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

413

Orlandi et al.

data. Studies on topical antibiotic delivery do not distin guish between those with CRSwNP and CRSsNP. Addi tionally, the majority of studies focus on the subpopula tion of recalcitrant CRS patients after ESS. However, post ESS patients seem to be an appropriate target for topical therapy as studies have shown that very little irrigation penetrates native paranasal sinuses and that ESS greatly improves penetration, especially into the frontal and sphe noid sinuses. 1076,1134,1135 Carlton et al. published a review of this topic in 2019 which includes the majority of updates since the first iteration of these guidelines. 1136 SevenRCTs and 9 systematic reviews have examined topical antibiotics inCRS. Videler et al. performed a randomized, placebo controlled, double-blind, cross-over pilot study in 14 people with refractory CRS post ESS having persistent Staphylococcus aureus after 2 treatments of oral antibiotics and nasal saline irrigations. 1137 Patients were randomized into groups of high-dose nebulized bacitracin-colimycin (8 weeks) and oral levofloxacin (2 weeks) or nebulized saline (control) and oral levofloxacin (2 weeks). Although nebulization improved CRS symptoms, it did not show benefit of bacitracin/colimycin over the nebulized saline. Authors acknowledge that this study was underpowered and may have been confounded by levofloxacin. Sykes et al. investigated the additive effective of neomycin with a nasal spray of trazoline and dexam ethasone compared to saline placebo. 1074 They studied 50 patients with symptoms of chronic purulent nasal drainage although there was no mention of prior surgical therapy. Comprehensive outcome measures were used including nasal MCC, imaging, rhinomanometry, bacterial cultures, and endoscopy. Both therapy groups showed improvement in objective measures of disease and no added benefit was seen with topical neomycin. Desrosiers et al. looked at 20 patients with a history of post-ESS recalcitrant CRS who were randomized to nebu lized tobramycin with saline compared to saline placebo alone for a total of 4 weeks. 1138 Tobramycin was found to improve pain more quickly than saline, but led to the side effect of nasal congestion. Both groups showed similar improvement in symptoms and QoL, and overall, tobramycin did not offer any significant benefit over saline. Headet al. 1105 performed a Cochrane systematic review of topical antibiotics for CRS and did not find any RCTs that met inclusion criteria, which were studies compar ing topical antibiotic treatment to (a) placebo or (b) no treatment or (c) other pharmacological interventions with at least 3 month follow-up, indicating that the available evidence could be stronger. Eight systematic reviews have nonetheless summarized the available evidence on topi cal antibiotics in CRS. The most comprehensive systematic review 1139 inclusive of 4 systematic reviews 1119,1140,1141,1142

concluded that topical antibiotics were not recommended due to lack of clear benefit, but made special mention that there may be a role for topical mupirocin in recal citrant cases of Staphylococcus aureus . Kim and Kwon 1143 performed systematic review of this subgroup of patients with recalcitrant staphylcoccal CRS treated with topical mupirocin. Evidence of 2 RCTs, 2 prospective studies, and 2 retrospective reviews indicate a short-term effect on reducing staphylococcal infection, however high level studies are needed to evaluate the durability of eradication and assessment of long-term risk. Jervis-Bardy et al. 1144 report low rate of mupirocin resistance, and Carr et al. 1145 reported changes to the sinonasal flora after mupirocin treatment with an increase in gram-negative species and more Corynebacterium species . The clinical implications of this shift in the microbiota are unknown. Existing high-level evidence of topical antibiotics in CRS fails to consistently demonstrate benefits and routine use cannot be recommended. Some lower-level studies have reported effectiveness, particularly in recalcitrant cases of CRS after ESS or in CF patients, 1146–1154 suggesting there may be a role in unusual cases, but higher level studies in these subgroups are needed. New ciprofloxacin-eluding stents have shown potential in-vitro and in a rabbit model, however they have not been studied in humans. 925 Topical Antibiotics for CRSsNP Aggregate Grade of Evidence: A (Level 1: 7 studies; level 2: 7 studies; level 3: 2 studies, level 4: 3 studies; Table IX-33). Benefit: Systematic reviews and RCTs failed to show benefit from the use of topical antibiotics in CRS. Harm: Nasal congestion, irritation, epistaxis. The oretical possibility of systemic absorption with topical aminoglycosides. Possibility of developing bacterial resistance. Cost: Moderate to high (USD$2.64 to USD$7.64) per dose, need for compounding pharmacy depending on antibiotic and formulation. Benefits-Harm Assessment: Relative harm over benefit. Value Judgments: Topical therapy may be a prefer able alternative to IV therapy for infections caused by organisms resistant to oral antibiotics. Policy Level: Recommendation against. Intervention: Topical antibiotics are not recom mended for routine CRS. They may be beneficial in unusual circumstances.