What rhinologists and allergists should know about the medico-legal implications of antibiotic use: a review of the literature

Sinonasal Packing is Not a Requisite for Successful Cerebrospinal Fluid Leak Repair

Background Numerous methods have been described to repair nasal cerebrospinal fluid (CSF) leaks. Most studies have focused on optimizing CSF leak repair success, leading to closure rates of 90 to 95%.

Objective This study aimed to determine if excellent reconstruction rates could be achieved without using sinonasal packing.

Methods A prospective case series of 73 consecutive patients with various CSF leak etiologies and skull base defects was conducted to evaluate reconstruction success without sinonasal packing. The primary outcome measure was postoperative CSF leak. Secondary outcome measures were postoperative epistaxis requiring intervention in operating room or emergency department, infectious sinusitis, and 22-item sinonasal outcome test (SNOT-22) changes.

Results Mean age was 54.5 years and 64% were female. Multilayered reconstructions were performed in 55.3% of cases, with collagen or bone epidural inlay grafts, and nasal mucosal grafts or nasoseptal flaps for onlay layers. Onlay-only reconstructions with mucosal grafts or nasoseptal flaps were performed in 44.7% of cases. Tissue sealants were used in all cases, and lumbar drains were used in 40.8% of cases. There were two initial failures (97.4% initial success), but both resolved with lumbar drains alone (no revision surgeries). There were no instances of postoperative epistaxis requiring intervention in the operating room or emergency department. Infectious sinusitis occurred in 2.7% of patients in the first 3 months postoperatively. SNOT-22 did not change significantly from preoperatively to first postoperative visits, then improved over time.

Conclusion Nasal CSF leaks from various etiologies and defect sites were successfully repaired without using sinonasal packing, and patients experienced minimal sinonasal morbidity.

International consensus statement on allergy and rhinology: rhinosinusitis 2021

I.

EXECUTIVE SUMMARY

BACKGROUND: The 5 years since the publication of the first International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR-RS) has witnessed foundational progress in our understanding and treatment of rhinologic disease. These advances are reflected within the more than 40 new topics covered within the ICAR-RS-2021 as well as updates to the original 140 topics. This executive summary consolidates the evidence-based findings of the document.

METHODS

ICAR-RS presents over 180 topics in the forms of evidence-based reviews with recommendations (EBRRs), evidence-based reviews, and literature reviews. The highest grade structured recommendations of the EBRR sections are summarized in this executive summary.

RESULTS

ICAR-RS-2021 covers 22 topics regarding the medical management of RS, which are grade A/B and are presented in the executive summary. Additionally, 4 topics regarding the surgical management of RS are grade A/B and are presented in the executive summary. Finally, a comprehensive evidence-based management algorithm is provided.

CONCLUSION

This ICAR-RS-2021 executive summary provides a compilation of the evidence-based recommendations for medical and surgical treatment of the most common forms of RS.

Prophylactic antibiotics after endoscopic sinus surgery for chronic rhinosinusitis: a randomized, double-blind, placebo-controlled noninferiority clinical trial

BACKGROUND

Surgeons commonly prescribe prophylactic antibiotics after endoscopic sinus surgery (ESS), yet minimal data exist to support this practice. In this study we aimed to assess the impact of post-ESS antibiotics on infection, quality of life (QOL), and endoscopic scores.

METHODS

This was a randomized, double-blind, placebo-controlled, noninferiority trial comparing amoxicillin-clavulanate vs placebo after ESS (NCT01919411, ClinicalTrials.gov). Adults (N = 77) with chronic rhinosinusitis (CRS) refractory to appropriate medical therapy who underwent ESS were randomized to antibiotics (N = 37) or placebo (N = 40) and followed clinically (mean ± standard deviation: 1.3 ± 0.3 and 8.8 ± 3.9 weeks postoperatively). At baseline and follow-up, QOL was measured with 22-item Sino-Nasal Outcome Test questionnaires and Lund-Kennedy endoscopic scores were evaluated. Outcomes were analyzed with repeated-measures analysis of variance and analysis of covariance and z tests for proportions.

RESULTS

Placebo was noninferior to antibiotic prophylaxis with regard to postoperative SNOT-22 scores (β = 0.18, 2-tailed p < 0.05). There were no significant differences between the antibiotic and placebo groups in LK score trajectories over time (p = 0.63) or in postoperative infection rates (2.6% vs 2.4%, respectively; p = 0.96). The rate of diarrhea was significantly higher in the antibiotic group (24.3% vs 2.5%; relative risk = 10.8; p = 0.02).

CONCLUSION

Although statistically underpowered, the results suggest placebo was noninferior to prophylactic antibiotics after ESS for CRS regarding postoperative sinonasal-specific QOL. There were no significant differences in postoperative endoscopic scores or rates of infection, but the rate of diarrhea was significantly higher in the antibiotic group. These findings add to the growing evidence that routine use of prophylactic postoperative antibiotics does not improve outcomes post-ESS and significantly increases the rate of diarrhea.

Cephalosporins' Cross-Reactivity and the High Degree of Required Knowledge. Case Report and Review of the Literature

Antibiotic cross-reactivity represents a phenomenon of considerable interest as well as antibiotic resistance. Immediate reactions to cephalosporins are reported in the literature with a prevalence of only 1%-3% of the population, while anaphylactic reactions are rarely described (approximately 0.0001%-0.1%) as well as fatalities. Allergic reaction to cephalosporins may occur because of sensitization to unique cephalosporin haptens or to determinants shared with penicillins. Cross-reactivity between cephalosporins represents, in fact, a well-known threatening event involving cephalosporins with similar or identical R1- or R2-side chains. The present report describes the case of a 79-year-old man who suddenly died after intramuscular administration of ceftriaxone. Serum dosage of mast cell tryptase from a femoral blood sample at 3 and 24 hours detected values of 87.7μg/L and 93.5μg/L, respectively (cut-off value 44.3 μg/L); the serum-specific IgE for penicillins, amoxicillin, cephaclor and also for the most common allergens were also determined. A complete post-mortem examination was performed, including gross, histological and immunohistochemical examination, with an anti-tryptase antibody. The cause of death was identified as anaphylactic shock: past administrations of cefepime sensitized the subject to cephalosporins and a fatal cross-reactivity of ceftriaxone with cefepime occurred due to the identical seven-position side chain structure in both molecules. The reported case offers food for thought regarding the study of cross-reactivity and the need to clarify the predictability and preventability of the phenomenon in fatal events.

Systematic review of professional liability when prescribing β-lactams for patients with a known penicillin allergy

OBJECTIVE

To describe medical negligence and malpractice cases in which a patient with a known penicillin allergy received a β-lactam and experienced an adverse reaction related to the β-lactam.

DATA SOURCES

Lexis-Nexus, Westlaw, and Google Scholar were searched.

STUDY SELECTIONS

Medical negligence and malpractice cases were eligible for inclusion if they met the following criteria: the plaintiff had a known penicillin allergy, received a β-lactam, and experienced an adverse event. All United States federal and state cases were eligible.

RESULTS

Twenty-seven unique cases met the inclusion criteria. Eighteen cases involved the receipt of a penicillin-based antibiotic; of these cases with a known legal outcome, the plaintiff (patient or representative) prevailed or settled in 3 cases and defendants (providers) prevailed in 7 cases. Seven cases involved the receipt of a cephalosporin; of these cases with a known legal outcome, the plaintiff settled with physicians before trial in 1 case and defendants prevailed in 3 cases. Two cases involved the receipt of a carbapenem. Defendants prevailed in one case and the legal outcome of the other case is unknown. In cases in which the defense successfully moved for summary judgment, judges cited a lack of scientific evidence demonstrating a cephalosporin or carbapenem was contraindicated for a patient with a penicillin allergy.

CONCLUSION

The cases with published legal outcomes found limited professional liability for clinicians who prescribed cephalosporins or carbapenems to a patient with a known penicillin allergy. These results may decrease the litigation fears of practitioners and risk managers within health care systems.

The effect of medical treatments on the bacterial microbiome in patients with chronic rhinosinusitis: a pilot study

BACKGROUND

Antibiotics and corticosteroids are prescribed to patients with chronic rhinosinusitis (CRS) to reduce bacterial burden and mucosal inflammation. Unfortunately, clinical improvement is often short-lived and symptoms frequently recur following cessation of treatment. The impact of these systemic therapies on bacterial communities is not well understood. Improved knowledge of how medical therapies influence the intranasal ecosystem may allow for more effective prescribing and the development of more targeted treatments.

METHODS

Twenty patients with CRS were randomized to receive either doxycycline 100 mg twice daily or prednisone 30 mg once daily for 7 days. A further 6 patients with CRS were recruited as untreated controls. Swabs were taken immediately before and after the study period. Symptom scores (22-item Sino-Nasal Outcome Test [SNOT-22]) were recorded. Bacterial communities were characterized using 16S ribosomal RNA (rRNA) gene-targeted amplicon sequencing. Bacterial abundance was estimated using quantitative polymerase chain reaction (PCR) of 16S rRNA gene copies.

RESULTS

Bacterial profiles were dominated by members of the genera Corynebacterium and Staphylococcus. Patients treated with either doxycycline or prednisone had variable and unpredictable changes in communities. The average relative abundance of Propionibacterium increased after treatment in the doxycycline treatment group, and Corynebacterium reduced in the prednisone group. Significant differences in clinical scores, bacterial community richness, diversity, and bacterial abundance were not seen after treatment.

CONCLUSION

The short-term response of bacterial communities to antibiotic or corticosteroid therapy is unpredictable. This study suggests that the use of systemic therapy in patients with stable CRS should be rationalized to minimize antibiotic-associated morbidity and bacterial dysbiosis.

Oral corticosteroids in the management of chronic rhinosinusitis with and without nasal polyps: Risks and benefits

BACKGROUND

Oral steroids are synthetic mimics of adrenal cortex hormones and are considered a staple in the management of chronic rhinosinusitis due to their anti-inflammatory effects. Despite their common use, many providers are not familiar with the potential risks of the drugs.

METHODS

Literature review.

RESULTS

An overview of the existing data on the risks of oral steroids is presented as well as a review of the malpractice lawsuits with regard to oral steroid use and a discussion of the data that support the use of oral steroids in patients with chronic rhinosinusitis with and those without nasal polyps.

CONCLUSION

It is essential for providers to be aware of the potential complications of a medication, the medical jurisprudence of the drugs, and the data that support their use.

Bactericidal antibiotics promote reactive oxygen species formation and inflammation in human sinonasal epithelial cells

BACKGROUND

Bactericidal antibiotics have been shown to stimulate reactive oxygen species (ROS) formation in mammalian cells through mitochondrial dysfunction. This results in oxidative tissue damage that may have negative consequences for long-term antibiotic use. Antibiotics are widely and heavily used in the treatment of acute and chronic sinusitis; however, the relationship between antibiotics and ROS formation in sinonasal epithelial cells (SNECs) has not yet been demonstrated.

METHODS

Human SNECs were collected from patients during endoscopic sinus surgery and grown in culture at the air-liquid interface. Differentiated SNECs were stimulated with the bactericidal antibiotics amoxicillin and levofloxacin and the bacteriostatic antibiotic clarithromycin for 24 hours. ROS were quantified via fluorescence. Cell death was quantified by lactate dehydrogenase (LDH) secretion. Expression of inflammatory markers such as tumor necrosis factor α (TNF-α) and nuclear factor erythroid 2-related factor 2 (Nrf2)-mediated antioxidant genes were measured by real-time polymerase chain reaction (RT-PCR).

RESULTS

Cultured SNECs treated with the bactericidal antibiotics amoxicillin and levofloxacin resulted in a significant increase in production of ROS (p < 0.05) and secretion of LDH (p < 0.05). The increase in ROS formation correlated with an increase in expression of Nrf2-mediated antioxidant genes as well as the expression and production of proinflammatory cytokine TNF-α, and interleukin 1 β (IL-1β) (p < 0.05). SNECs treated with clarithromycin did not demonstrate statistically significant increases in ROS or proinflammatory cytokine production.

CONCLUSION

In this study, we show that treatment of cultured human SNECs with bactericidal antibiotics leads to formation of ROS with an associated increase in inflammatory and antioxidant gene expression and cell death. This suggests that long-term or inappropriate antibiotic use in the treatment of sinusitis may result in oxidative tissue damage to the sinonasal epithelium. Future studies will explore the clinical implications of such damage to the sinonasal epithelium.

Medicolegal Implications of Common Rhinologic Medications

As otolaryngologists, we prescribe many medications to our patients. The objective of this article is to review the potential side effects and medicolegal risks of the common medications used to treat chronic rhinosinusitis. The authors evaluate some of the common side effects as well as the published literature on the lawsuits associated with those medications. Finally, the authors review the informed consent discussion and opportunities to improve patient care and decrease the risk of litigation.