The role of antibiotics in endoscopic sinus surgery

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.

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.

Antibiotics Affect ROS Production and Fibroblast Migration in an In-vitro Model of Sinonasal Wound Healing

Introduction: Antibiotics are often administered to patients perioperatively and have been shown to affect ROS production of nasal cells in vitro, but their effect in the setting of active wound healing remains unclear. Reactive oxygen species (ROS) are known to play a significant role in wound healing. This study analyzed a broad array of antibiotics used after sinus surgery to assess their effect on wound healing and ROS production in vitro. It was hypothesized that ROS production would be affected by these antibiotics and there would be a negative relationship between ROS activity and cell migration speed. Methods: Monolayers of primary human nasal epithelial cells (HNEC) and primary fibroblasts were disrupted with a linear wound, treated with 10 different antibiotics or a ROS inhibitor and observed over 36 h in a controlled environment using confocal microscopy. ROS activity and migration speed of the wound edge were measured at regular intervals. The relationship between the two parameters was analyzed using mixed linear modeling. Results: Performing a linear scratch over the cell monolayers produced an immediate increase in ROS production of ~35% compared to unscratched controls in both cell types. Incubation with mitoquinone and the oxazolidinone antibiotic linezolid inhibited ROS activity in both fibroblasts and HNEC in association with slowed fibroblast cell migration (p < 0.05). Fibroblast cell migration was also reduced in the presence of clarithromycin and mupirocin (p < 0.05). A significant correlation was seen between ROS suppression and cell migration rate in fibroblasts for mitoquinone and all antibiotics except for azithromycin and doxycycline, where no clear relationship was seen. Treatments that slowed fibroblast cell migration compared to untreated controls showed a significant correlation with ROS suppression (p < 0.05). Conclusion: Increased ROS production in freshly wounded HNEC and fibroblast cell monolayers was suppressed in the presence of antibiotics, in correlation with reduced fibroblast cell migration. In contrast, HNEC cell migration was not significantly affected by any of the antibiotics tested. This differential effect of antibiotics on fibroblast and HNEC migration might have clinical relevance by reducing adhesion formation without affecting epithelial healing in the postoperative setting.

Survey of endoscopic skull base surgery practice patterns among otolaryngologists

Background

Endoscopic skull base surgery (ESBS) is a rapidly expanding field. Despite divergent reported preferences for reconstructive techniques and perioperative management, limited data exist regarding contemporary practice patterns among otolaryngologists performing ESBS. This study aims to elucidate current practice patterns, primarily the volumes of cases performed and secondarily a variety of other perioperative preferences.

Methods

An anonymous 32‐item electronic survey examining perioperative ESBS preferences was distributed to the American Rhinologic Society membership. Statistical significance between variables was determined utilizing Student t, chi‐square, and Fisher exact tests.

Results

Seventy otolaryngologists completed the survey. The effective response rate was approximately 22.5%. Sixty percent of respondents were in full‐time academic practice and 70% had completed rhinology/skull base fellowships. Annually, 43.3 mean ESBS cases were performed (29.1 private practice vs. 52.9 academic practice, P = .009). Academic practice averaged 24.1 expanded cases versus only 11 in private practice (P = .01). Of respondents, 55.7% stood on the same side as the neurosurgeon and 72.9% remained present for the entire case. Current procedural terminology coding and antibiotic regimens were widely divergent; 31.4% never placed lumbar drains preoperatively, while 41.4% did so for anticipated high‐flow cerebrospinal fluid leaks. While considerable variation in reconstructive techniques were noted, intradural defect repairs utilized vascularized flaps 86.3% of the time versus only 51.3% for extradural repairs (P < 0.001). Major complications were rare. Postoperative restrictions varied considerably, with most activity limitations between 2–8 weeks and positive airway pressure use for 2–6 weeks. Most respondents started saline irrigations 0–2 weeks postoperatively.

Conclusions

Based on responses from fellowship‐ and non‐fellowship‐trained otolaryngologists in various practice settings, there remains considerable variation in the perioperative management of patients undergoing ESBS.

Level of Evidence

5

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

BACKGROUND

There is a paucity of data supporting antibiotic use in endoscopic sinus surgery (ESS). The objective of this study is to determine perioperative antibiotic use patterns and factors which influence use in ESS.

METHODS

An online-based survey was distributed to members of the American Rhinologic Society (ARS). Outcomes included timing of perioperative antibiotic use, practice environment, years of experience, and patient factors that influenced antibiotic use.

RESULTS

There were 204 responses (response rate 18.3%); 36.8% of respondents were in academic positions, 32.8% were in private practice, and 30.4% were in academic-affiliated private practice; 20.6% routinely gave preoperative antibiotics, most commonly to reduce bacterial burden (59.5%) and mucosal inflammation (59.5%); 54.4% routinely gave intraoperative antibiotics, most commonly to reduce the risk of postoperative infection (63.1%); 62.3% routinely gave postoperative antibiotics, citing the need to reduce the risk of postoperative infection (75.6%). Diagnosis influenced postoperative antibiotic use in 63.0%. Preoperative antibiotics were more likely to be prescribed by respondents with more than 5 years of experience (odds ratio [OR] 2.97; 95% confidence interval [CI], 1.04 to 8.54; p = 0.043). Compared to private practitioners, academicians were more likely to give intraoperative antibiotics (OR 2.68; 95% CI, 1.39 to 5.17; p = 0.003), but not preoperative or postoperative antibiotics. Use of nonabsorbable packing was significantly associated with use of postoperative antibiotics (OR 2.01; 95% CI, 1.07 to 3.77; p = 0.031).

CONCLUSION

This study demonstrates the significant variation in perioperative antibiotic use among otolaryngologists. These results provide support for the establishment of evidence-based practice guidelines for perioperative antibiotic use in ESS.

Avoiding Complications in Endoscopic Sinus Surgery

Complications of endoscopic sinus surgery (ESS) can range from the mundane to the catastrophic, with nasal hemorrhage being the most common. Intraorbital and intracranial complications are much less common. Despite the rarity of complications, they are often avoidable. Certain identifiable risk factors can be appreciated during the preoperative, intraoperative, and postoperative evaluations of the sinus patient. With awareness of these risk factors the rhinologist can develop a strategic plan of risk factor mitigation. This article identifies areas of increased risk that are amenable to preventive strategies before complications become realized.