xRead - Nasal Obstruction (September 2024) Full Articles

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receiving IV antibiotics as an alternative to surgery. 1125 Indications for IV therapy included 1) pathogen resistance to effective oral antimicrobial agents, 2) patient intoler ance or allergy to effective oral antimicrobial agents, and 3) extranasal complications of CRS (eg, orbital cellulitis, frontal osteomyelitis). The duration of outpatient therapy was 4 weeks delivered via peripherally inserted central catheter. Clinical endpoints examined response to therapy; of the 14 patients treated, 79% were noted to show a par tial or complete response. Adverse events were reported in 5 patients (35%), including 3 catheter-related events (2 patients with thrombophlebitis and 1 patient with deep vein thrombosis) and 2 allergic drug reactions. Fowler et al. reported a retrospective case series of 31 CRS patients who failed 3 courses of oral antibiotics and were subsequently treated with 4-8 weeks of culture directed IV antibiotics. 1126 Only 29% of patients were noted to have resolution of disease on CT scan or nasal endoscopy following treatment. Of these responders, 89% relapsed at an average of 11.5 weeks after cessation of therapy. Com plications occurred in 10 patients (32%) including throm bophlebitis, peripheral venous thrombosis, catheter infec tion, red man syndrome, diarrhea, and neutropenia. Anand et al. reported a prospective case series of 52 non-surgical patients, all with evidence of osteitis of the paranasal sinuses on CT scan. 1127 However, 45 of these patients were enrolled based on subjective symp tomatology alone without report of endoscopic findings nor mucosal thickening on imaging. All patients were treated with culture-directed antibiotics for a period of 6 weeks; a wide variety of antibiotics were utilized. Clin ical endpoints included patient-reported symptom scores and RSDI scores; there was significant improvement in patient-reported symptom scores noted at 3 weeks after completion of therapy. RSDI was only recorded from a sub set of 7 patients, and thus, despite a trend toward improve ment, significance could not be calculated. Minor com plications were reported in 7 patients (13%) and included rash, elevations in liver enzymes, neutropenia, septicemia, and bleeding at the peripherally inserted central catheter (PICC) insertion site. Tabaee et al. performed a retrospective analysis of CRS patients with endoscopic cultures positive for MRSA who then underwent 6-8 weeks of IV antibiotics. 1128 Of the 6 patients that the authors treated, 5 had improve ment in SNOT-20 scores with pretreatment median of 62 dropping to a post-treatment median of 43. Inter estingly, the 1 patient whose SNOT-20 scores did not improve had negative cultures post-treatment. Five of 6 patients were culture negative at follow-up (median follow-up 1.3 years). Adverse reactions were recorded in 4 of 6 patients (67%) and included allergic reactions and neutropenia.

Based on these studies, macrolides demonstrate benefits in selected CRS patients. Currently, there are no defini tive biomarkers or prognostic factors for macrolide treat ment selection in CRS. However, Seresirikachorn et al. 1121 found benefits of macrolides in treating patients with the CRSsNP phenotype, as opposed to CRSwNP. Oakley et al. 1123 reported that patients with low tissue and serum eosinophilia may reflect an endotype suitable for a trial of macrolide therapy. Macrolide Antibiotics for CRSsNP Aggregate Grade of Evidence: B (Level 1: 5 studies; level 2: 7 studies; level 3: 1 study; Table IX-31). Benefit: Some studies show reduction in endoscopy and symptom scores, others show no benefit. Harm: Gastrointestinal side effects, ototoxicity, hepatotoxicity, cardiotoxicity, and drug-drug inter actions; potential microbial resistance (see Table II-1). Cost: Low. Benefits-Harm Assessment: Mixed results about benefits and potential for harm make a balance unclear. Value Judgments: Optimal drug, dosage, and treatment duration are not known. Policy Level: Option. Intervention: Macrolides are an option for patients with CRSsNP, especially for pateints at low risk of harm. There have been no new publications in this area since ICAR-RS-2016. The evidence for IV antibiotics in the treat ment of CRS is limited, with no differentiation of CRSsNP vs CRSwNP in the literature. In the literature, the use of IV antibiotics has been suggested in: 1) patients who are not surgical candidates, 2) cases in which oral antibiotic ther apy has failed, 3) pediatric patients, 4) cases in which the infection being treated has no oral equivalent, 5) cases in which serious extra-nasal complications are present, and 6) as an adjuvant or alternative to surgery. Only 1 review of the literature from 2004 was identified; Tanner et al. reviewed 4 case series of which 3 were retrospective and 1 prospective. 1124 Gross et al. reported outcomes of 13 patients receiving culture-directed IV antibiotics following ESS and 1 patient IX.D.4.d. Antibiotics for CRS: Intravenous Antibiotics Because of limited data, CRSsNP and CRSwNP are com bined in this analysis and recommendations.