xRead - Nasal Obstruction (September 2024) Full Articles

20426984, 2021, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/alr.22741 by Stanford University, Wiley Online Library on [01/07/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License

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Orlandi et al.

There is some limited literature regarding use of IV antibiotics in the pediatric CRS population. Don et al. pub lished a retrospective case series of 70 pediatric patients who had failed a 3-4 week course of oral antibiotics. 1129 All patients had post-treatment CT scans with disease, under went operative nasal endoscopy with maxillary aspira tion/irrigation, and then had culture-directed, outpatient IV antibiotics for at least 1 week. Adenoidectomies were performed at the surgeon’s discretion. The primary end point was symptomatic improvement. The mean duration of therapy was 17 days (range 7-42 days). Immediately fol lowing IV antibiotics, the authors report that 62 patients (89%) were improved. After 6 months, there was data on 52 patients, of whom 44 (88%) were improved. However, the majority of patients (67%) were also placed on oral antibiotics after their IV courses (range 4-16 weeks). Ten patients (14%) developed complications, mostly related to the catheter. This protocol was repeated by Adappa et al. with the addition of concurrent adenoidectomy for all patients. 1130 Immediately following cessation of culture-directed antibiotics (mean 5 weeks, range 1-10 weeks) all 22 pedi atric patients were symptomatically improved (100%). After 12 months, 17 of 22 patients were symptom free (77%). Two patients (9%) had line-related complications. Criddle et al. reviewed the charts of pediatric CRS patients who had failed a 3-week course of oral antibiotics. 1131 Twenty-three patients underwent adenoidectomy and maxillary irrigations and afterward were placed on culture-directed, oral double-therapy antibiotics. Four patients did not improve after 4 weeks of oral treatment and were placed on 3-4 weeks of outpatient IV antibiotics. All 4 patients achieved short-term resolution of symptoms but 3 had recurrent symptoms in follow-up that responded to oral antibiotics. All 4 patients were later tested and found to have various immune deficiencies. One of the 4 had diarrhea requiring hospitalization and change in antibiotic (25%). The high rates of complications associated with use of IV antibiotics noted above was also reported in a subse quent larger patient series. In a 2005 chart review, Lin et al. examined 177 patients who underwent IV antibiotic therapy for CRS. 1132 The majority receiving some combina tion of ceftriaxone, clindamycin, and/or vancomycin. The overall complication rate was reported at 18%, with 16% antibiotic-related adverse events (eg, neutropenia, elevated LFTs, and rash) and 2% catheter-related adverse events (eg, thrombosis). The current literature regarding the treatment of CRS with parenteral antibiotics is sparse. One challenge is that IV antibiotics are frequently used as a “last resort” and therefore standardization and guidelines of appropriate use are not well established. The published studies are

case series, often with subjective endpoints, resulting in data that are difficult to evaluate and compare. In addi tion, there is a substantial rate of adverse events noted with both PICC placement and antibiotics (9-67% in the reviewed studies). Further, practitioners may need to take into account the patient’s time and cost burden of PICC placement, antibiotics, and home health care. A large review by Mitchell et al. found conflicting evidence on the cost-efficacy of long-term IV antibiotics. 1133 For these rea sons, we recommend against the use of IV antibiotics for standard therapy in CRS. However, for a subset of patients with CRS complications, extranasal manifestations of CRS, or lack of response to standard oral therapy the benefits of treatment may outweigh the cost and risk of possible adverse events. Intravenous Antibiotics for CRSsNP Aggregate Grade of Evidence: C (Level 4: 7 studies; Table IX-32). Benefit: Potential improvement in patient reported symptoms in case-series studies. Harm: Thrombophlebitis, neutropenia, sepsis, deep vein thrombosis, elevated liver enzymes, allergic events, rash, bleeding, gastrointestinal dis turbance (see Table II-1). Cost: High. Benefits-Harm Assessment: Preponderance of harm over benefits. Value Judgments: Lack of evidence, risk of adverse events, and cost of treatment outweigh the possi ble benefit for routine use in CRS. Policy Level: Recommendation against. Intervention: Intravenous antibiotics should not be used for routine cases of CRS. For extenuat ing circumstances such as nonoperative patients, those who have failed oral/topical therapy, or those with extranasal manifestations of CRS the benefits of treatment may outweigh the risks. IX.D.4.e. Antibiotics for CRS: Topical Antibiotics Because of limited data, CRSsNP and CRSwNP are com bined in this analysis and recommendations. The goal of topical antibiotic therapy in CRS is to deliver a high concentration of antibiotics directly to the diseased sinonasal mucosa, thereby increasing efficacy and decreas ing systemic absorption and associated side effects com pared to oral antibiotics. Disadvantages to topical antibi otic therapy include user-dependent variations in deliv ery technique, local adverse effects, and limited long-term