Activité in vitro du cefpodoxime sur Streptococcus pneumoniae : dernières données françaises et revue de la littérature

[Community-acquired acute maxillary sinusitis or rhinosinusitis in adults in France: current management]

Sinus infections, often viral, are a common reason for physician visits. The multiplicity of clinical presentations makes its diagnosis difficult. The problem is to recognize bacterial infection without additional testing, except in cases of treatment failures, complications or relapse. Patients with signs suggestive of rhinosinusitis fall into one of four basic clinical situations: common colds, 'doubtful' rhinosinusitis, apparent acute maxillary bacterial rhinosinusitis, and complications. Anterior rhinoscopy may help confirm diagnosis. Current bacterial epidemiology is based on the results of clinical studies, microbial ecology, and samples taken in cases of treatment failure. The two bacteria isolated most frequently are Streptococcus pneumoniae and Haemophilus influenzae, both of which pose resistance problems. Moraxella catarrhalis, Streptococcus pyogenes and Staphylococcus aureus are isolated less often. The dominant issue in management of acute rhinosinusitis is whether to use antibiotic or symptomatic treatment. For viral infections, antibiotic therapy is useless and highly inadvisable. For 'doubtful' infections, symptomatic treatment is likely to lead to recovery. The use of non-recommended antibiotics also increases the risk of selection of resistant bacteria. When bacterial rhinosinusitis is strongly suspected, recourse to antibiotic treatment is recommended in view of the benefits in this situation (AFSSAPS 2005). This treatment is probabilistic, should be decided at the end of the consultation, and follows the AFSSAPS guidelines.

[Treatment of acute maxillary sinusitis in adults. Comparison of cefpodoxime-proxetil and amoxicillin-clavulanic acid]

OBJECTIVE

The aim was to demonstrate the equivalence of the clinical efficacy and safety of cefpodoxime-proxetil (200 mg bid for 5 days) to that of amoxicillin-clavulanic acid (1 g/125 mg bid for 8 days) in adults with acute maxillary sinusitis.

METHOD

In this prospective, multicenter, centrally-randomized, open-label study, 73 general practitioners and 11 ear, nose, and throat specialists included 512 patients with unilateral acute maxillary sinusitis.

RESULTS

The clinical success rates at day 12-19 in the per-protocol population (primary analysis) were 92.3% (215/233) in the cefpodoxime-proxetil group and 93.6% (204/218) in the amoxicillin-clavulanic acid group. The 95% confidence interval of [6.5%; 3.9%] demonstrated that cefpodoxime-proxetil was not inferior to amoxicillin-clavulanic acid. Cure rates at follow-up (day 25-30) were 90.6% and 92.7%, respectively. Results were similar in the intent-to-treat population. Compliance was significantly better in the cefpodoxime-proxetil group (99.2% versus 95.5%; p=0.011). Tolerance was also significantly better: 1.2% (3/247) of cefpodoxime-proxetil patients reported a treatment-related adverse event, compared with 10.7% (26/244) in the amoxicillin-clavulanic acid group (p<0.001). Most events were gastrointestinal and of mild to moderate intensity.

CONCLUSION

In this study, a 5-day course of cefpodoxime-proxetil at 200 mg bid was as clinically effective as amoxicillin-clavulanic acid 1 g/125 mg bid for 8 days with a significantly better safety profile and compliance.