Antibiotic use patterns in endoscopic sinus surgery: a survey of the American Rhinologic Society membership

An examination of antibiotic administration in septorhinoplasty: A systematic review and meta-analysis

PURPOSE

Septoplasty and rhinoplasty are common otolaryngological procedures, often combined as septorhinoplasty (SRP), offering aesthetic and functional benefits. These surgeries are believed to potentially risk postoperative infections due to natural bacterial flora in the nares. This study evaluates the effectiveness of prophylactic antibiotics in reducing post-surgical infection complications.

MATERIALS AND METHODS

A systematic review was conducted using PubMed, Cochrane, and Web of Science, adhering to PRISMA guidelines, focusing on antibiotic use in septoplasty, rhinoplasty, and SRP. The study included randomized control trials, single/double-blind studies, retrospective chart reviews, and prospective cohort studies, excluding pediatric, non-human research, or studies with inaccessible data. Postoperative infection rates were analyzed utilizing R software as a form of Statistic.

RESULTS

From 697 articles, 15 studies were chosen for meta-analysis, involving 2225 patients, with 1274 receiving prophylactic antibiotics and 951 as controls. The meta-analysis indicated an odds ratio of 0.65 (95 % CI: [0.23, 1.89]), showing no significant protective effect of prophylactic antibiotics.

DISCUSSION

The study found no significant infection rate reduction with prophylactic antibiotic use. Notable were inconsistencies in study designs, antibiotic administration timing, and varied surgical practices. Antibiotic use risks were considered. Study limitations include potential biases and the retrospective nature of many studies.

CONCLUSIONS

This review and meta-analysis found no substantial evidence supporting prophylactic antibiotics' effectiveness in reducing postoperative infection rates in septoplasty, rhinoplasty, and SRP, indicating a need to reevaluate practices and develop evidence-based guidelines. Future research should focus on comprehensive, randomized control studies, covering both preoperative and postoperative stages.

Plus moist HS-W®: a new nasal packing material for the middle meatus in endoscopic sinus surgery

PURPOSE

Removal of the current calcium alginate packing materials to the middle meatus in endoscopic sinus surgery (ESS) is usually accompanied by discomfort or pain owing to the hard and brittle nature of these materials. Plus moist HS-W® is a new calcium alginate packing material released in 2022 developed to overcome this issue by changing the uronic acid component. We aimed to compare the discomfort/pain during the removal of Plus moist HS-W® with Kaltostat®, as well as their suitability as packing materials in ESS.

METHODS

Kaltostat® and Plus moist HS-W® were used as packing materials in 22 and 21 patients who underwent ESS in 2021 and 2022, respectively. Patients were asked to rate the pain during the packing removal 10 days after ESS using the Numerical Rating Scale (NRS). The ratio of residual packing materials, number of suctions (insertions/extractions of the suction cannula), and time required to remove packing materials were measured. Postoperative complications such as hemorrhage, local infection, lateralization of the middle turbinate, and synechia of the middle meatus were also evaluated.

RESULTS

The Plus moist HS-W® group exhibited significantly lower NRS pain scores, a lower ratio of residual packing materials, a reduced number of suctions, and a shorter time required to remove the packing. No obvious postoperative complications occurred in both groups except for one suspicious case of a slight infection in the Kaltostat® group.

CONCLUSION

Compared with Kaltostat®, Plus moist HS-W®, characterized by better gelatinization than Kaltostat®, benefits patients by minimizing discomfort/pain during removal.

LEVEL OF EVIDENCE

Level 3.

Systematic Review and Meta-analysis: Macrolide in the Treatment of Chronic Rhinosinusitis After Endoscopic Sinus Surgery

OBJECTIVES

To evaluate the efficacy and safety of macrolide antibiotics therapy in patients with chronic rhinosinusitis (CRS) receiving endoscopic sinus surgery.

DATA SOURCES

PubMed, Web of Science, Embase, and Cochrane Library.

REVIEW METHODS

The electronic databases were comprehensively searched on June 2, 2022, for randomized controlled trials on macrolide antibiotics in the treatment of patients undergoing CRS endoscopic surgery. The primary outcome measures were the sinonasal outcome test (SNOT) score and the visual analog scale (VAS) score. The secondary outcome measures were the nasal endoscopy score (NES), the sinus computed tomography score, and adverse events.

RESULTS

A total of 8 studies were included, involving 606 patients who used macrolide for a long time. Meta-analysis showed that no significant difference was observed in SNOT (standardized mean difference [SMD] = -0.13; 95% confidence interval [CI]: -0.38 to 0.13, I2  = 0%) and VAS (SMD = -0.10; 95% CI, -0.88 to 0.68, I2  = 81%) between the macrolide and placebo groups. However, macrolide outperformed the placebo in improving NES (SMD = -0.32; 95% CI, -0.62 to -0.03, I2  = 21%). The use of macrolide did not increase the incidence of adverse events.

CONCLUSION

Long-term use of macrolide after CRS surgery may not significantly improve the quality of life and disease severity of the patients but may play a role in improving postoperative NES in patients with CRS. There is still no sufficient evidence to determine whether the disease phenotype of CRS or the patient's race will affect the efficacy of long-term use of macrolide after CRS.

Current practices regarding middle turbinate resection among otolaryngologists

Objectives

Resection of the middle turbinate (MT) during endoscopic sinus surgery (ESS) has been a controversial topic among otolaryngologists for many years. Some studies advocate resection and have shown improved outcomes postoperatively, while studies favoring preservation show a decreased incidence of postoperative complications. The current practice pattern regarding this subject is unknown. The goal of this study was to learn the current practice of MT resection during ESS among otolaryngologists.

Method

We performed an electronic anonymous survey of practicing otolaryngologists.

Results

We found that the majority of the 252 responders stated that they will perform an MT resection in certain clinical situations, while there is a small subset that advocates never resecting the MT for inflammatory sinus disease (n = 6, 2.4%). Participants were significantly more likely to perform MT resection in patients undergoing revision compared to primary ESS for all conditions included. The complication of greatest concern among participants was iatrogenic frontal sinus obstruction, while empty nose was of the least concern. The majority of participants responded that MT resection was of extreme or moderate benefit for improved visualization and drug delivery postoperatively. When compared to general otolaryngologists, fellowship-trained rhinologists were less concerned about potential complications following MT resection and were more likely to perceive an extreme or moderate benefit from turbinate resection postoperatively.

Conclusion

There remains debate over MT resection among otolaryngologists, but the results of this study show that the majority of participating otolaryngologists will perform a resection in certain clinical situations.

Economic Viability of Penicillin Allergy Testing to Avoid Improper Clindamycin Surgical Prophylaxis

OBJECTIVE

Patients mislabeled with a penicillin allergy are often unnecessarily given prophylactic clindamycin. Thus, otolaryngologists may cause harm due to clindamycin's associated risk of Clostridioides difficile infections (CDI) and surgical site infections (SSI). The objective of this study was to determine the economic feasibility of penicillin allergy testing in preventing unnecessary clindamycin use among patients with an unconfirmed penicillin allergy prior to otolaryngologic surgery.

METHODS

A break-even analysis was performed using the average cost of penicillin allergy testing and a CDI/SSI to calculate the absolute risk reduction (ARR) in baseline CDI/SSI rate due to clindamycin required for penicillin testing to be economically sustainable. The binomial distribution was used to calculate the probability that current penicillin testing can achieve this study's ARR.

RESULTS

Preoperative penicillin testing was found to be economically sustainable if it could decrease the baseline CDI rate by an ARR of 1.06% or decrease the baseline SSI rate by an ARR of 1.34%. The probability of penicillin testing achieving these ARRs depended on the baseline CDI and SSI rates. When the CDI rate was at least 5% or the SSI rate was at least 7%, penicillin allergy testing was guaranteed to achieve economic sustainability.

CONCLUSION

In patients mislabeled with a penicillin allergy, preoperative penicillin allergy testing may be an economically sustainable option to prevent the unnecessary use of prophylactic clindamycin during otolaryngologic surgery. Current practice guidelines should be modified to recommend penicillin allergy testing in patients with an unconfirmed allergy prior to surgery.

LEVEL OF EVIDENCE

N/A Laryngoscope, 2022.

Is there a role for antibiotics in the treatment of chronic rhinosinusitis?

Rhinosinusitis is one of the most common reasons for adult outpatient antibiotic prescriptions, though there is little clinical evidence to support this practice, especially for chronic rhinosinusitis. Despite considerable research, the etiology of chronic rhinosinusitis, including the pathogenic role of microbes, remains poorly understood. Rigorous studies of the efficacy of antibiotic treatment of chronic sinusitis are surprisingly few in number and the results are somewhat conflicting. This review article will review the rationales for and against the treatment of chronic rhinosinusitis with antibiotics, based on current evidence and understanding of pathophysiology, and will also summarize the current guidelines.

Antimicrobial Prophylaxis in Neonates and Children Undergoing Dental, Maxillo-Facial or Ear-Nose-Throat (ENT) Surgery: A RAND/UCLA Appropriateness Method Consensus Study

Surgical site infections (SSIs) represent a potential complication in surgical procedures, mainly because clean/contaminated surgery involves organs that are normally colonized by bacteria. Dental, maxillo-facial and ear-nose-throat (ENT) surgeries are among those that carry a risk of SSIs because the mouth and the first respiratory tracts are normally colonized by a bacterial flora. The aim of this consensus document was to provide clinicians with recommendations on surgical antimicrobial prophylaxis in neonates (<28 days of chronological age) and pediatric patients (within the age range of 29 days−18 years) undergoing dental, maxillo-facial or ENT surgical procedures. These included: (1) dental surgery; (2) maxilla-facial surgery following trauma with fracture; (3) temporo-mandibular surgery; (4) cleft palate and cleft lip repair; (5) ear surgery; (6) endoscopic paranasal cavity surgery and septoplasty; (7) clean head and neck surgery; (8) clean/contaminated head and neck surgery and (9) tonsillectomy and adenoidectomy. Due to the lack of pediatric data for the majority of dental, maxillo-facial and ENT surgeries and the fact that the recommendations for adults are currently used, there is a need for ad hoc studies to be rapidly planned for the most deficient areas. This seems even more urgent for interventions such as those involving the first airways since the different composition of the respiratory microbiota in children compared to adults implies the possibility that surgical antibiotic prophylaxis schemes that are ideal for adults may not be equally effective in children.

The Use of Postoperative Antibiotics Following Endoscopic Sinus Surgery for Chronic Rhinosinusitis: A Systematic Review and Meta-analysis

BACKGROUND

Endoscopic sinus surgery is performed for medically recalcitrant chronic rhinosinusitis. There is no universally accepted strategy regarding post-operative antibiotics despite the high rates of usage worldwide. The aim of this study was to analyse patient-reported and objective outcomes behind antibiotic use following endoscopic sinus surgery.

METHODS

A search of electronic databases was performed. Eligible randomised controlled trials (RCTs) and observational trials were included. The primary outcome was patient reported outcome measures. Secondary outcomes were local infections, endoscopy scores and adverse events. Meta-analysis was performed.

RESULTS

Of 1045 publications identified, 7 were included in the qualitative synthesis and 5 RCTs were included in meta-analysis. Antibiotic regimens varied between studies in terms of antibiotic selection, timing commenced and duration of use. Meta-analysis suggested no significant difference between placebo and antibiotics in patient reported outcome measures (standardised mean difference (SMD) -0.215, 95% confidence interval (CI) -0.637 to 0.207) or endoscopic scores (SMD -2.86, 95% CI -0.846 to 0.273). There was no consistent definition in reporting of infection; therefore, this outcome cannot be comprehensively considered. No severe adverse events were attributable to antibiotics.

CONCLUSIONS

From the studies analysed, there is no level 1 evidence to suggest that antibiotics improved patient outcomes following sinus surgery. However, there was significant heterogeneity in outcome measures and no clear data exists regarding the effects of antibiotics on postoperative infections. The available evidence at present is not enough to make a recommendation in either direction. Further designed larger RCTs are required to investigate these questions in more detail.

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.