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Abstract
BACKGROUND Chronic rhinosinusitis (CRS) is one of the most frequent chronic diseases. Among these patients the prevalence of immune defects is higher than in the healthy general population. METHODS A selective review of the literature was carried out in PubMed and Medline covering the period between 2008 and 2019. Additionally, recent German publications in journals not listed in the abovementioned databases were analyzed. RESULTS The diagnostic workflow with respect to the immunodeficiency consists of a detailed anamnesis and physical examination, laboratory tests and the antibody reaction to polysaccharide vaccines and antigens. Beside antibiotic treatment, vaccinations and immunoglobulin replacement are available. Notwithstanding the above, functional endoscopic surgery of the paranasal sinuses should be performed according to guideline recommendations. CONCLUSION Patients with CRS who do not sufficiently respond to conservative and surgical treatment should be checked for underlying immunodeficiencies.
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Liu YF, Richardson CM, Bernard SH, Church CA, Seiberling KA. Antibiotics, steroids, and combination therapy in chronic rhinosinusitis without nasal polyps in adults. EAR, NOSE & THROAT JOURNAL 2018; 97:167-172. [PMID: 30036413 DOI: 10.1177/014556131809700614] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Despite a lack of robust data regarding their efficacy, oral antibiotics and steroids remain two of the most common treatments for chronic rhinosinusitis without nasal polyps (CRSsNP). We sought to objectively compare the efficacy of antibiotics and steroids, independently and in combination, for the initial treatment of CRSsNP. To that end, we conducted a retrospective chart review of 100 patients-51 men and 49 women, age 20 to 85 years (mean: 50)-who were treated for CRSsNP from January 2010 through January 2015. Of this group, 17 patients were treated with an antibiotic only, 28 with a steroid only, and 55 with both agents. All patients underwent computed tomography (CT) before and after treatment, and we compared the three groups' pre- and post-treatment Lund-Mackay CT scores, symptom scores, and rates of surgery. The average time between the pre- and post-treatment visits was 4.4 weeks. The mean Lund-Mackay CT score for the entire study population was significantly lower after treatment than at baseline (6.3 vs. 9.1; p < 0.001); however, there were no significant differences among the three groups in either pre- or post-treatment scores. Symptom scores were significantly better in the combination therapy group than in the two monotherapy groups (p < 0.001). In all, 40 of the 100 patients underwent surgery; the difference in surgery rates among the three groups was not statistically significant (p = 0.884). Surgery was performed on 9 of the 52 (17.3%) patients who either were followed for at least 1 year or who had had surgery within the first year postoperatively; again, there were no significant differences among the three groups (p = 0.578). We conclude that although the Lund-Mackay CT scores decreased significantly in the antibiotic, steroid, and combination therapy groups, no one regimen was superior to any other for treating CRSsNP in our study.
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Affiliation(s)
- Yuan F Liu
- Department of Otolaryngology-Head and Neck Surgery, Loma Linda University Medical Center, 11234 Anderson St., Room 2586A, Loma Linda, CA 92354, USA.
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Arianpour K, Svider PF, Guys N, Shenouda K, Folbe E, Hsueh WD, Eloy JA, Folbe AJ. Incorporation of antibiotics and systemic steroids by sinus surgeons: is there widespread consensus? Int Forum Allergy Rhinol 2018; 8:1034-1040. [PMID: 29979841 DOI: 10.1002/alr.22131] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 03/15/2018] [Accepted: 03/27/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND The objective of this work was to evaluate factors associated with antibiotic and oral corticosteroid (OCS) prescription among otolaryngologists regularly performing sinus surgery. METHODS Fellowship-trained rhinologists, including fellowship directors, were identified via the American Rhinologic Society (ARS) website. Non-fellowship-trained otolaryngologists performing ≥25 balloons (frontal/maxillary) or ≥25 functional endoscopic sinus surgeries (FESSs) (frontal/maxillary/ethmoids) were also included in "balloon surgeons" and "sinus surgeon" cohorts, respectively. Prescribing data for Medicare Part D beneficiaries was obtained for 2015. RESULTS Otolaryngologists included in this analysis wrote a median of 54 scripts for antibiotics, with a 15.1% antibiotic prescription rate. The overall script length per antibiotic was 11.1 days. Of fellowship-trained rhinologists, 90.2% wrote fewer than 100 scripts, compared to 25.6% and 32.5% of sinus surgeons and balloon surgeons, respectively. Fellowship-trained rhinologists wrote lengthier antibiotic scripts (14.1 vs 10.3 days, p < 0.05). Clinicians who have been in practice longer prescribed antibiotics significantly more frequently. Fellowship-trained rhinologists had a greater OCS rate (8.9%) than balloon and sinus surgeons (7.1%), also writing lengthier courses (15.0 vs 8.1 days). Early-career otolaryngologists wrote lengthier steroid prescriptions than those with 11 to 20 years and >20 years in practice. CONCLUSION Antibiotic and OCS utilization varies by type of training, as non-fellowship-trained sinus surgeons and balloon surgeons tend to utilize antibiotics more aggressively, and fellowship-trained rhinologists utilize OCS more frequently. Otolaryngologists with more years in practice are more likely to incorporate antibiotics in the management of sinus disorders, although these conclusions must be considered in the context of this resource's limitations. Further clarification of guidelines may be helpful for minimizing divergent practices and maintaining a consensus.
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Affiliation(s)
- Khashayar Arianpour
- Department of Otolaryngology-Head and Neck Surgery, Wayne State University School of Medicine, Detroit, MI.,Department of Otolaryngology, William Beaumont Hospital, Royal Oak, MI
| | - Peter F Svider
- Department of Otolaryngology-Head and Neck Surgery, Wayne State University School of Medicine, Detroit, MI.,Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NJ
| | - Nicholas Guys
- Department of Otolaryngology-Head and Neck Surgery, Wayne State University School of Medicine, Detroit, MI
| | - Kerolos Shenouda
- Department of Otolaryngology-Head and Neck Surgery, Wayne State University School of Medicine, Detroit, MI
| | - Elana Folbe
- Department of Otolaryngology-Head and Neck Surgery, Wayne State University School of Medicine, Detroit, MI
| | - Wayne D Hsueh
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NJ
| | - Jean Anderson Eloy
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NJ.,Department of Ophthalmology and Visual Science, Rutgers New Jersey Medical School, Newark, NJ.,Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, NJ.,Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, NJ
| | - Adam J Folbe
- Department of Otolaryngology, William Beaumont Hospital, Royal Oak, MI.,Barbara Ann Karmanos Cancer Institute, Detroit, MI
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Božić DD, Pavlović B, Milovanović J, Jotić A, Čolović J, Ćirković I. Antibiofilm effects of amoxicillin-clavulanic acid and levofloxacin in patients with chronic rhinosinusitis with nasal polyposis. Eur Arch Otorhinolaryngol 2018; 275:2051-2059. [PMID: 29959565 DOI: 10.1007/s00405-018-5049-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 06/25/2018] [Indexed: 02/07/2023]
Abstract
PURPOSE Microbial biofilms have been implicated in the pathogenesis of chronic rhinosinusitis with nasal polyposis (CRSwNP). The aim of our study was to evaluate in vitro effects of amoxicillin-clavulanic acid and levofloxacin on biofilm formation by bacterial species isolated from sinus tissue in patients with CRSwNP. METHODS The sinus mucosal specimens were harvested from the upper parts and roof of ethmoid cavity of 48 patients with CRSwNP. Each sample was washed thoroughly in three separate beakers of sterile saline to remove any planktonic bacteria and further subjected to microbiology analysis. The biofilm-forming capacity of isolated strains was detected by microtiter-plate method and the effects of subinhibitory (1/2× to 1/16× MIC) and suprainhibitory concentrations (4, 8, 16, 32, and 64 µg/ml) of amoxicillin-clavulanic acid and levofloxacin on biofilm production were investigated. RESULTS Bacterial strains were isolated in 42 (87.5%) patients: one microorganism in 80.9% and two microorganisms in 19.1% of patients. The most prevalent bacteria in CRSwNP biofilms were Staphylococcus epidermidis (34%) and S. aureus (28%) followed by S. haemolyticus (12%), Pseudomonas aeruginosa (8%), Moraxella catarrhalis (6%), Streptococcus pneumoniae (6%), and other staphylococci (6%). Subinhibitory concentrations of amoxicillin-clavulanic acid and levofloxacin significantly reduced biofilm formation (p < 0.01 and p < 0.05, respectively), with better efficacy of amoxicillin-clavulanic acid (1/2-1/8× MIC) on staphylococci and levofloxacin (1/2- 1/4× MIC) on M. catarrhalis and P. aeruginosa biofilm formation. Suprainhibitory concentrations of both tested antibiotics (4-64 µg/ml) significantly eradicated mature biofilms of staphylococci (p < 0.01). The effect of levofloxacin on eradication of staphylococcal biofilms was more noticeable, compared to the effect of amoxicillin-clavulanic acid (p < 0.01). Suprainhibitory concentrations of both tested antibiotics had no effect on eradication of previously formed M. catarrhalis and P. aeruginosa biofilms (p > 0.05). CONCLUSIONS The amoxicillin-clavulanic acid and levofloxacin are shown to be potent antibiofilm agents in patients with CRSwNP. The effects of tested compounds depend on bacterial species and the volume of formed biofilm.
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Affiliation(s)
- Dragana D Božić
- Department of Microbiology and Immunology, Faculty of Pharmacy, University of Belgrade, Belgrade, 11221, Serbia
| | - Bojan Pavlović
- Clinic of Otorhinolaryngology and Maxillofacial Surgery, Clinical Centre of Serbia, Belgrade, 11000, Serbia.,Faculty of Medicine, University of Belgrade, Belgrade, 11000, Serbia
| | - Jovica Milovanović
- Clinic of Otorhinolaryngology and Maxillofacial Surgery, Clinical Centre of Serbia, Belgrade, 11000, Serbia.,Faculty of Medicine, University of Belgrade, Belgrade, 11000, Serbia
| | - Ana Jotić
- Clinic of Otorhinolaryngology and Maxillofacial Surgery, Clinical Centre of Serbia, Belgrade, 11000, Serbia.,Faculty of Medicine, University of Belgrade, Belgrade, 11000, Serbia
| | - Jelena Čolović
- Faculty of Medicine, Institute of Microbiology and Immunology, University of Belgrade, Belgrade, 11000, Serbia
| | - Ivana Ćirković
- Faculty of Medicine, Institute of Microbiology and Immunology, University of Belgrade, Belgrade, 11000, Serbia.
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Günel C, Bleier BS, Meteoglu I. Antibiotics in eosinophilic chronic rhinosinusitis: Rethinking maximal antimicrobial medical therapy. Laryngoscope 2016; 127:794-796. [PMID: 27888519 DOI: 10.1002/lary.26415] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Revised: 09/19/2016] [Accepted: 10/11/2016] [Indexed: 01/26/2023]
Abstract
OBJECTIVES/HYPOTHESIS Eosinophilic chronic rhinosinusitis (eCRS) has recently been recognized as a CRS subtype characterized by inflammation rather than chronic infection. Consequently, the role of antibiotics as a component of maximal medical therapy for eCRS has been called into question. The purpose of this study was to investigate whether the use of antibiotics, which lack any secondary anti-inflammatory properties, are useful in the treatment of eCRS. STUDY DESIGN Prospective individual cohort study. METHODS Institutional review board-approved, prospective study of 39 patients presenting with chronic rhinosinusitis (CRS). In all patients, Lund-Kennedy endoscopy scores, Lund-Mackay computed tomography scores, and Sino-Nasal Outcome Test-22(SNOT-22) scores were obtained before and after treatment with amoxicillin-clavulanic acid twice a day (625 mg) for 4 weeks. Patients were subsequently stratified into eCRS and non-eCRS groups based on having over 10 eosinophils per high-power field by histopathological examination. The efficacy of antibiotic therapy was compared between groups using the nonparametric Mann-Whitney U test. RESULTS Within the non-eCRS group (n = 14), there was a significant improvement in both the Lund-Mackay score (P = .002) and SNOT-22 score (P < .001) but not the endoscopy score. Among the eCRS patients (n = 25), the Lund-Mackay score was similarly improved (P = .007); however, there was no significant improvement in the endoscopy or SNOT-22 scores. CONCLUSIONS The use of antibiotics without independent anti-inflammatory properties have limited efficacy in patients with eCRS. The concept of maximal medical therapy using antibiotics must continue to evolve in the setting of new evidence for inflammatory subtypes of CRS. LEVEL OF EVIDENCE 2b. Laryngoscope, 127:794-796, 2017.
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Affiliation(s)
- Ceren Günel
- Department of Otolaryngology-Head and Neck Surgery, Faculty of Medicine, Adnan Menderes University, Aydin, Turkey
| | - Benjamin S Bleier
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Ibrahim Meteoglu
- Department of Medical Pathology, Medical Faculty, Adnan Menderes University, Aydin, Turkey
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Stern S, Hadar T, Nachalon Y, Ben-Zvi H, Soudry E, Yaniv E. Bacteriology of the Middle Meatus in Chronic Rhinosinusitis with and without Polyposis. ORL J Otorhinolaryngol Relat Spec 2016; 78:223-31. [PMID: 27427936 DOI: 10.1159/000446188] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 04/12/2016] [Indexed: 11/19/2022]
Abstract
There are only limited data in the literature, and none specifically from the Middle East, on the pathogenic bacteria in chronic rhinosinusitis (CRS) as opposed to healthy nasal cavities and their association with disease severity. The present study was conducted in the department of head and neck surgery of a tertiary medical center. Middle meatal swabs were taken preoperatively from patients with CRS with nasal polyposis (CRSwNP) (n = 60), CRS without nasal polyposis (CRSsNP) (n = 50), and control patients with septal deviation (n = 26) or no nasal abnormalities (n = 27). Culture findings were compared among the groups and correlated with CRS severity. Positive pathogenic culture rates were 78% in the CRSwNP group and 64% in the CRSsNP group. Twenty pathogenic bacterial species were identified; the most common was Staphylococcus aureus (27%). The most common Gram-negative isolate was Citrobacter spp. (17%). Gram-negative species were significantly more prevalent in the CRSwNP group than the others. Mean Lund-Mackay scores were 12.8 in the CRSwNP group and 6.9 in the CRSsNP group, and were unrelated to the culture findings. Positive culture rates were significantly higher in the septal deviation (54%) than the nasal healthy group (26%), although both values were significantly lower than in the CRS groups. In conclusion, patients with CRS have higher rates of bacterial isolates than patients without CRS. CRSwNP is associated with more Gram-negative bacteria than CRSsNP, regardless of disease severity. The relatively high positive culture rate in patients with septal deviation merits investigation.
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Affiliation(s)
- Sagit Stern
- Department of Otorhinolaryngology and Head and Neck Surgery, Rabin Medical Center, Petah Tikva, Israel
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Lam A, Hoang JD, Singleton A, Han X, Bleier BS. Itraconazole and clarithromycin inhibit P-glycoprotein activity in primary human sinonasal epithelial cells. Int Forum Allergy Rhinol 2015; 5:477-80. [PMID: 25907295 DOI: 10.1002/alr.21454] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Revised: 09/28/2014] [Accepted: 10/13/2014] [Indexed: 01/04/2023]
Abstract
BACKGROUND Itraconazole and clarithromycin are clinically effective in the treatment of chronic rhinosinusitis (CRS) through incompletely understood anti-inflammatory properties. P-glycoprotein (P-gp) is overexpressed in CRS and inhibition results in decreased inflammatory cytokine secretion. Both itraconazole and clarithromycin have also been shown to have P-gp inhibitory properties in other tissues, suggesting a novel explanation for their immunomodulatory effects in CRS. The purpose of this study is to therefore confirm whether these drugs are capable of inhibiting P-gp specifically in sinonasal epithelial cells. METHODS This was an institutional review board (IRB)-approved study in which primary sinonasal epithelial cells were cultured in 96-well plates. A Calcein AM assay was used to quantify P-gp inhibition as determined by an increase in intracellular fluorescence. A dose-response curve was generated for itraconazole and clarithromycin (maximal concentration 100 μM) and compared to that of Zosuquidar, a highly specific known P-gp inhibitor. Results were compared using a Student t test with a significance defined as p < 0.05. RESULTS Both itraconazole and clarithromycin demonstrated a dose-response curve for P-gp inhibition similar to that of Zosuquidar. The respective maximal inhibitory concentrations of Zosuquidar, itraconazole, and clarithromycin prior to induction of cytotoxicity were 0.31, 3.13, and 1.56 μM, respectively, as demonstrated by a statistically significant increase in total intracellular fluorescence (p < 0.05 in all groups). CONCLUSION Both itraconazole and clarithromycin are capable of inhibiting sinonasal epithelial cell associated P-gp. The anti-inflammatory effects of these agents in CRS may be attributable, in part, to their heretofore unrecognized P-gp modulatory properties.
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Affiliation(s)
- Allen Lam
- Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA
| | - John D Hoang
- Department of Biomedical Engineering, Boston University, Boston, MA
| | - Amy Singleton
- Department of Biomedical Engineering, Boston University, Boston, MA
| | - Xue Han
- Department of Biomedical Engineering, Boston University, Boston, MA
| | - Benjamin S Bleier
- Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA
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