Pseudomonas rhinosinusitis

Outcomes in Treatment of Rhinosinusitis in the Setting of Medication Induced Immunosuppression

Background

There is no data currently available to direct nuanced treatment for recurrent acute and chronic rhinosinusitis (RARS, CRS) in patients on daily, long term medications that suppress the immune system.

Objective

This study sought to evaluate the outcomes of different treatment pathways when treating immunosuppressed patients with chronic rhinosinusitis or recurrent acute rhinosinusitis.

Methods

A retrospective review of patients on immune suppressing medication presenting to a tertiary care center with RARS or CRS between the years 2014–2019 was completed. Patients were categorized into three groups based on treatment: medical management alone (MM), surgery after medical management (SAMM), or upfront surgery (US). Lund-Kennedy scores (LKS) and SNOT-22 scores were evaluated at baseline, 1 month, 3 months and 6 months from presentation.

Results

68 patients met inclusion criteria, with no difference in demographics between groups. Patients who were treated with US and SAMM had significantly higher baseline LKS than those who were treated with MM alone (p = 0.050, p = 0.039). Once this difference was controlled for, there was no significant difference in overall change of LKS between the three groups over time. There was no significant disparity in baseline SNOT-22 scores between the three groups, but patients who underwent US had a significantly higher improvement in SNOT-22 from baseline compared to those undergoing MM alone (p = 0.013).

Conclusion

Patients experiencing chronic rhinosinusitis and recurrent acute rhinosinusitis who are taking immunosuppressive medication can significantly improve from both medical and surgical management, but upfront surgical management appears to result in greater disease resolution relative to medical management in those with CRS. More study is needed in the RARS patient population regarding upfront surgery versus medical management.

Gram Negative Sinusitis: An Emerging Clinical Entity?

Traditionally sinusitis has been classified as acute or chronic based on the duration of patient symptoms, and treatment has been based on empiric principles, as the bacteriologic spectrum is felt to be understood, and culturing of nasal secretions has been frowned upon in the past. In this investigation, endoscopically guided cultures were obtained and analyzed from patients, with chronic sinusitis referred to a rhinologic surgeon for evaluation. Often sinusitis was “recalcitrant” to Standard medical and/or surgical therapy. Ninety-eight cultures were obtained from 47 patients with chronic sinusitis who had pathologic sinus secretions noted during the study period. Gram negative enteric bacteria were noted in 47/134 (34.1%) total isolates, a particularly high frequency. Organisms isolated included Pseudomonas aeruginosa, Klebsiella pneumonia, Proteus mirabilis, and Enterobacter aerogenes. The results are significant as gram negative bacteria have been previously reported only infrequently as a cause of sinusitis. Data from this study suggest that endoscopically guided cultures may be helpful in directing medical therapy, especially in longstanding cases of chronic sinusitis that has been “recalcitrant” to traditional medical and surgical therapy. In these patients a shift in the bacterial spectrum to include gram negative organisms, not typically associated with sinusitis, may occur. Empiric selection of standard antimicrobial therapy for chronic sinusitis may not address these bacteria. Classifying sinus disease solely on symptom duration is an oversimplification, and the bacterial spectrum of sinusitis may not be as limited as previous studies suggest. Possible pathophysiologic mechanisms for the shift in the bacterial spectrum and poor response to treatment are discussed.

Practice patterns regarding noninvasive rhinosinusitis in the immunosuppressed patient population

The number of immunosuppressed patients is growing remarkably. Currently, there is no guideline on how treatment of noninvasive sinusitis in these patients may differ from that of the general population, and practice patterns vary widely across the country. The purpose of this survey was to examine practice patterns and management for this patient population. A survey and literature review were performed. The survey was sent to the membership list serve of the American Rhinologic Society. Twelve questions were asked. Four demographic questions were asked about the physicians and their practices. Four questions were asked about the type of immunocompromised patients they saw. Two questions were asked about management in the setting of significant acute and chronic sinusitis. The responses were collected and analyzed using Pearson independent chi-square testing. Of 871 members on the list serve only 89 physicians responded. The majority of responders were sinus and skull base surgeons practicing in an academic setting. There was a large range of geographic location, years in practice, and patient population. Two significant findings related years in practice to management of chronic sinus immunocompromised patients (p = 0.012) and correlated the choice of management option in acute and chronic sinus immunocompromised patients (p = 0.006). There is no standardized method of treating the vulnerable patient population of immunocompromised patients with noninvasive acute and chronic sinusitis and this survey shows the wide range of practice. Clinical research is needed to standardize and optimize treatment for these patients.

Endoscopically guided cultures in chronic sinusitis

In chronic sinusitis, culture-directed antibiotics are often recommended as a cornerstone of treatment. The significance of Gram-negative rods (GNRs), coagulase-negative Staphylococci (SCN), and Staphylococcus aureus has been controversial. In an effort to determine host factors which correlate with culture results, 507 endoscopically-guided cultures are reviewed from 265 patients. A history of asthma, allergic rhinitis, prior sinus surgery, and the concurrent use of antibiotics, steroids, and irrigations were some of the host factors compared by X2. The results were compared to a control group of 50 cultures from healthy volunteers. SCN, S. aureus, P. aeruginosa, and Streptococcus were the most common isolates. GNRs were present in 27% of cultures and were more common in patients who had prior sinus surgery or were using irrigations. P. aeruginosa was more common in patients taking systemic steroids. SCN occurred with the same incidence in patients and control subjects but was more prevalent in cultures obtained intraoperatively and in patients taking systemic steroids. No identifiable host factor was associated with S. aureus. S. aureus occurred at similar rates in patients and control subjects but grew heavily in patients and exhibited only light growth in controls. Topical nasal steroids appear to have no statistically significant effect on bacterial cultures. Findings from this study further our understanding of chronic sinusitis and may help guide practitioners in the treatment of this disease.

Mucociliary clearance abnormalities in the HIV-infected patient: a precursor to acute sinusitis

An increasing number of patients with human immunodeficiency virus (HIV) suffer from acute infectious sinusitis, and many suffer recurrent episodes at a higher rate than their non-HIV counterparts. This study investigates a mechanism underlying the increased incidence of sinusitis, that of prolonged mucociliary transport time (MTT). Nasal mucociliary clearance was examined in 30 HIV-infected patients and 30 matched, non-HIV controls using a nasal saccharin transport test. MTTs for the study group and the controls were 11.9 +/- 5.9 minutes and 7.4 +/- 3.7 minutes, respectively. This difference attained statistical significance (P < .05). Study group patients with a history of sinusitis had a mean MTT of 13.7 +/- 6.8 minutes. Those with complaints of "new onset" nasal obstruction since HIV conversion had a mean MTT of 13.5 +/- 6.8 minutes. Statistical significance (P < .05) was found comparing these times to controls, as well as to study patients without these symptoms. These data support an inherent delay of mucociliary clearance in HIV-infected patients which is chronic, possibly irreversible, and, in association with nasal obstruction, represents a major mechanism of both the high acute and recurrent sinusitis rate in this population. The cause of the mucociliary delay is still unclear and needs to be further investigated.

Serious Infections Caused by Pseudomonas Aeruginosa

Over the last 3 decades, Pseudomonas aeruginosa has become a leading cause of infectious morbidity and mortality in certain predisposed patient populations. It primarily affects those with impaired host defenses, and its prevalence in the hospital environment makes it an important nosocomial pathogen. Infection with this organism may result in a broad spectrum of clinical manifestations, many of which may be seen in the intensive care setting. This review focuses on epidemiology, clinical presentations, nad treatment of serious Pseudomonas infections.

Evolving epidemiology of Pseudomonas aeruginosa infections

The dramatic increase in infections caused by Pseudomonas aeruginosa over the last three decades is examined in this review. By virtue of its unique growth characteristics, this organism occupies a firm niche in the hospital environment where it continues to be a major nosocomial pathogen, with particularly high rates of infection in traditionally susceptible patient subpopulations: the compromised host, patients with malignancy, cystic fibrosis, burn wounds and trauma. In recent years infection with Pseudomonas aeruginosa has become more prominent in other patient subpopulations: for example, post-surgical, pediatric and dialysis patients, as well as the elderly. A more interesting evolution in the epidemiology of infections caused by Pseudomonas aeruginosa is the appearance, often anecdotal, of new manifestations in healthy, non-hospitalized hosts e.g. the water-associated syndromes, puncture wounds, drug addiction. The need for better data on the prevalence of these infections, the required host-organism interactions and their practical impact sets an agenda for future investigation.