xRead - Nasal Obstruction (September 2024) Full Articles

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International consensus statement on rhinosinusitis

the combination of clarithromycin and budesonide spray with budesonide spray alone for treatment of CRS patients, Deng et al. 1114 found that the improvement in SNOT-22, visual analog scale, CT and endoscopic scores that was seen did not significantly differ between the 2 groups. However, Amali et al. 1115 found that azithromycin with nasal steroid showed significant improvement in SNOT 22 scores compared with nasal steroid alone in post-ESS CRS patients. Haxel et al. 1116 published an RCT in 2015 examining outcomes after three-month treatment with erythromycin in both CRS phenotypes following sinus surgery, demonstrating greater improvements in nasal endoscopy scores in CRSsNP patients when treated with erythromycin than in CRSwNP patients. Several systematic reviews and meta-analyses have been conducted to assess the effect of macrolides in CRS. For instance, Pynnonen et al. 1117 systematically reviewed patient QoL outcomes after long-term macrolide therapy and, based on limited evidence from only 3 prospective clinical studies, did not recommend use in CRS patients. In a meta-analysis by Huang et al. 1118 in 2019, authors concluded that adding oral clarithromycin to intranasal steroid spray likely achieves better results than using intranasal steroid spray alone; however, evidence was insufficient to conclude that oral clarithromycin alone has similar efficacy as nasal spray alone. In 2 reviews evaluat ing the effect of macrolides in CRSsNP or CRSwNP, both ultimately concluded it is a treatment option, with one specifying it should only be used in select patients. 1119,1120 On a similar note, in 2019 Seresirikachorn et al. 1121 assessed prognostic factors that predicted favorable outcomes of low dose macrolides in treating CRS and found benefits in patients with CRSsNP as opposed to CRSwNP. Gastrointestinal complaints are the most common side effects noted from use of macrolides in the CRS literature. 1111,1113,1114 Hepatotoxicity and ototoxicity may also occur. 1113 In addition, care should be taken when administering macrolides to patients with cardiac comorbidities. 1120 Concerns have also been raised about the development of antibiotic resistance with use of macrolides, particularly for long durations and at low doses. 1122 Videler et al. 1111 reported that 1 bacterial culture demonstrated resistance to macrolides after previous azithromycin treatment. In the Jiang et al. study, bacterial culture rate increased and growth of gram-negative aerobic bacteria was heavier in patients who took erythromycin than in patients who took Chinese herbal medicine. 1112 Finally, macrolides are metabolized in the liver and have known interactions with drug metabolism via the CYP450 system. 1120 Briefly, there are a total of 3 RCTs investigating macrolides for CRSsNP. 1072,1110,1112 Others on this topic were cohort or observational studies without controls.

TABLE IX-30 Evidence for CRSsNP management with oral non-macrolide antibiotics for > 3weeks Study Year LOE Study Design Study Groups Clinical Endpoint Conclusions Dubin 1108 2007 5 Prospective case series Oral antibiotics Lund-Mackay score Improvement in LM scores at 3 weeks and 6 weeks