Acute bacterial rhinosinusitis: a review of U.S. treatment guidelines

Extrapulmonary Tuberculosis Presenting As Stage V Bilateral Cervical Lymphadenitis With Cortical Cerebral Watershed Infarct Along With Maxillary and Sphenoid Sinusitis

Extrapulmonary tuberculosis is an infrequently reported condition. However, in endemic settings, it contributes to a significant number of cases. The most common site of extrapulmonary tuberculosis is the lymph nodes. Herein, an exceedingly rare case of extrapulmonary tuberculosis presenting as bilateral cervical lymphadenitis with external cerebral watershed infarct along with sphenoid and maxillary sinusitis in an Indian male is presented. A detailed literature search revealed that a case with all these clinical conditions together has never been reported to date. A diagnostic workup supported by radiometric investigations helped in the diagnosis, and timely management was initiated.

Urgent Infections of the Head and Neck

Infections of the head and neck are common and appropriately managed by primary care providers in most cases. However, some infections are associated with significant morbidity and require urgent recognition and management by specialty services. These include deep neck space infections originating in the oral cavity, pharynx, and salivary glands, as well as complicated otologic and sinonasal infection. This article provides a review of these conditions, including the pathophysiology, presenting features, and initial management strategy.

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.

Variations in antibiotic prescribing of acute rhinosinusitis in United States ambulatory settings

OBJECTIVE

To identify variations in antibiotic treatment of acute rhinosinusitis (ARS) on a national level.

STUDY DESIGN

Cross-sectional study of a national database.

SETTING

Otolaryngology and primary care ambulatory settings.

SUBJECTS AND METHODS

A nationally representative sample of adult outpatient visits was extracted from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Care Survey data for 2006 to 2009. Antibiotic prescriptions associated with ARS were tabulated. Statistical analyses were conducted to identify variations in antibiotic prescribing by patient and physician characteristics.

RESULTS

Antibiotics were prescribed in 82.3% ± 2.6% of 18.7 million visits for ARS (mean age, 46.2 years; 65.9% female). The ratio of primary care physician (PCP) to otolaryngologist (ENT) ARS visits was 18.6:1. Antibiotic prescription rates were inversely related to increasing age groups of 18 to 39, 40 to 64, and ≥ 65 years (87.8%, 81.2%, and 71.0%, respectively; P = .02). Physicians in general medicine outpatient departments, internal medicine, and family medicine were more likely to prescribe antibiotics compared with ENTs (adjusted odds ratio [OR], 7.9 [95% confidence interval (CI), 3.5-17.8]; 6.9 [2.5-19.2]; and 3.9 [2.0-7.7], respectively). The most commonly prescribed antibiotics were azithromycin, amoxicillin, and amoxicillin/clavulanate acid (27.5%, 15.5%, and 14.6%, respectively). The ENTs selected broad-spectrum antibiotics more often than PCPs (94.3% vs 75.7% of visits with antibiotics were broad-spectrum agents; P = .01).

CONCLUSION

Antibiotics were prescribed frequently despite recent consensus guidelines that discourage antibiotic use in mild cases. Furthermore, antibiotic prescription was more likely for younger patients and in primary care settings. This highlights the need to promote awareness of practice guidelines.

Antibiotic resistance and otomycosis in the draining ear: culture results by diagnosis

OBJECTIVE

The objective of the study was to better define changes in the bacteriology of suppurative otitis in recent years and the role of cultures in the management of these patients.

STUDY DESIGN

A retrospective review was performed.

METHODS

Outpatient records from 170 patients collected over 3 years with information regarding the bacteria cultured, antibiotic resistance, and clinical diagnosis were analyzed.

RESULTS

A large variety of organisms were seen, with Staphylococcus aureus, Corynebacterium sp, and Pseudomonas aeruginosa being the most common. Forty percent of cultures showed bacteria with moderate antibiotic resistance, whereas 5% were sensitive to only intravenous antibiotics. Resistant bacteria were found in all diagnosis categories and were significantly higher in cases of chronic mastoiditis. The rate of methicillin-resistant S aureus infections was 7.8% and was significantly higher in cases of chronic myringitis. Fungus was often cultured in patients without clinical signs of otomycosis.

CONCLUSIONS

Community-acquired ear infections may be caused by antibiotic-resistant bacteria in a substantial number of patients. In our opinion, outpatient cultures play an important role in the management of suppurative otitis.

Canadian clinical practice guidelines for acute and chronic rhinosinusitis

This document provides healthcare practitioners with information regarding the management of acute rhinosinusitis (ARS) and chronic rhinosinusitis (CRS) to enable them to better meet the needs of this patient population. These guidelines describe controversies in the management of acute bacterial rhinosinusitis (ABRS) and include recommendations that take into account changes in the bacteriologic landscape. Recent guidelines in ABRS have been released by American and European groups as recently as 2007, but these are either limited in their coverage of the subject of CRS, do not follow an evidence-based strategy, or omit relevant stakeholders in guidelines development, and do not address the particulars of the Canadian healthcare environment.

Advances in understanding the pathophysiology of CRS, along with the development of appropriate therapeutic strategies, have improved outcomes for patients with CRS. CRS now affects large numbers of patients globally and primary care practitioners are confronted by this disease on a daily basis. Although initially considered a chronic bacterial infection, CRS is now recognized as having multiple distinct components (eg, infection, inflammation), which have led to changes in therapeutic approaches (eg, increased use of corticosteroids). The role of bacteria in the persistence of chronic infections, and the roles of surgical and medical management are evolving. Although evidence is limited, guidance for managing patients with CRS would help practitioners less experienced in this area offer rational care. It is no longer reasonable to manage CRS as a prolonged version of ARS, but rather, specific therapeutic strategies adapted to pathogenesis must be developed and diffused.

Guidelines must take into account all available evidence and incorporate these in an unbiased fashion into management recommendations based on the quality of evidence, therapeutic benefit, and risks incurred. This document is focused on readability rather than completeness, yet covers relevant information, offers summaries of areas where considerable evidence exists, and provides recommendations with an assessment of strength of the evidence base and degree of endorsement by the multidisciplinary expert group preparing the document.

These guidelines have been copublished in both Allergy, Asthma & Clinical Immunology and the Journal of Otolaryngology-Head and Neck Surgery.

Effectiveness of antibiotics for acute sinusitis in real-life medical practice

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT

Determining bacterial aetiology of acute sinusitis is difficult without employing invasive procedures. Most episodes of acute sinusitis resolve spontaneously. Antibiotics have demonstrated efficacy for the treatment of acute bacterial sinusitis in clinical trials yet little is known of their effectiveness in real-life treatment settings.

WHAT THIS STUDY ADDS

Most cases of untreated acute sinusitis resolved spontaneously. Antibiotics were more effective when given within the first 10 days of treatment. This had no effect on later recurrence. Patients with poor oro-dental condition or recent antibiotic use may derive the most benefit from an antibiotic prescription and this should be considered by prescribers. The antibiotics used were found to be equally effective. Existing recommendations to identify acute sinusitis with high probability of bacterial origin, such as the French recommendations, fever or duration of symptoms fail to identify patients in whom antibiotics are more effective.

AIMS

To assess the effectiveness of antibiotics in acute bacterial sinusitis.

METHODS

This was a prospective cohort study with 2 months follow-up of 5640 patients with acute sinusitis included by a random sample from 1174 GPs and 120 ENT specialists. Main outcomes were short-term initial success, defined as the absence of prescription of (another) antibiotic or sinus lavage within 10 days, and lack of recurrence between the 11th and 60th day, after initial success.

RESULTS

Initial success was found in 88.7% (95% CI 85.1, 91.4%) of patients without antibiotic prescription at inclusion and 96.2% (95% CI 95.7, 96.7%) of patients prescribed antibiotics. The 10 day adjusted hazard ratio (HR) for treatment failure (new antibiotic prescription or sinus drainage) with initial antibiotics compared with no antibiotics was 0.30 (95% CI 0.21, 0.42) with no difference between antibiotics. Antibiotics were more effective in patients with poor oro-dental condition (HR 0.04, 95% CI 0.01, 0.20) and in patients who had already used antibiotics during the previous 2 months (HR 0.09, 95% CI 0.03, 0.28). For patients without failure at 10 days, recurrence between the 11th and 60th day was similar whether or not they had initially been prescribed an antibiotic, 94.1% (95% CI 93.4, 94.7%) and 93.4% (95%CI 90.3, 95.5%), respectively.

CONCLUSION

Most acute sinusitis cases not prescribed antibiotics resolve spontaneously. Antibiotics reduced by 3.3-fold the risk of failure within 10 days, without impact on later recurrence. The greatest benefit of antibiotics was found for patients with poor oro-dental condition or with antibiotic use within the previous 2 months.

Evaluation and management of the patient with "sinus"

The patient with "sinus" is common. However, an accurate diagnosis for a patient's sinus complaints may be elusive. The diagnostic uncertainty with these patients is a result of nonspecific symptoms, subtle or absent physical examination findings, and limited diagnostic testing options. Rhinitis should be distinguished from sinusitis. In acute illness, viral upper respiratory tract infection should be distinguished from acute bacterial sinusitis. For patients with chronic sinus symptoms, objective evidence of paranasal sinus inflammation should be confirmed before labeling the patient with chronic sinusitis.

Current bacteriology of suppurative otitis: resistant patterns and outcomes analysis

INTRODUCTION

Antibiotic resistance has complicated the management of the draining ear. In this study, we examine the factors predisposing to resistance, as well as the role culture played in the management of these patients.

MATERIALS AND METHODS

A retrospective chart review was performed on all patients with a complaint of otorrhea during a 3-year period. Demographic factors, the patients diagnosis, previous antimicrobial use, the organism isolated, the resistance pattern of the organism, the treatment instituted, the treatment changed, and the efficacy of treatment were all examined.

RESULTS

Previous antibiotic use resulted in a significantly increased rate of resistance only for the diagnosis of otitis externa (p = 0.01). No other factors were found to be clinically significant. The previous use of ototopical quinolones was shown to be correlated with a significant increase in quinolone resistance (p = 0.01). Methicillin-resistant Staphylococcus aureus isolated was shown to have 60% and 33% resistance rates to clindamycin and trimethoprim/sulfamethoxazole, respectively. The overall treatment failure rate was 36% but rose to 50% for infections involving highly resistant bacteria (p = 0.01). Treatment was changed based on culture results in 21% of cases.

CONCLUSION

Previous antibiotic use is correlated with increased bacterial resistance in the case of otitis externa. Highly resistant bacteria were associated with an increased rate of treatment failure. Culture plays an essential role in the management of refractory otorrhea.

Important research questions in allergy and related diseases: 3-chronic rhinosinusitis and nasal polyposis - a GALEN study

Chronic rhinosinusitis is one of the most common health care challenges, with significant direct medical costs and severe impact on lower airway disease and general health outcomes. The diagnosis of chronic rhinosinusitis (CRS) currently is based on clinical signs, nasal endoscopy and CT scanning, and therapeutic recommendations are focussing on 2 classes of drugs, corticosteroids and antibiotics. A better understanding of the pathogenesis and the factors amplifying mucosal inflammation therefore seems to be crucial for the development of new diagnostic and therapeutic tools. In an effort to extend knowledge in this area, the WP 2.7.2 of the GA(2)LEN network of excellence currently collects data and samples of 1000 CRS patients and 250 control subjects. The main objective of this project is to characterize patients with upper airway disease on the basis of clinical parameters, infectious agents, inflammatory mechanisms and remodeling processes. This collaborative research will result in better knowledge on patient phenotypes, pathomechanisms, and subtypes in chronic rhinosinusitis. This review summarizes the state of the art on chronic rhinosinusitis and nasal polyposis in different aspects of the disease. It defines potential gaps in the current research, and points to future research perspectives and targets.

Effect of topical ciprofloxacin/dexamethasone or dexamethasone alone on acute Streptococcus pneumoniae rhinosinusitis in mice

OBJECTIVE: To test whether intranasal ciprofloxacin/dexamethasone or dexamethasone alone affects the course of acute bacterial rhinosinusitis in mice.

STUDY DESIGN: We performed a randomized, double-blind, parallel, placebo-controlled study in mice.

SUBJECTS AND METHODS: Three groups of 10 C57B1/6 mice were infected with Streptococcus pneumoniae, and then 1 day later randomized to treatment with placebo, ciprofloxacin plus dexamethasone, or dexamethasone. The mice were killed 3 or 10 days after treatment was begun.

RESULTS: The placebo-treated mice became infected and developed an inflammatory cell infiltration in their sinuses. None of the treatments significantly affected the course of the illness.

CONCLUSION: The lack of topical, intranasal efficacy of ciprofloxacin and dexamethasone could be attributed to subpotent dosage, rapid nasal clearance, or inability of the drops to reach the site of infection. Treatment with dexamethasone neither improved nor worsened the bacterial infection.

Bacterial superinfection in upper respiratory tract infections estimated by increases in CRP values: a diagnostic follow-up in primary care

OBJECTIVE

The aim of this study was to estimate the rate of bacterial superinfection in patients with URTI by using on-site determination of C-reactive protein (CRP).

DESIGN

A prospective cohort study.

SETTING

A total of 30 primary care practices.

SUBJECTS

Patients with URTI.

INTERVENTION

The CRP value was determined at the first consultation and at a follow-up within 3-5 days. CRP values of 30 units (mg) or higher were considered to be an indication of bacterial involvement.

MAIN OUTCOME MEASURES

CRP values during follow-up and duration of illness.

RESULTS

Among the 506 patients included, 73.1% exhibited a CRP value below the defined limit at their first visit and were considered to suffer from URTI of viral origin. The rate of subsequent bacterial superinfection was 8.1%. Compared with patients suffering from URTI of bacterial or viral origin the duration of illness in patients with bacterial superinfection was significantly longer.

CONCLUSION

During follow-up of patients with URTI, the prevalence of bacterial superinfection detected by using a near patient CRP determination is surprisingly low. This result should help to reduce the prescription rate of antibiotics in primary care.

Rhinosinusitis: prevention strategies

Risk factors of recurrent sinusitis involve upper respiratory infections, bacterial load of the adenoids, day care attendance and exposure to tobacco smoke as well as sinonasal abnormalities, including septal deviation, choanal atresia, polyps and hypoplasia of sinuses. Furthermore, several systemic disorders can facilitate the development of chronic sinusitis, such as allergic rhinitis, gastro-esophageal reflux disease (GER), cystic fibrosis, primary ciliary dyskinesia, and immunodeficiency diseases. A clinical practice guideline for the management of sinusitis is available only for the acute disease, but does not include for the management of the chronic form (i.e. chronic/recurrent sinusitis) and even less for the prevention strategies. As several studies indicate that the majority of children respond to sequential medical followed by surgical interventions, when needed, the best prevention of recurrence or chronicity is to properly treat acute sinusitis; in addition, children should be removed from larger and crowded day care whenever possible and should not be exposed to cigarette smoke. If allergic rhinitis co-exists, it can be managed with nasal steroids sprays and anti-histamines, although the long-term results are controversial. In case of chronic sinusitis, the strategy of prevention is to assess and to cure the associated conditions.

Activity of garenoxacin, an investigational des-F(6)-quinolone, tested against pathogens from community-acquired respiratory tract infections, including those with elevated or resistant-level fluoroquinolone MIC values

Garenoxacin, a novel des-F(6)-quinolone, was tested against 40423 pathogenic isolates associated with community-acquired respiratory tract infections (CA-RTIs). The strains included Streptococcus pneumoniae (18887), Haemophilus influenzae (15555), and Moraxella catarrhalis (5981), each isolated from a significant infection monitored by the SENTRY Antimicrobial Surveillance Program (1999-2005; North America, Latin America, and Europe). All tests were performed by reference broth microdilution methods for garenoxacin and 19 comparison agents. The garenoxacin MIC(90) and percentage (%) of strains inhibited at < or =1 microg/mL (proposed susceptible breakpoint) were S. pneumoniae (0.06 microg/mL, >99.9% susceptible), H. influenzae (< or =0.03 microg/mL, >99.9%), and M. catarrhalis (< or =0.03 microg/mL, 100.0%). The garenoxacin potency versus the pneumococci was 16- to 32-fold greater than levofloxacin or ciprofloxacin and 2-fold superior to moxifloxacin (MIC(90), 0.12 microg/mL). Resistances to other classes of antimicrobials did not adversely influence garenoxacin MIC results. Ciprofloxacin- or levofloxacin-resistant (MIC, > or =4 microg/mL) S. pneumoniae had higher garenoxacin MIC(90) values (1 microg/mL), but 90.6% to 97.5% of strains remained susceptible. Strains of all 3 monitored pathogens with mutations in the quinolone resistance determining region (QRDR) had higher garenoxacin MIC results, with > or =3 to 4 QRDR mutations required to elevate garenoxacin MIC values to > or =2 microg/mL. In conclusion, garenoxacin possesses a potent activity against pneumococci, H. influenzae, and M. catarrhalis strains worldwide, at a level significantly greater than the available tested agents in the fluoroquinolone class (ciprofloxacin, levofloxacin, and moxifloxacin). Only 13 and 4 isolates (0.07% and 0.03%) of S. pneumoniae and H. influenzae, respectively, had a garenoxacin MIC at > or =2 microg/mL, thus, making this new "respiratory antipneumococcal" quinolone an attractive candidate for the therapy of contemporary CA-RTI (bronchitis, pneumonia, and sinusitis).

Garenoxacin activity against isolates form patients hospitalized with community-acquired pneumonia and multidrug-resistant Streptococcus pneumoniae

Community-acquired pneumonia (CAP) continues to cause significant morbidity worldwide, and the principal bacterial pathogens (Streptococcus pneumoniae and Haemophilus influenzae) have acquired numerous resistance mechanisms over the last few decades. CAP treatment guidelines have suggested the use of broader spectrum agents, such as antipneumococcal fluoroquinolones as the therapy for at-risk patient population. In this report, we studied 3087 CAP isolates from the SENTRY Antimicrobial Surveillance Program (1999-2005) worldwide and all respiratory tract infection (RTI) isolate population of pneumococci (14665 strains) grouped by antibiogram patterns against a new des-F(6)-quinolone, garenoxacin. Results indicated that garenoxacin was highly active against CAP isolates of S. pneumoniae (MIC(90), 0.06 microg/mL) and H. influenzae (MIC(90), < or =0.03 microg/mL). This garenoxacin potency was 8- to 32-fold greater than gatifloxacin, levofloxacin, and ciprofloxacin against the pneumococci and >99.9% of strains were inhibited at < or =1 microg/mL (proposed susceptible breakpoint). Garenoxacin MIC values were not affected by resistances among S. pneumoniae strains to penicillin or erythromycin; however, coresistances were high among the beta-lactams (penicillins and cephalosporins), macrolides, tetracyclines, and trimethoprim/sulfamethoxazole. Analysis of S. pneumoniae isolates with various antimicrobial resistance patterns to 6 drug classes demonstrated that garenoxacin was active against >99.9% (MIC, < or =1 microg/mL) of strains, and the most resistant pneumococci (6-drug resistance, 1051 strains or 7.2% of all isolates) were completely susceptible (100.0% at < or =1 microg/mL) to garenoxacin (MIC(90), 0.06 microg/mL). These results illustrate the high activity of garenoxacin against contemporary CAP isolates and especially against multidrug-resistant (MDR) S. pneumoniae that have created therapeutic dilemmas for all RTI presentations. Garenoxacin appears to be a welcome addition to the CAP treatment options, particularly for the emerging MDR pneumococci strains.

Oral beta-lactams in the treatment of acute bacterial rhinosinusitis

Acute bacterial rhinosinusitis (ABRS) is a well-known complication of viral upper respiratory tract infection and is associated with a significant socioeconomic burden. Difficulties in diagnosis, a substantial spontaneous resolution rate, and growing concerns regarding antimicrobial resistance make the proper management of ABRS quite challenging. Treatment guidelines have been developed, taking into account the major bacterial pathogens, rates of antimicrobial resistance, spontaneous resolution rates, and pharmacokinetic and pharmacodynamic considerations. Optimal choices for initial treatment of ABRS in patients without prior antibacterial exposure include the oral beta-lactam agents amoxicillin/clavulanate, cefdinir, cefpodoxime, and cefuroxime. Clinicians are encouraged to consider the local pathogen distribution and rates of antibacterial resistance in selecting therapy for ABRS.