xRead - Nasal Obstruction (September 2024) Full Articles

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Orlandi et al.

X.D.5.b. Antibiotics for CRSwNP: Oral Non-Macrolide Antibiotics for ≥ 3Weeks There is little in the published literature regarding longer courses ( > 3 weeks) of oral non-macrolide antibiotic for treatment of CRSwNP. As discussed in the preceding sec tion, there is only 1 study specifically addressing the dura tion of antibiotic therapy in this cohort. Sreenath et al. prospectively treated CRSwNP patients with a variable duration of antibiotics to determine any difference in the primary outcome of recommendation for surgery. 1622 The authors found that at follow-up providers recommended surgery independent of whether patients had completed a 3-week or a 6-week course of doxycycline. They found that patients had no difference in Lund-Mackay CT score nor significant change in symptoms as measured by RSDI. The authors actually noted a trend toward worsening symp toms in patients on the longer prescription. They con cluded that duration of antibiosis did not affect outcomes and that antibiotics were potentially not indicated in treat ing CRSwNP. In contrast, Bezerra et al. reported a prospective cohort trial of CRSwNP patients who had failed surgery and were treated with either 1) INCS or 2) INCS plus doxycycline. 1625,1626 The authors treated patients for 12 weeks and evaluated a primary endpoint of SNOT-20 scores. They found a statistically significant improvement in SNOT-20 scores, NOSE scores, and Lund-Kennedy scores for those treated with INCS and doxycycline. The authors noted a benefit, but a decrease in significance, in patients with high levels of serum IgE or the comorbidities of asthma or AERD. In a proof-of-concept case-series regarding a novel antibiotic for patients with CRSwNP, Hoza et al. examined the efficacy of erdosteine, a mucolytic agent with antibac terial, antioxidant, and anti-inflammatory effects. 1627 Oral erdosteine was prescribed alone or in combination with an INCS over the course of 3 months. Significant reduction of symptoms based on SNOT-22 testing was seen in both groups, with significantly better response seen in the group treated without INCS. It is unclear whether the antimicro bial, mucolytic, or some other property of erdosteine was responsible for the improvement seen in this study. There are only a few studies examining whether greater than 3 weeks of oral non-macrolide antibiotics are indi cated in treatment of CRSwNP. The studies available examine several different medications (eg, doxycycline, erdosteine) and have inconsistent results. On the other hand, the side effects of antibiotics are well known and carry significant risks. Moreover, the authors of these stud ies are not clear on whether it is the antibiotic or anti inflammatory effect of these medications that is helpful in certain patients. Therefore, at this time there is insuf

TABLE X-22 Evidence for CRSwNP management with non-macrolide oral antibiotics for < 3weeks Study Year LOE Study Design Study Groups Clinical Endpoint Conclusions VanZele 1619 2010 2 RCT Doxycycline Methylprednisolone Placebo Polyp size Symptoms Inflammatory markers Reduction in polyp size at week 12. No sustained symptom changes. Parasher 1624 2019 3 RCT Doxycycline + steroid Placebo + steroid SNOT-22 VAS Nasal polyp scale Early end to trial due to high drop out rate; no difference between arms. Sreenath 1622 2015 3 Prospective, randomized cohort 3 weeks of antibiotics 6 weeks of antibiotics Recommendation for surgery RSDI score LMCTscore No difference in recommendation for surgery.