently. Study authors were contacted for missing information.

MAIN RESULTS

447 abstracts were found and reviewed for suitability. Six trials were included and 302 patients were randomised amongst these trials. 40% of the patients were contributed by one trial. Antibiotics were given for between 4 weeks and one year. There were 40 withdrawals due to treatment failure and intolerable side effects. Only limited meta-analysis was possible due to the diversity of the trials. Response rates showed significant effects in favour of prolonged antibiotic treatment (Peto OR (95% CI), 3.37 (1.60 to 7.09)). Conversely for exacerbation rates there was no significant difference between prolonged antibiotics and placebo (Peto OR (95% CI), 0.96 (0.27 to 3.46)). For withdrawals there was no significant difference between treatment and placebo management (Peto OR (95% CI), 1.06 (0.42 to 2.65)). Data for lung function showed no significant benefit in favour of antibiotic treatment (% predicted FEV1, WMD (95% CI) -1.05 (-6.93 to 4.83)).

REVIEWER'S CONCLUSIONS

The evidence available shows a small benefit for the use of prolonged antibiotics in the treatment of bronchiectasis. This review is limited by the diversity of the trials. Further randomised controlled trials with adequate power and standardised end points are required.

Addition of a 2-month low-dose course of levofloxacin to long-term erythromycin therapy in sinobronchial syndrome

BACKGROUND

We previously reported that a 6-month low-dose course of ofloxacin combined with long-term low-dose erythromycin therapy (EM therapy) was superior to EM therapy alone for sinobronchial syndrome (SBS), especially during the initial 2 months of treatment. However, there was no data as to whether discontinuation of low-dose ofloxacin after 2 months results in symptom relapse. This study was designed to clarify this issue.

METHODOLOGY

Twenty-three patients with SBS received a 2-month course of levofloxacin (LVFX) therapy (100 mg once a day) concurrent with a 6-month course of EM therapy (200 mg three times a day) (group A). Eighteen other patients were given the EM therapy alone (group B). Clinical parameters, including quantity of morning sputum, were recorded in a daily symptom diary, and reviewed by each doctor in charge at 2-4 week intervals.

RESULTS

The quantity of morning sputum decreased more rapidly in group A than in group B. No relapse of symptoms was recognized after discontinuation of LVFX in group A.

CONCLUSIONS

A 2-month low-dose course of LVFX in conjunction with long-term EM therapy may be efficacious for the treatment of SBS, as evidenced by rapid improvement of expectoration without any relapse after LVFX discontinuation.

Effect of macrolides on the expression of HLA-DR and costimulatory molecules on antigen-presenting cells in nasal polyps

To clarify the basis of macrolide therapy for improvement of chronic sinusitis, we investigated the effect of macrolides on the expression of HLA-DR and costimulatory molecules such as CD54 and CD80 on macrophages in nasal polyps. Nasal polyps taken from 54 patients who had or had not been treated with macrolides were immunohistochemically studied. The percentages of CD68-positive macrophages expressing HLA-DR or CD54 were not significantly different between patients treated with macrolides and those not treated with macrolides. However, among patients exhibiting no atopic predisposition, the number of CD80-positive macrophages was higher in patients treated with macrolides than in those not treated. In addition, the percentage of CD80-positive macrophages was negatively correlated with the percentage of infiltrating eosinophils in the polyps. These results demonstrate that macrophages act as antigen-presenting cells, expressing both major histocompatibility complex II and costimulators, and that the expression of CD80 may play a key role in the immune responses occurring in a nasal polyp. Macrolides may modulate the mucosal immune responses through CD80 expression.

Health care utilization and cost in children with asthma and selected comorbidities

Children with asthma use significantly more health services than other children, yet the majority of their health care costs are for nonasthma services. The objective of this study was to measure the impact of asthma and specific upper respiratory comorbidities on the use and cost of health care by children. A population-based historical cohort study from January 1, 1992 to December 31, 1992 was conducted. Multiple visits for otitis media, sinusitis, and allergic rhinitis were considered comorbidities. The outcome measures were nonurgent outpatient care, pharmacy fills, urgent care visits, and hospital care along with the associated total costs. Children between ages 1 and 17 years were studied (n = 71,818). Children with asthma were more likely than children without asthma to have a comorbidity (26% vs. 9%). Children with multiple visits for otitis media, sinusitis, and allergic rhinitis were 1.8, 4, and 12 times more likely, respectively, to have a diagnosis of asthma in the same year. Children with asthma had a 47% probability of being in the highest total cost quintile compared to a 29% likelihood once adjusted for comorbidities. Visits for otitis media, sinusitis, and particularly allergic rhinitis appear to be overrepresented in children with asthma and contribute to their high utilization rate. Once a high-risk cohort is identified, the needs of those children can be addressed through targeted, organized systems of care that may include guidelines or other disease management strategies.

The anti-inflammatory effect of erythromycin and its derivatives, with special reference to nasal polyposis and chronic sinusitis

Macrolides have been used for decades as an important chemotherapeutic agent in the treatment of infectious diseases. In the last 10 years there has also been increasing interest in the interaction between macrolide antibiotics and the immune system. The aim of this review is to focus on the anti-inflammatory action of erythromycin and its derivatives in the treatment of chronic sinusitis and nasal polyps. Systematic clinical investigations have been few and to the author's knowledge there have been no placebo-controlled studies. However there have been, especially from Japan, a number of clinical reports stating that long-term, low-dose macrolide antibiotics are effective in treating chronic sinusitis incurable by surgery or glucocorticosteroid treatment, with an improvement in symptoms varying between 60% and 80% in different studies. In animal studies macrolides have increased mucociliary transport, reduced goblet cell secretion and accelerated apoptosis of neutrophils, all factors that may reduce the symptoms of chronic inflammation. There is also increasing evidence in vitro of the anti-inflammatory effects of macrolides. Several studies have shown macrolides to inhibit interleukin gene expression for IL-6 and IL-8 and also to inhibit the expression of intercellular adhesion molecule essential for the recruitment of inflammatory cells. There is also evidence in vitro, as well as clinical experience, showing that macrolides reduce the virulence and tissue damage caused by chronic bacterial colonization without eradicating the bacteria. The benefit of long-term, low-dose macrolide treatment seems to be that it is, in selected cases, effective when steroids fail. The exact mechanism of action is not known, but it probably involves downregulation of the local host immune response as well as a downgrading of the virulence of the colonizing bacteria. In the future, placebo-controlled studies should be performed to establish the efficacy of macrolides if this treatment is to be accepted as evidence-based medicine.

Inhibitory effect of erythromycin on interleukin-8 secretion from exudative cells in the nasal discharge of patients with chronic sinusitis

OBJECTIVES

The mechanism of the efficacy of long-term low-dose macrolide therapy for chronic sinusitis is not fully understood. The authors studied the inhibitory effect of erythromycin on interleukin-8 (IL-8) secretion from exudative cells in the nasal discharge of patients with chronic sinusitis.

STUDY DESIGN AND METHODS

Exudative cells in the nasal discharge were isolated from six patients with nonallergic chronic sinusitis. The cells, more than 90% of which were neutrophils, were incubated with or without erythromycin in the presence of 10 micrograms/mL of lipopolysaccharide. The IL-8 concentrations in the culture supernatants were measured by enzyme-linked immunoassay.

RESULTS

The amount of secreted IL-8 in the absence of erythromycin was 682 +/- 226 pg/10(6) cells/24 h. The IL-8 secretion was significantly reduced to 66 +/- 15% and 46 +/- 13% of the control in the presence of 10(-6) and 10(-5) M of erythromycin, respectively.

CONCLUSION

Erythromycin may act as a biologic modulator that inhibits IL-8 secretion from exudative cells and thereby blocks the vicious circle of neutrophil recruitment and IL-8 generation in the inflammatory site in chronic sinusitis.

Roxythromycin reinforces epithelial defence function in rabbit trachea

Our study elucidates the effect of roxythromycin (RXM) on airway epithelial defence functions, especially the mucociliary and epithelial barrier functions, in the rabbit trachea. In vitro ciliary activity was not affected in the presence of 3.3 mg/ml of RMX, but was enhanced in the presence of 6.7 mg/ml of RXM. Oral administration of 10 and 100 mg of RXM for 14 days enhanced both ciliary activity and mucociliary transport velocity in the trachea. Epithelial permeability to fluorescein isothiocyanate-dextrans (FD-70s; molecular weight: 70,000 daltons) was not affected by oral administration of 10 mg of RXM for 14 days, but was significantly reduced by oral administration of 100 mg of RXM for 14 days. Inhalation of platelet activating factor (PAF) compromised the function of the mucociliary system and the tight junction barrier. However, pretreatment with 20 mg of RXM significantly alleviated the PAF-induced decrease in mucociliary function and the increase in epithelial permeability to FD-70s. In conclusion, such reinforcement of the epithelial defence functions is likely to be involved in the pharmacological action underlying the clinical efficacy of RXM for chronic airway inflammatory disease.

Risk factors for recurrent and residual cholesteatoma in children determined by second stage operation

OBJECTIVE

To clarify the risk factors for the development of recurrent and residual cholesteatoma in children.

METHODS

We studied 84 ears of 83 children aged 10 years or younger who underwent a second stage operation 1 year after primary surgery with a canal wall reconstruction procedure, and analyzed the clinical risk factors for recurrent and residual cholesteatoma.

RESULTS

Recurrent cholesteatoma was detected in 21 ears (25%) and residual cholesteatoma was noted in 35 (42%) of 84 ears. With respect to recurrent cholesteatoma, significant risk factors were determined to be male gender, pars flaccida type of cholesteatoma and the association of otitis media with effusion either in the side affected by cholesteatoma or on the opposite side. On the other hand, congenital type of cholesteatoma was a significant negative risk factor. With respect to residual cholesteatoma, the only risk factor was a posterosuperior type of cholesteatoma. Residual cholesteatoma was sometimes found even when the surgeon had declared complete removal of the cholesteatoma matrix at the time of primary surgery.

CONCLUSIONS

High incidence of recurrent and residual cholesteatoma was noted at the second stage operation. Occurrence of recurrent cholesteatoma is closely related to eustachian tube dysfunction. Thin and highly proliferative cholesteatoma matrix in children may be responsible for high occurrence of residual cholesteatoma. Therefore, planned staged surgery is preferable to single stage surgery for the treatment of pediatric cholesteatoma.

Serum antibodies specific to CD outer membrane protein of Moraxella catarrhalis, P6 outer membrane protein of non-typeable Haemophilus influenzae and capsular polysaccharides of Streptococcus pneumoniae in children with otitis media with effusion

We measured the levels of serum IgG antibodies to CD outer membrane protein of Moraxella catarrhalis, P6 outer membrane protein of non-typeable Haemophilus influenzae and capsular polysaccharides of Streptococcus pneumoniae in 168 children with otitis media with effusion (OME) who were followed prospectively, using ELISA. Serum IgG antibodies to CD, P6 and pneumococcal capsular polysaccharides were detected in all samples. The anti-pneumococcal polysaccharides antibody level was highest, followed by the anti-P6 antibody level and anti-CD antibody was lowest (median:interquartile ranges were 45.9:19.1-100 microg/ml, 15.6:9.70-23.2 microg/ml and 1.06:0.73-1.87 microg/ml, respectively). In children aged 0-6 years, there were positive correlations among the antibody levels (anti-CD vs anti-P6, r=0.325, p <0.001; anti-CD vs anti-polysaccharide, r=0.397, p <0.0001; anti-P6 vs anti-polysaccharide, r=0.175, p=0.057). However, no relationship was seen in children aged 7-15 years. Children were classified according to severity of OME during the 1-year follow-up. In children aged 0-6 years, the severity of OME correlated inversely with the levels of anti-CD antibody (r=-.23, p=0.012), of anti-P6 antibody (r=-0.292, p=0.0015), and of anti-pneumococcal polysaccharides antibody (r=-0.25, p=0.0064). However, no correlation was found between antibody levels and severity of OME in children aged 7-15 years. These data suggest that persistence and/or recurrence of OME may be due to an insufficient serum antibody response to middle ear pathogens in young children.

Inhibitory effect of macrolides on interleukin-8 secretion from cultured human nasal epithelial cells

The mechanism of macrolide therapy in chronic sinusitis patients is unclear. The authors studied the effect of macrolides on interleukin (IL)-8 secretion from cultured human nasal epithelial cells. Epithelial cells harvested from the nasal polyps of patients with chronic sinusitis were primary-cultured, and secreted IL-8 in culture media was measured by enzyme immunoassay. The cells secreted considerable amounts of IL-8 constitutively and in response to lipopolysaccharide. The secretion was significantly inhibited by 10(-5) M of erythromycin, clarithromycin, roxithromycin, and josamycin. 10(-6) M erythromycin still showed the inhibitory effect, whereas the same concentration of josamycin did not. These results indicate that macrolide antibiotics may act as an immunomodulator to reduce IL-8 in inflammatory sites and, at least partially, account for the clinically discrepant effects between 14- and 16-membered ring macrolides in long-term low-dose therapy for chronic sinusitis.

Roxythromycin stimulates the mucociliary activity of the Eustachian tube and modulates neutrophil activity in the healthy guinea pig

Low-dosage, long-term erythromycin chemotherapy is useful in the treatment of chronic airway inflammatory diseases such as chronic sinusitis. The exact working mechanism of macrolides behind the clinical effectiveness still remains unclear. However, some have been considered including anti-inflammatory effect, effects on airway secretory functions, and steroid sparing effects. Otitis media with effusion (OME) is a chronic inflammatory disease in the tubotympanum. The epithelium of the tubotympanum is a modified respiratory epithelium. Therefore, macrolides might be effective in the treatment of patients with chronic OME. It was recently demonstrated that macrolides such as roxythromycin (RXM), enhance the ciliary activity in vitro. However, such ciliostimulatory effects found in an in vitro system are not always applicable to the mucociliary system in situ. The mucociliary system in situ might behave differently when in contact with RXM, and might deteriorate following oral administration of RXM. The present study aimed at investigating the in vivo effect of RXM on the mucociliary system in the tubotympanum and neutrophil activities of the guinea pig. The healthy guinea pigs were treated with oral administration of 5 or 50 mg/kg/day of RXM for 14 successive days, and the ciliary activity and the mucociliary clearance time of the tubotympanum was determined 24 h after the final administration. The ciliary activity in the Eustachian tube was significantly increased by oral administration of either dosage of RXM for 14 successive days. In addition, the mucociliary clearance velocity was accelerated by oral administration of such dosages of RXM. Therefore, the present data clearly demonstrate that RXM is a pharmacological agent with ciliostimulation and concurrent acceleration ability of the mucociliary clearance in the Eustachian tube. Oral administration of 5 as well as 50 mg/kg/day of RXM for 14 successive days did not significantly affect the phagocytosis activity of neutrophils but significantly increased the superoxide production of neutrophils. Since the effusions are considered to be the result of inflammatory events in the tubotympanum, the increased superoxide production activity of neutrophils confirmed in our study should result in an increased killing activity of infectious pathogens, thereby leading to control of the disease chronicity. In conclusion, our study argues in favor of the clinical usefulness of RXM in the treatment of OME.

Ototoxic effect of erythromycin on cochlear potentials in the guinea pig

The mechanism of hearing loss due to the administration of intravenous erythromycin was investigated in the albino guinea pig, and it was found for the first time that this drug causes cochlear dysfunction. The endocochlear potential (EP) and the cochlear microphonics (CM) recorded at the first cochlear turn transiently decreased when erythromycin was administered intravenously at dosages of 100 and 150 mg/kg. The averaged maximum decrease in EP was 16 mV (n = 5) and 33 mV (n = 5) for 100 and 150 mg/kg, respectively. The maximum decrease in the CM was about 25% when the EP reached its lowest value with the injection of 150 mg/kg. A complete recovery of the EP and CM ensured within 20 minutes after each erythromycin dose. The perilymphatic perfusion of 3 mmol/L of erythromycin decreased the EP and CM; however, in contrast to the intravenous administration, the decrease of the CM was nearly complete and both the EP and CM were irreversible. Hearing loss due to intravenously administered erythromycin could likely be attributle to the transient dysfunction of the stria vascularis, although concomitant dysfunction of the central auditory pathway cannot be excluded.

Effects of long-term low-dose macrolide administration on neutrophil recruitment and IL-8 in the nasal discharge of chronic sinusitis patients

Effects of long-term low-dose macrolide administration were studied in patients with chronic sinusitis. Twelve patients with non-allergic chronic sinusitis were orally given 150 mg roxithromycin once a day without other treatments. The patients underwent computed tomography before and after the treatment, and paranasal sinus aeration was analyzed quantitatively. The number of neutrophils in the nasal smear was semiquantitatively assessed on a grading scale, and the IL-8 concentration in the nasal discharge was measured by enzyme immunoassay. The aeration of all four sinuses significantly improved, and recruited neutrophils and the IL-8 level in the nasal discharge were simultaneously reduced after the treatment. These findings suggest that long-term low-dose roxithromycin administration inhibits the positive feedback mechanism of neutrophil recruitment and IL-8 production by the recruited neutrophils, which is considered to be an essential cause of the prolongation of sinusitis.

Mechanism of neutrophil recruitment induced by IL-8 in chronic sinusitis

BACKGROUND

The mechanism of neutrophil recruitment in patients with chronic sinusitis is unclear.

OBJECTIVE

This study aims to elucidate the role of IL-8 in inducing neutrophil accumulation in the nasal discharge of patients with chronic sinusitis.

METHODS

Nasal discharge and mucosal specimens were obtained from two groups of patients, those with chronic sinusitis and those with allergic rhinitis. The samples were subjected to immunohistochemical examination and in situ hybridization. The IL-8 level in the nasal discharge was measured by enzyme immunoassay.

RESULTS

Immunoreactivity to IL-8 was observed in polymorphonuclear cells of nasal smear, in nasal gland duct cells, and in epithelial cells of the chronic sinusitis group; whereas those of the allergic rhinitis group mostly showed little or no reaction. Similar patterns of localization were shown by in situ hybridization for IL-8 messenger RNA. The IL-8 level in nasal discharge was significantly higher in the chronic sinusitis group than in the allergic rhinitis group.

CONCLUSION

These results suggest that chemotactic factors in sinus effusion, including IL-8 derived from nasal gland duct cells and epithelial cells, attract neutrophils out of mucosa, and the neutrophils that have emigrated into the sinus effusion secrete IL-8. This induces further neutrophil accumulation in the sinus effusion of patients with chronic sinusitis.

Additive effect of continuous low-dose ofloxacin on erythromycin therapy for sinobronchial syndrome

It has been established that long-term low-dose erythromycin therapy (EM therapy) is very effective for sinobronchial syndrome, a common condition in Japan characterized by chronic upper and lower airway inflammation. The effect does not result from its bacteriocidal activity and the detailed mechanisms are not known. It takes 3-6 months for EM therapy to improve the symptoms. This study was designed to evaluate the additive effect of continuous low dosage or intermittent usual dosage of ofloxacin (OFLX) on EM therapy in patients with sinobronchial syndrome. Patients with sinobronchial syndrome were randomly allocated to receive one of the following four regimens. Patients in Group A received both low-dose OFLX and EM therapy daily for 6 months. Patients in Group B received EM therapy and intermittent treatment of OFLX for 6 months. Patients in Group C underwent EM therapy for 6 months. Patients in Group D received neither OFLX nor EM therapy. All patients were given carbocystein for more than 2 months before starting each treatment and during the study period. In patients receiving OFLX and/or EM therapy, these antimicrobial agents were well-tolerated during the treatment period. Amount of sputum in the morning was significantly less in Group C than in Group D after 3-6 months, and decreased significantly in Group A as compared with Group B after 2 weeks, Group C after 2 weeks to 2 months, and Group D after 2 weeks to 6 months. Other symptoms such as number of expectorations, difficulty of expectoration and severity of cough also improved rapidly in Group A. These findings suggest that it is useful to add low-dose OFLX to EM therapy for sinobronchial syndrome, especially within 1-2 months from starting treatment, and it may be cost-effective as this combination therapy can shorten the treatment period of EM therapy.

Prognostic factors for persistent middle ear effusion after acute otitis media in children

The present study was carried out to determine the clinical course of acute otitis media (AOM) in children and to analyze the risk factors that lead to persistent effusion. One hundred and twenty children aged 9 months to 10 years diagnosed as having AOM were included in this study. Sixty-two children (52%) recovered from AOM without middle ear effusions within a month. In 26 cases (22%), middle ear effusions resolved after 1 to 3 months, while 32 children (26%) had persistent effusions for more than 3 months after the onset of acute inflammation. Statistical analysis between the group showing quick recovery and that with persistent effusion was carried out in relation to various clinical factors at the onset. The significant risk factors were: younger age, bilateral AOM, presence of otorrhea, tympanogram type B or C2 on an AOM ear. Moreover, the most significant prognostic factor was a tympanogram type B or C2 on an opposite ear at the acute onset. On the other hand, factors such as sex, fever, history of otitis media, season at onset or complications did not correlate with the duration of persistent effusion. From these results we conclude that careful examination should be performed not only on the ear with AOM but also on the opposite ear in order to predict the course of otitis media.