The prevalence of bacterial infection in acute rhinosinusitis: a Systematic review and meta-analysis

Temporal Trends in Pediatric Acute Sinusitis Surrounding the COVID-19 Pandemic

OBJECTIVE

We assessed patterns in the national incidence of pediatric acute sinusitis and associated complications surrounding the initial COVID-19 lockdown.

STUDY DESIGN

Retrospective National Database review.

SETTING

The Pediatric Health Information System.

METHODS

Acute sinusitis and associated complication incidence data from 2015 to 2022 were queried. Three time periods of T1, T2, and T3 were defined as: pre-COVID-19 baseline, initial pandemic, and postpandemic. Statistical analysis included Wilcoxon rank sum tests, multivariable logistic regressions, and autoregressive integrated moving averages (ARIMA) to assess differences between the observed complication rates in T2 and T3 and the expected incidence rates in these time periods as estimated from T1 data.

RESULTS

We identified 2535 acute sinusitis admissions across 42 centers. The incidence differed between T1 (31.5 cases/month), T2 (15.8 cases/month), and T3 (29 cases/month). Children aged 10 to 14 years had the highest acute sinusitis incidence rate (32.5%) compared to other ages in T2. At T1, acute sinusitis and associated complication rates followed parallel seasonal patterns. Although sinusitis incidence decreased during T2, complications increased significantly during T2 and T3 compared to T1 (37.4% and 39% vs 27.5%, P < .001). In the ARIMA model, the ratio of the observed to expected incidence (95% confidence interval) of complications was 1.09 (0.69, 2.60) in T2 and 1.14 (0.73, 2.62) in T3.

CONCLUSION

We report the simultaneous decrease in acute sinusitis incidence and an increase in associated complications during and after the initial COVID-19 pandemic compared to the prepandemic baseline, reflecting changing patterns in viral infection due to the pandemic.

Abducens Nerve Neuropraxia due to Acute Bacterial Rhinosinusitis: Case Report and Literature Review

Background

Acute bacterial rhinosinusitis (ABRS) is a common infection of the paranasal sinuses that can lead to complications such as orbital and intracranial extension. The abducens nerve course is adjacent to the sphenoid sinus. Diplopia is rarely the initial presentation of sphenoid sinus pathology. In this article, we present the case of a middle-aged male who presented with diplopia and abducens nerve palsy secondary to ABRS, and we conducted a literature review in search of similar cases. Case Presentation. A 52-year-old male presented with diplopia secondary to ABRS. Imaging revealed the complete opacification of the bilateral sphenoid and frontal sinuses, with the extension of the inflammatory process to the optic nerve and cavernous sinus. The patient underwent a surgical intervention, which revealed a pyocele collection in the opticocarotid recess inside the sphenoid sinuses. After the surgery, the patient received antibiotics and reported a complete recovery.

Conclusions

Acute bacterial rhinosinusitis can present with atypical symptoms and lead to serious complications, such as abducens nerve palsy. Early diagnosis, appropriate management, and timely referral to a multidisciplinary team are crucial to preventing residual nerve damage and ensuring favorable outcomes.

The Detection of Bacteria in the Maxillary Sinus Secretion of Patients With Acute Rhinosinusitis Using an Electronic Nose: A Pilot Study

OBJECTIVE

Detecting bacteria as a causative pathogen of acute rhinosinusitis (ARS) is a challenging task. Electronic nose technology is a novel method for detecting volatile organic compounds (VOCs) that has also been studied in association with the detection of several diseases. The aim of this pilot study was to analyze maxillary sinus secretion with differential mobility spectrometry (DMS) and to determine whether the secretion demonstrates a different VOC profile when bacteria are present.

METHODS

Adult patients with ARS symptoms were examined. Maxillary sinus contents were aspirated for bacterial culture and DMS analysis. k-Nearest neighbor and linear discriminant analysis were used to classify samples as positive or negative, using bacterial cultures as a reference.

RESULTS

A total of 26 samples from 15 patients were obtained. After leave-one-out cross-validation, k-nearest neighbor produced accuracy of 85%, sensitivity of 67%, specificity of 94%, positive predictive value of 86%, and negative predictive value of 84%.

CONCLUSIONS

The results of this pilot study suggest that bacterial positive and bacterial negative sinus secretion release different VOCs and that DMS has the potential to detect them. However, as the results are based on limited data, further conclusions cannot be made. DMS is a novel method in disease diagnostics and future studies should examine whether the method can detect bacterial ARS by analyzing exhaled air.

Topical Adenosine Inhibits Inflammation and Mucus Production in Viral Acute Rhinosinusitis

OBJECTIVE

Viral acute rhinosinusitis (ARS) is the leading cause of work and school absence and antibiotic over-prescription. There are limited treatment options available to ameliorate the symptoms caused by viral ARS. We have previously demonstrated that topical adenosine treatment enhances mucociliary clearance in the sino-nasal tract. Here, we assessed the therapeutic potential of topical adenosine in a mouse model of viral ARS.

METHODS

The effect of topical adenosine on inflammatory response and mucin gene expression was examined in a mouse model of viral ARS induced by respiratory syncytial virus (RSV) nasal-only infection. We also investigated the inflammatory effect of both endogenous and exogenous adenosine in the sino-nasal tract.

RESULTS

Topical adenosine significantly inhibited the expression of pro-inflammatory cytokines, goblet hyperplasia, mucin expression, and cell damage in the nose of mice with viral ARS. This treatment did not prolong virus clearance. This inhibitory effect was primarily mediated by the A2A adenosine receptor (AR). Although previous studies have shown that adenosine induces a robust inflammatory response in the lungs, neither endogenous nor exogenous adenosine produced inflammation in the sino-nasal tract. Instead, exogenous adenosine inhibited the baseline expression of TNF and IL-1β in the nose. Additionally, baseline expression of ARs was lower in the nose than that in the trachea and lungs.

CONCLUSION

We demonstrated that intranasal adenosine administration effectively decreased inflammation and mucus production in a mouse model of viral ARS.

LEVEL OF EVIDENCE

N/A Laryngoscope, 133:2095-2103, 2023.

Bacterium detected by gram stain and drug sensitivity in Chinese children with acute sinusitis

BACKGROUND

Acute rhinosinusitis (ARS) is one of the common diseases of upper respiratory tract infection in children. Bacterial infection is a significant aggravating factor in pediatric ARS. In this research, our goal was to detected the bacterial flora and antibiotic sensitivity of ARS in Chinese children.

METHODS

We recruited 133 children with ARS between January 2020 and January 2022 from our hospital. Sinus secretion were collected and cultured for Gram stain as well as antimicrobial susceptibility tests.

RESULTS

Moraxella catarrhalis, Staphylococcus aureus, Haemophilus influenzae, Streptococcus pneumoniae and Pseudomonas aeruginosa were detected in order in children with ARS, of which 25% were negative for bacterial culture and 10% were positive for two strains. Amoxicillin and clavulanate potassium were useful for Haemophilus influenzae, Streptococcus pneumoniae and Moraxella catarrhalis. Quinolones are useful for Staphylococcus aureus, Haemophilus influenzae, Streptococcus pneumoniae and Pseudomonas aeruginosa.

CONCLUSIONS

This research updates the proportion of ARS bacterial infection in children in southern China and the antibiotic sensitivity.

Hyaluronic Acid in Rhinology: Its Uses, Advantages and Drawbacks-A Review

Hyaluronic acid has been increasingly involved in recent research due to its many chemical and physical properties. This is a review of the literature for studies involving the use of hyaluronic acid in rhinology. Hyaluronic acid washes and irrigation have been increasingly used in chronic sinusitis medical therapy and post-operatively with mixed results. It has also been shown to play a role in the treatment of nasal polyposis, allergic rhinitis, acute rhinosinusitis and empty nose syndrome. Its effect on biofilm in many disease entities has also been studied. HA is being recently used as ancillary treatment for several rhinologic conditions such as post-operative endoscopy care and chronic sinonasal infections. The properties of HA have intrigued researchers over the past years particularly in biofilm management, healing and inflammation.

Prevalence of Antibiotic Prescription in Patients with Acute Rhinosinusitis Treated by General Practitioners and Otolaryngologists in Germany-A Retrospective Cohort Study

(1) Background: The goal of this retrospective cohort study, based on real-world data and conducted in Germany, was to investigate the prevalence of antibiotic (AB) prescription in patients with acute rhinosinusitis (ARS). (2) Methods: Data from the Disease Analyzer database were used for this cross-sectional study. Patients aged ≥18 years diagnosed with acute sinusitis by general practitioners (GPs) and ear, nose, throat (ENT) specialists between January 2012 and December 2020 were included. The main outcome of the study was the proportion of patients with ARS who received an AB prescription on the day of diagnosis or within three days afterwards. The proportion was estimated separately for patients treated by GPs and ENTs, and also for five age groups, as well as women and men. (3) Results: In total, 308,095 patients were diagnosed with ARS (187,838 by GPs and 120,257 by ENTs). 50.9% of patients treated by GPs and 50.0% treated by ENTs received an AB prescription. AB prevalence increased with age from 46.9% in the age group 18−30 years to 55.5% in the age group > 60 years. (4) Conclusions: We have shown a high prevalence of potentially inappropriate AB prescription for adult patients with ARS in both GP and ENT practices and also among both women and men and in several age groups. There is an urgent need for interventions to reduce inappropriate AB use.

Clinical decision support system RHINA in the diagnosis and treatment of acute or chronic rhinosinusitis

Background

Rhinosinusitis is an inflammation of the sinonasal cavity which affects roughly one in seven people per year. Acute rhinosinusitis (ARS) is mostly, apart from allergic etiology, caused by a viral infection and, in some cases (30–50%), by a bacterial superinfection. Antibiotics, indicated only in rare cases according to EPOS guidelines, are nevertheless prescribed in more than 80% of ARS cases, which increases the resistant bacterial strains in the population.

Methods

We have designed a clinical decision support system (CDSS), RHINA, based on a web application created in HTML 5, using JavaScript, jQuery, CCS3 and PHP scripting language. The presented CDSS RHINA helps general physicians to decide whether or not to prescribe antibiotics in patients with rhinosinusitis.

Results

In a retrospective study of a total of 1465 patients with rhinosinusitis, the CDSS RHINA presented a 90.2% consistency with the diagnosis and treatment made by the ENT specialist.

Conclusion

Patients assessed with the assistance of our CDSS RHINA would decrease the over-prescription of antibiotics, which in turn would help to reduce the bacterial resistance to the most commonly prescribed antibiotics.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-021-01599-3.

Gas Monitoring in Human Frontal Sinuses-Stability Considerations and Gas Exchange Studies

Acute rhinosinusitis is a common infectious disease, which, in more than 90% of cases, is caused by viruses rather than by bacteria. Even so, antibiotics are often unnecessarily prescribed, and in the long run this contributes to the alarming level of antibiotics resistance. The reason is that there are no good guiding tools for defining the background reason of the infection. One main factor for the clearance of the infection is if there is non-obstructed ventilation from the sinus to the nasal cavity. Gas in Scattering Media Absorption Spectroscopy (GASMAS) has potential for diagnosing this. We have performed a study of frontal sinuses of volunteers with a focus on signal stability and reproducibility over time, accurate oxygen concentration determination, and assessment of gas transport through passages, naturally and after decongestant spray administration. Different from earlier studies on frontal sinuses, water vapor, serving the purpose of oxygen signal normalization, was measured at 818 nm rather than earlier at 937 nm, now closer to the 760 nm oxygen absorption band and thus resulting in more reliable results. In addition, the action of decongestants was objectively demonstrated for the first time. Evaluated oxygen concentration values for left- and right-hand side sinus cavities were found to agree within 0.3%, and a left-right geometrical asymmetry parameter related to anatomical differences was stable within 10%.

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.

Can Diffusion-Weighted Imaging Serve as an Imaging Biomarker for Acute Bacterial Rhinosinusitis?

Acute rhinosinusitis is defined as symptomatic inflammation of the mucosal lining of the nasal cavity and paranasal sinuses lasting less than four weeks. It is most commonly secondary to viral infection but is often challenging to distinguish from bacterial etiologies. Even with recommendations from several specialty societies, there continues to be a frequent practice of overprescribing oral antibiotics for acute rhinosinusitis, thus leading to multidrug-resistant organisms, and rendering oral medication useless when actually clinically warranted. We observed a potential non-invasive imaging biomarker that could predict which patients would benefit from anti-microbial therapy. Often computed tomography (CT) imaging is obtained by the provider before consultation with the otolaryngologist, sometimes leading to unnecessary radiation to the patient. In addition, there are no clear CT findings to make the diagnosis of acute rhinosinusitis. The diagnosis is challenging for all clinicians involved, and therefore, additional signs on other imaging modalities would be helpful. We present a series of four patients with incidentally discovered culture-positive acute rhinosinusitis. Patients with incidentally discovered culture-positive acute rhinosinusitis were found to also have magnetic resonance imaging (MRI) that showed corresponding restricted diffusion on diffusion-weighted imaging (DWI). An imaging biomarker for acute bacterial rhinosinusitis may improve the appropriate use of antibiotic therapy. DWI MRI should be further investigated as a potential candidate screening modality.

Management of Acute Sinusitis via e-Visit

Background: Acute sinusitis is the most common diagnosis in online health care delivery and is the diagnosis most associated with antibiotic prescriptions in the outpatient setting. Few studies have evaluated the effectiveness of managing sinusitis through e-visit in terms of antibiotic prescribing and follow-up rates. Introduction: The purpose of this study was to investigate whether e-visits for the management of acute sinusitis have equivalent clinical outcomes for patients when compared with face-to-face (F2F) visits and nurse-administered phone protocols in terms of antibiotic prescriptions and follow-up rates. Materials and Methods: A retrospective chart review was conducted on empaneled primary care patients between the ages of 18 and 75 years who had a clinical encounter for acute sinusitis at Mayo Clinic Rochester through e-visit, retail health clinic, or phone protocol. Initial antibiotic prescribing rates and follow-up rates for each encounter type were compared. Results: Both e-visit and phone protocol sinusitis encounters were less likely to result in initial treatment with an antibiotic than an F2F visit (84/150 [56%] e-visit, 92/150 [61%] phone, 108/150 [72%]; p = 0.01). There was no significant difference in follow-up rate between e-visits and F2F (27/150 [18%] vs. 21/150 [14%]; p = 0.34), and e-visits had significantly fewer follow-up visits than phone protocol (27/150 [18%] vs. 53/150 [35%]; p < 0.001). Conclusions: e-Visits are an effective modality to care for patients with acute sinusitis, offering equivalent or lower treatment and follow-up rates than more traditional avenues such as F2F visit at a retail clinic and phone protocol.

Common Cold and Acute Rhinosinusitis: Up-to-Date Management in 2020

PURPOSE OF REVIEW

The purposes of the review are as follows: (1) to define acute rhinosinusitis (ARS) and their phenotypes, (2) to highlight the ARS management according to international guidelines, (3) to compare the physicians' management with the ARS guideline recommendations, and (4) to report ARS socioeconomic burden.

RECENT FINDINGS

Bacterial and non-bacterial ARS have similar symptoms, although they can be discriminated by using a combination of specific signs and symptoms. The prescription of antibiotics should be limited to clearly suspected bacterial ARS. There is an overuse of diagnosis tools and treatment prescriptions. The total cost per ARS episode in Europe is over €1000. ARS is mainly an inflammatory disease triggered by viral infection, and few cases end up developing bacterial infection. In most of the cases, it is a self-resolving disease which diagnosis is mainly clinical and the treatment symptomatic. The incidence of complications is low and independent of antibiotic use. There is a high socioeconomic burden associated to ARS.

[The specific features of the clinical course and the treatment strategy in the children presenting with viral sinusitis]

The objective of the present study was to elucidate the peculiar features of acute viral and bacterial sinusitis in the children and to elaborate the algorithm for their treatment based on the results of the primary clinical and laboratory examination. As many as 224 children at the age varying from 1-17 years suffering from acute sinusitis were enrolled in the study. The following methods were employed for the purpose of the study; the analysis of the medical histories of the patients, general examination by an otorhinolaryngologist, diagnostic endoscopy of the nasal cavity and nasopharynx, radiological studies and computed tomography of the paranasal sinuses, echosinusoscopy, the comprehensive microbiological and virological investigation, and evaluation of the peripheral blood characteristics. The study allowed to elucidate the main clinical specific features of acute sinusitis of different etiology including the virological one. The scoring system for the estimation of the risk of development of acute bacterial sinusitis was proposed and the algorithm was developed for the treatment of the children suffering from acute sinusitis to be used in the practical work by general practitioners and otorhinolaryngologists.

In vitro detection of common rhinosinusitis bacteria by the eNose utilising differential mobility spectrometry

Acute rhinosinusitis (ARS) is a sudden, symptomatic inflammation of the nasal and paranasal mucosa. It is usually caused by respiratory virus infection, but bacteria complicate for a small number of ARS patients. The differential diagnostics between viral and bacterial pathogens is difficult and currently no rapid methodology exists, so antibiotics are overprescribed. The electronic nose (eNose) has shown the ability to detect diseases from gas mixtures. Differential mobility spectrometry (DMS) is a next-generation device that can separate ions based on their different mobility in high and low electric fields. Five common rhinosinusitis bacteria (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, Staphylococcus aureus, and Pseudomonas aeruginosa) were analysed in vitro with DMS. Classification was done using linear discriminant analysis (LDA) and k-nearest neighbour (KNN). The results were validated using leave-one-out cross-validation and separate train and test sets. With the latter, 77% of the bacteria were classified correctly with LDA. The comparative figure with KNN was 79%. In one train-test set, P. aeruginosa was excluded and the four most common ARS bacteria were analysed with LDA and KNN; the correct classification rate was 83 and 85%, respectively. DMS has shown its potential in detecting rhinosinusitis bacteria in vitro. The applicability of DMS needs to be studied with rhinosinusitis patients.

Cyclamen europaeum extract for acute sinusitis

BACKGROUND

Acute sinusitis is a common reason for primary care encounters. It causes significant symptoms including facial pain, congested nose, headache, thick nasal mucus, fever, and cough and often results in time off work or school. Sinusitis treatment focuses on eliminating causative factors and controlling the inflammatory and infectious components. The frozen, dried, natural fluid extract of the Cyclamen europaeum plant delivered intranasally is thought to have beneficial effects in relieving congestion by facilitating nasal drainage, and has an anti-inflammatory effect.

OBJECTIVES

To assess the effectiveness of topical intranasal Cyclamen europaeum extract on clinical response in adults and children with acute sinusitis.

SEARCH METHODS

We searched CENTRAL, which includes the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE, Embase, and trials registers (ClinicalTrials.gov; WHO ICTRP) in January 2018. We also searched the reference lists of included studies and review literature for further relevant studies and contacted trial authors for additional information.

SELECTION CRITERIA

Randomised controlled trials comparing Cyclamen europaeum extract administered intranasally to placebo, antibiotics, intranasal corticosteroids, or no treatment in adults or children, or both, with acute sinusitis. Acute sinusitis was defined by clinical diagnosis and confirmed by nasal endoscopy or by radiological evidence.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed trial quality. We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included two randomised controlled trials that involved a total of 147 adult outpatients with acute sinusitis confirmed by radiology or nasal endoscopy who were assigned to Cyclamen europaeum nasal spray or placebo study arms for up to 15 days. The risk of selection and detection bias was unclear, as allocation concealment and blinding of outcome assessors were not reported in either study. Attrition was high (60%) in one study, although dropouts were balanced between study arms.Neither study reported our two primary outcomes: proportion of participants whose symptoms resolved or improved at 14 days and 30 days. No serious adverse events or complications related to treatment were reported; however, more mild adverse events such as nasal and throat irritation, mild epistaxis, and sneezing occurred in Cyclamen europaeum group participants (50%) compared to placebo group participants (24%) (risk ratio 2.11, 95% confidence interval 1.35 to 3.29); moderate-quality evidence.

AUTHORS' CONCLUSIONS

The effectiveness of Cyclamen europaeum for people with acute sinusitis is unknown. Although no serious side effects were observed, 50% of participants who received Cyclamen europaeum reported adverse events compared with 24% of those who received placebo.

Overuse of diagnostic tools and medications in acute rhinosinusitis in Spain: a population-based study (the PROSINUS study)

OBJECTIVES

Acute rhinosinusitis (ARS) has a high incidence. Diagnosis is clinical, and evolution is mostly self-limited. The aim of this study was to describe the sociodemographic characteristics and use of diagnostic tools and medications in patients with ARS.

DESIGN

This is a prospective observational study in real-life clinical practice.

SETTING

Patients with clinical diagnosis of ARS (n=2610) were included from ear, nose and throat clinics in Spain. A second visit at resolution was done.

PARTICIPANTS

Patients were classified according to the duration of symptoms: viral ARS (≤10 days), postviral ARS (>10 days, ≤12 weeks) and chronic rhinosinusitis (>12 weeks).

MAIN OUTCOME MEASURES

Sociodemographic characteristics, symptoms, disease severity, quality of life (Sino-Nasal Outcome Test-16), used diagnostic tools and medications, and the management performed by primary care physicians (PCPs) and by otorhinolaryngologists (ORLs) were assessed.

RESULTS

Of the patients 36% were classified as having viral ARS, 63% postviral ARS and 1% as chronic rhinosinusitis. Working in a poorly air-conditioned environment was a risk factor (OR: 2.26, 95% CI 1.27 to 4.04) in developing postviral ARS. A higher number of diagnostic tools (rhinoscopy/endoscopy: 80% vs 70%; plain X-ray: 70% vs 55%; CT scan: 22% vs 12%; P<0.0001) were performed in postviral than viral cases. PCPs performed more X-rays than ORLs (P<0.0001). Patients, more those with postviral than viral ARS, received a high number of medications (oral antibiotics: 76% vs 62%; intranasal corticosteroids: 54% vs 38%; antihistamines: 46% vs 31%; mucolytic: 48% vs 60%; P<0.0001). PCPs prescribed more antibiotics, antihistamines and mucolytics than ORLs (P<0.0068). More patients with postviral than viral ARS reported symptoms of potential complications (1.5% vs 0.4%; P=0.0603). Independently of prescribed medications, quality of life was more affected in patients with postviral (38.7±14.2 vs 36.0±15.3; P=0.0031) than those with viral ARS. ARS resolution was obtained after 6.04 (viral) and 16.55 (postviral) days, with intranasal corticosteroids being associated with longer (OR: 1.07, 95% 1.02 to 1.12) and phytotherapy with shorter (OR: 0.95, 95% CI 0.91 to 1.00) duration.

CONCLUSIONS

There is a significant overuse of diagnostic tools and prescribed medications, predominantly oral antibiotics, by PCPs and ORLs, for viral and postviral ARS.

[Epithelial dysfunction associated with pyo-inflammatory diseases of the ENT organs]

The modern concept of epithelial-endothelial dysfunction and epithelial-endothelial distress-syndrome associated with pyo-inflammatory ENT diseases is presented. It has provided a basis for the analysis of the initial stages of etiopathogenesis of acute and chronic inflammation in the ENT system including the mucous and associated lymphoid tissues as well as the Pirogov-Waldeyer limphopharyngeal ring making up the first protective barrier. The leading role of dysbiosis of synanthropic microflora and endotoxins of the Gram-negative bacteria in the mechanisms of regional responsiveness of the organism to the infection and chronic endotoxic aggression is demonstrated. The regional and synthetic mechanisms underlying the interaction between the external and internal media of the organism are subjected to the analysis with special reference to those operating in epithelium. The possible variants of the outcome of these processes are considered including both the recovery and the development of chronic inflammation. It has been proved that the exhaustion of the internal reserves for the stabilization of the epithelium-associated lymphoid tissue system including the Pirogov-Waldeyer limphopharyngeal ring leads to the formation of epithelial dysfunction as the initial stage of epithelial-endothelial dysfunction and epithelial-endothelial distress-syndrome. It is concluded that the modern concept of epithelial-endothelial dysfunction and epithelial-endothelial distress-syndrome is a fundamental interdisciplinary phenomenon.

Acute rhinosinusitis during Hajj season 2014: Prevalence of bacterial infection and patterns of antimicrobial susceptibility

BACKGROUND

The presence of large number of pilgrims during Hajj in Makkah region increases the risk of respiratory diseases. In this study, we aimed to assess the bacteriology of acute rhinosinusitis (ARS) during Hajj season and to demonstrate the antimicrobial susceptibility patterns that should guide the clinicians towards more appropriate antibiotic use.

METHODS

Patients with ARS presenting during Hajj season of 2014 were prospectively enrolled. According to EPOS2012 criteria. Sampling of sinus secretions was performed from the middle meatus adjacent to the maxillary sinus ostium via endoscopic guidance. Over all, the study has covered all ENT, emergency and outpatient departments in Hajj.

RESULTS

Two hundred and twenty six patients with ARS were enrolled in the study. Pathogenic bacteria were identified in 93 (41.2%) patients. Of the 93 patients with bacterial ARS, Staphylococcus aureus was isolated in 46 (49.5%) patients, out of which 13 (28.3%) were methicillin-resistant Staphylococcus aureus (MRSA).The second most common group of bacterial isolates was Enterobacteriaceae such as Escherichia coli, and various Klebsiella species. Antibiotic sensitivity showed that methicillin-sensitive Staphylococcus aureus (MSSA) was also sensitive to cephalosporins, quinolones and clindamycin, while exhibiting relatively less sensitivity rates to amoxicillin-clavulinic acid and macrolides.

CONCLUSION

Our study demonstrates the importance of assessing the bacteriology of ARS to help implement guidelines for proper treatment and prevention protocols during Hajj season.

Antibiotic Prescribing by Physicians Versus Nurse Practitioners for Pediatric Upper Respiratory Infections

Background:

This study investigates differences in antibiotic prescribing rates for pediatric upper respiratory infections (URIs) between physicians and nurse practitioners (NPs).

Methods:

Visits by children <18 years old diagnosed with URI to physicians or NPs between 2001 and 2010 were abstracted from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Care Survey. Logistic regression analyses examined variations in antibiotic prescribing rates.

Results:

Upper respiratory infections accounted for approximately 439 ± 21.5 million visits. Patients seen by NPs were more likely to have Medicaid, live in the lowest median household income quartile zip codes and micropolitan locations, and live in the South compared to patients seen by physicians. Nurse practitioners prescribed antibiotics 66.7% ± 4.2% of the time versus physicians at 52.8% ± 0.8% for URI visits (unadjusted P-value = .002). Adjusted by specialty, URI type, and chronic diseases, NPs had marginally significantly different odds of prescribing antibiotics (OR = 1.6, 95% CI, 1.0-2.6, P-value = .048), but the association with prescribing broad-spectrum antibiotics is not as strong (adjusted P-value = .063). Patient visits to a pediatric (OR = 0.54, 95% CI, 0.43-0.67) or ENT/surgery practice (OR = 0.11, 95% CI, 0.06-0.18) had lower odds of antibiotic prescribing compared to general/family medicine practices. Year (2001-2010) was not significantly associated with antibiotic or broad-spectrum antibiotic prescribing rates for physicians, but rates for NPs fell for otitis media ( P-value = .007) from 90.2% ± 8.2% (2001-2002) to 74.8% ± 6.8% (2009-2010) of visits.

Conclusions:

Nurse practitioners have higher rates of antibiotic prescribing compared to physicians for pediatric patients with URIs; however, this difference is less after adjusting for specialty. Examining comparative antibiotic prescribing is important to promote evidence-based practice and adoption of clinical guidelines.

Molecular epidemiology of nonencapsulated Streptococcus pneumoniae among Japanese children with acute otitis media

The introduction of pneumococcal conjugate vaccine may change the epidemiology of Streptococcus pneumoniae. The increased prevalence of non-vaccine serotypes as the cause of pneumococcal diseases has already reported in the United States and Europe. However, little attention has been focused on the S. pneumoniae. In this study, nonencapsulated S. pneumoniae were identified in 15 isolates (6.4%) out of 236 pneumococcal strains obtained from the nasopharynges of children with acute otitis media (AOM), in 3 isolates (14.3%) out of 21 strains from acute rhinosinusitis, and in 2 isolates (12.5%) out of 16 nasopharyngeal carriage strains obtained from normal healthy children. Among the 20 nonencapsulated S. pneumoniae isolates, 15 (75.0%) isolates had the pspK gene. Seven sequence types (STs) were identified: ST7502 (5 strains), ST1106 (2 strains), ST7803 (2 strains), ST7786 (1 strain), ST6741 (1 strain), ST7496 (1 strain), and ST8642 (1 strain). Because nonencapsulated S. pneumoniae strains are not targeted by the current available pneumococcal vaccines, these strains will gradually become more common in nasopharyngeal carriage. The increase in colonization and dissemination of these strains would increase the risk of AOM and other systemic pneumococcal diseases against which current vaccines cannot provide protection. Nonencapsulated S. pneumoniae may thus become more prevalent as human pathogen.

Diagnostic accuracy of history and physical examination in bacterial acute rhinosinusitis

OBJECTIVES/HYPOTHESIS

To evaluate the diagnostic accuracy of symptoms, the symptom progression pattern, and clinical signs in identifying bacterial acute rhinosinusitis (ARS).

STUDY DESIGN

We conducted an inception cohort study among 50 military recruits with ARS.

METHODS

We collected symptoms daily from the onset of symptoms to approximately 10 days. At 9 to 10 days, standardized data on symptoms and physical findings were gathered. A positive culture of maxillary sinus aspirate was considered to be the reference standard for bacterial ARS.

RESULTS

At 9 to 10 days, the presence or deterioration after 5 days of any of the symptoms could not be used to diagnose bacterial ARS. Toothache had an adequate positive likelihood ratio (positive likelihood ratio [LR+] 4.4) but was too rare to be used for screening. In contrast, several physical findings at 9 to 10 days were of more diagnostic use and frequent enough for screening. Moderate or profuse (vs. none/minimal) amount of secretion in nasal passage seen in anterior rhinoscopy satisfactorily either ruled in, if present (LR+ 3.2), or ruled out, if absent (negative likelihood ratio 0.2), bacterial ARS. If any secretion was seen in the posterior pharynx or middle meatus, the probability of bacterial ARS increased markedly (LR+ 5.3 and LR+ 11.0, respectively).

CONCLUSION

We found symptoms or their change to be of little use in identifying bacterial ARS. In contrast, we observed several clinical findings after 9 to 10 days of symptoms to predict bacterial ARS quite accurately.

The relationship of C-reactive protein levels and positive culture with quality of life in acute rhinosinusitis

BACKGROUND

Acute rhinosinusitis (ARS) has been shown to significantly reduce patient quality of life (QoL). While the QoL in patients with chronic rhinosinusitis has been the subject of intensive research over the last decade, studies measuring the impact of ARS on patient QoL have remained relatively scarce. The aim of this study was to determine the relationship between the QoL and parameters suggestive of acute bacterial rhinosinusitis (C-reactive protein [CRP] levels and positive culture) and to see if measurement of the QoL could be used as an indicator for antibiotic treatment in ARS.

METHODS

Eighty patients with ARS were enrolled in the study. A novel QoL instrument for patients with ARS, called Measurement of Acute Rhinosinusitis (MARS) questionnaire, was given to patients at the time of diagnosis. We assessed patient QoL, obtained endoscopically guided cultures from the middle meatus, and measured levels of CRP. The relationship between QoL MARS scores (QoL-Mscores) and CRP was determined using a correlation coefficient. To compare QoL-Mscores, relative to culture-positive and culture-negative patients, the Student's t-test was used.

RESULTS

No correlation between the QoL, assessed using the MARS questionnaire, and positive middle meatus culture was demonstrated (P=0.332). A weak correlation was found between QoL-Mscores and CRP values, with a correlation coefficient of 0.221 and P=0.0498.

CONCLUSION

No correlation between the QoL in ARS patients and positive culture was found in this study. The clinical significance of the correlation between QoL-Mscores and CRP values in the antibiotic decision making process needs further research.