Systemic and topical antibiotics for chronic rhinosinusitis

83 Pages·2016·0.97 MB·English

CochraneDatabaseofSystematicReviews
Systemic and topical antibiotics for chronic rhinosinusitis
(Review)
HeadK,ChongLY,PiromchaiP,HopkinsC,PhilpottC,SchilderAGM,BurtonMJ
HeadK,ChongLY,PiromchaiP,HopkinsC,PhilpottC,SchilderAGM,BurtonMJ.
Systemicandtopicalantibioticsforchronicrhinosinusitis.
CochraneDatabaseofSystematicReviews2016,Issue4.Art.No.:CD011994.
DOI:10.1002/14651858.CD011994.pub2.
www.cochranelibrary.com
Systemicandtopicalantibioticsforchronicrhinosinusitis(Review)
Copyright©2016TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
PLAINLANGUAGESUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
SUMMARYOFFINDINGSFORTHEMAINCOMPARISON . . . . . . . . . . . . . . . . . . . 5
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Figure1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Figure2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Figure3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
ADDITIONALSUMMARYOFFINDINGS . . . . . . . . . . . . . . . . . . . . . . . . . . 26
DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
AUTHORS’CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
CHARACTERISTICSOFSTUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
DATAANDANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Analysis1.1.Comparison1Systemicantibioticsversusplacebo,Outcome1Disease-specifichealth-relatedqualityoflife. 63
Analysis1.2.Comparison1Systemicantibioticsversusplacebo,Outcome2Gastrointestinaldisturbances. . . . . 64
Analysis1.3.Comparison1Systemicantibioticsversusplacebo,Outcome3Suspectedallergicreaction(rashorskin
irritation). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
Analysis1.4.Comparison1Systemicantibioticsversusplacebo,Outcome4Endoscopicscore. . . . . . . . . 65
Analysis2.1.Comparison2Systemicantibiotics+saline+intranasalcorticosteroidsversusplacebo+saline+intranasal
corticosteroids,Outcome1Diseaseseverityscore(at3months-endoftreatment). . . . . . . . . . . 65
Analysis2.2.Comparison2Systemicantibiotics+saline+intranasalcorticosteroidsversusplacebo+saline+intranasal
corticosteroids,Outcome2Gastrointestinaldisturbances. . . . . . . . . . . . . . . . . . . . 66
Analysis3.1.Comparison3Systemicantibioticsversusintranasalcorticosteroids,Outcome1Diseaseseverityscore(at3
months-endoftreatment). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
Analysis3.2.Comparison3Systemicantibioticsversusintranasalcorticosteroids,Outcome2Individualsymptomscores
(at3months-endoftreatment). . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Analysis3.3.Comparison3Systemicantibioticsversusintranasalcorticosteroids,Outcome3Endoscopicscore. . . 68
Analysis4.1.Comparison4Systemicantibioticsversusoralsteroids,Outcome1Gastrointestinaldisturbances. . . 69
Analysis4.2.Comparison4Systemicantibioticsversusoralsteroids,Outcome2Suspectedallergicreaction(rashorskin
irritation). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Analysis4.3.Comparison4Systemicantibioticsversusoralsteroids,Outcome3Adverseeventsrelatedtooralsteroiduse:
insomnia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
CONTRIBUTIONSOFAUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
DECLARATIONSOFINTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
SOURCESOFSUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
DIFFERENCESBETWEENPROTOCOLANDREVIEW . . . . . . . . . . . . . . . . . . . . . 80
INDEXTERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Systemicandtopicalantibioticsforchronicrhinosinusitis(Review) i
Copyright©2016TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
[InterventionReview]
Systemic and topical antibiotics for chronic rhinosinusitis
KarenHead1,LeeYeeChong1,PatornPiromchai2,ClaireHopkins3,CarlPhilpott4,AnneGMSchilder5,MartinJBurton1
1UKCochraneCentre,Oxford,UK.2DepartmentofOtorhinolaryngology,FacultyofMedicine,KhonKaenUniversity,KhonKaen,
Thailand.3ENTDepartment,Guy’sHospital,London,UK.4DepartmentofMedicine,NorwichMedicalSchool,UniversityofEast
Anglia,Norwich,UK.5evidENT,EarInstitute,FacultyofBrainSciences,UniversityCollegeLondon,London,UK
Contact address: Karen Head, UK Cochrane Centre, Summertown Pavilion, 18 - 24 Middle Way, Oxford, UK.
[email protected].
Editorialgroup:CochraneENTGroup.
Publicationstatusanddate:New,publishedinIssue4,2016.
Reviewcontentassessedasup-to-date: 29September2015.
Citation: Head K, Chong LY, Piromchai P, Hopkins C, Philpott C, Schilder AGM, Burton MJ. Systemic and topical
antibiotics for chronic rhinosinusitis. Cochrane Database of Systematic Reviews 2016, Issue 4. Art. No.: CD011994. DOI:
10.1002/14651858.CD011994.pub2.
Copyright©2016TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
ABSTRACT
Background
Thisreviewisoneofsixlookingattheprimarymedicalmanagementoptionsforpatientswithchronicrhinosinusitis.
Chronicrhinosinusitisiscommonandischaracterisedbyinflammationoftheliningofthenoseandparanasalsinusesleadingtonasal
blockage,nasaldischarge,facialpressure/painandlossofsenseofsmell.Theconditioncanoccurwithorwithoutnasalpolyps.Systemic
andtopicalantibioticsareusedwiththeaimofeliminatinginfectionintheshortterm(andsometoreduceinflammationinthelong
term),inordertonormalisenasalmucusandimprovesymptoms.
Objectives
Toassesstheeffectsofsystemicandtopicalantibioticsinpeoplewithchronicrhinosinusitis.
Searchmethods
The Cochrane ENT Information Specialist searchedthe Cochrane ENT Trials Register; CENTRAL (2015, Issue 8); MEDLINE;
EMBASE; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 29
September2015.
Selectioncriteria
Randomisedcontrolledtrials(RCTs)withafollow-upperiodofatleastthreemonthscomparingsystemicortopicalantibiotictreatment
to(a)placeboor(b)notreatmentor(c)otherpharmacologicalinterventions.
Datacollectionandanalysis
WeusedthestandardmethodologicalproceduresexpectedbyCochrane.Ourprimaryoutcomesweredisease-specifichealth-related
qualityoflife(HRQL),patient-reporteddiseaseseverityandthecommonestadverseevent-gastrointestinaldisturbance.Secondary
outcomesincludedgeneralHRQL,endoscopicnasalpolypscore,computerisedtomography(CT)scanscoreandtheadverseevents
ofsuspectedallergicreaction(rashorskinirritation)andanaphylaxisorotherveryseriousreactions.WeusedGRADEtoassessthe
qualityoftheevidenceforeachoutcome;thisisindicatedinitalics.
Systemicandtopicalantibioticsforchronicrhinosinusitis(Review) 1
Copyright©2016TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
Mainresults
WeincludedfiveRCTs(293participants),allofwhichcomparedsystemicantibioticswithplacebooranotherpharmacologicalinter-
vention.
The varying study characteristics made comparison difficult. Four studies recruitedonly adults and one only children. Threeused
macrolide,onetetracyclineandoneacephalosporin-typeantibiotic.Threerecruitedonlypatientswithchronicrhinosinusitiswithout
nasalpolyps,onerecruitedpatientswithchronicrhinosinusitiswithnasalpolypsandonehadamixedpopulation.Threefollowedup
patientsfor10to12weeksaftertreatmenthadfinished.
Systemicantibioticsversusplacebo
Threestudiescomparedantibioticswithplacebo(176participants).
Onestudy(64participants,withoutpolyps)reporteddisease-specificHRQLusingtheSNOT-20(0to5,0=bestqualityoflife).At
theendoftreatment(threemonths)theSNOT-20scorewaslowerinthegroupreceivingmacrolideantibioticsthantheplacebogroup
(meandifference(MD)-0.54points,95%confidenceinterval(CI)-0.98to-0.10),correspondingtoamoderateeffectsizefavouring
antibiotics(moderatequalityevidence).Threemonthsaftertreatment,itisuncertainiftherewasadifferencebetweengroups.
Onestudy(33participants,withpolyps)providedinformationongastrointestinaldisturbancesandsuspectedallergicreaction(rashor
skinirritation)afterashortcourseoftetracyclineantibioticcomparedwithplacebo.Weareveryuncertainifantibioticswereassociated
withanincreaseingastrointestinaldisturbances(riskratio(RR)1.36,95%CI0.22to8.50)orskinirritation(RR6.67,95%CI0.34
to128.86)(verylowqualityevidence).
Systemic antibiotics plussalineirrigation and intranasal corticosteroids versusplaceboplussalineirrigation andintranasal
corticosteroids
Onestudy(60participants,somewithandsomewithoutpolyps)comparedathree-monthcourseofmacrolideantibioticwithplacebo;
allparticipantsalsousedsalineirrigationand70%usedintranasalcorticosteroids.Disease-specificHRQLwasreportedusingSNOT-
22(0to110,0=bestqualityoflife).Dataweredifficulttointerpret(highlyskewedandbaselineimbalances)anditisunclearifthere
wasanimportantdifferenceatanytimepoint(lowqualityevidence).Toassesspatient-reporteddiseaseseverityparticipantsrated
theeffectoftreatmentonafive-pointscale(-2for“desperatelyworse”to2for“cured”)attheendoftreatment(threemonths).For
improvementinsymptomstherewasnodifferencebetweentheantibiotics andplacebogroups; theRRwas1.50(95%CI0.81to
2.79;verylowqualityevidence),althoughtherewerealsoslightlymorepeoplewhofeltworseaftertreatmentintheantibioticsgroup.
Therewasnodemonstrable differenceintherateofgastrointestinaldisturbancesbetweenthegroups(RR1.07, 95%CI0.16to
7.10).GeneralHRQLwasmeasuredusingtheSF-36.Theauthorsstatedthattherewasnodifferencebetweengroupsattheendof
treatment(12weeks)ortwoweekslater.
Systemicantibioticsversusintranasalcorticosteroids
Onestudy(43participants,withoutpolyps)comparedathree-monthcourseofmacrolideantibioticwithintranasalcorticosteroids.
Patient-reporteddiseaseseveritywasassessedusingacompositesymptomscore(0to40;0=nosymptoms).Itisveryuncertainif
therewasadifferenceaspatient-reporteddiseaseseveritywassimilarbetweengroups(MD-0.32,95%CI-2.11to1.47;lowquality
evidence).
Systemicantibioticsversusoralcorticosteroids
Onestudy(28participants,withpolyps)comparedashortcourseoftetracyclineantibiotic(unclearduration,~20days)witha20-day
courseoforalcorticosteroids.Wewereunabletoextractdataonanyoftheprimaryefficacyoutcomes.Itisuncertainiftherewasa
differenceingastrointestinaldisturbances(RR1.00,95%CI0.16to6.14)orskinirritation(RR2.00,95%CI0.20to19.62)asthe
resultsfortheseoutcomesweresimilarbetweengroups(verylowqualityevidence).
Authors’conclusions
Wefoundverylittleevidencethatsystemicantibioticsareeffectiveinpatientswithchronicrhinosinusitis.Wedidfindmoderatequality
evidenceofamodestimprovementindisease-specificqualityoflifeinadultswithchronicrhinosinusitiswithoutpolypsreceivingthree
monthsofamacrolideantibiotic.Thesizeofimprovementwasmoderate(0.5pointsonafive-pointscale)andonlyseenattheendof
thethree-monthtreatment;bythreemonthslaternodifferencewasfound.
Despite ageneral understanding that antibiotics can be associated with adverse effects,including gastrointestinal disturbances, the
resultsinthisreviewwereveryuncertainbecausethestudiesweresmallandfeweventswerereported.
Systemicandtopicalantibioticsforchronicrhinosinusitis(Review) 2
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NoRCTsoftopicalantibioticsmettheinclusioncriteria.
Moreresearchinthisarea,particularlyevaluatinglonger-termoutcomesandadverseeffects,isrequired.
PLAIN LANGUAGE SUMMARY
Systemicandtopicalantibioticsforchronicrhinosinusitis
Reviewquestion
Wereviewedtheevidenceforthebenefitsandharmsofsystemic(givenbymouth)ortopical(givenbynose)antibioticsforpeoplewith
chronicrhinosinusitis.
Background
Chronicrhinosinusitisisacommonconditionthatisdefinedasinflammationofthenoseandparanasalsinuses(agroupofair-filled
spacesbehindthenose,eyesandcheeks).Patientsexperienceatleasttwoormoreofthefollowingsymptomsforatleast12weeks:
blockednose,dischargefromtheirnoseorrunnynose,painorpressureintheirfaceand/orareducedsenseofsmell(hyposmia).Some
peoplewillalsohavenasalpolyps,whicharegrape-likeswellingsofthenormalnasallininginsidethenasalpassageandsinuses.
Studycharacteristics
Weincludedfiverandomisedcontrolledtrials(RCTs)withatotalof293participants.Thestudiesweresmall(43to79participants).
Fourrecruitedadultsandthefifthchildren.Threestudiesonlyincludedpeoplewithchronicrhinosinusitiswithoutnasalpolyps,one
amixofpeoplewithandwithoutpolypsandtheremainingstudyonlypeoplewithpolyps.Alluseddifferenttypesoforalantibiotics;
nonelookedattopicalantibiotics.Theantibioticsweregiventopatientsaseitherantimicrobialoranti-inflammatoryagentsandfor
differentlengthsoftime,althoughinallcaseswewereabletolookattheoutcomesafterthreemonths.Antibioticswerecompared
withplacebo,withintranasal(inthenose)steroidsorwithoralsteroids.Onestudyusedantibioticsasanadditionaltreatment,ontop
ofnasalsalineirrigationandmostpeoplealsotookintranasalsteroidsinthisstudy.
Keyresultsandqualityoftheevidence
Whencomparedtoaplacebo(threestudies),therewasmoderatequalityevidenceinonestudythattheremaybeanimprovementin
disease-specifichealth-relatedqualityoflife(HRQL)withoralantibioticsinpeoplewithchronicrhinosinusitis(withoutpolyps)atthe
endoftreatment(threemonths),butitisunclearifHRQLwasstillimprovedthreemonthslater.Theremayhavebeenanincreasein
gastrointestinaldisturbancesandsuspectedallergicreaction(rashorskinirritation)withantibioticsbutweareveryuncertainandthe
qualityoftheevidenceisverylow.
Antibioticswereusedalongsidenasalsalineirrigationandintranasalsteroids(comparedtoplaceboplusthesame)inonestudy.Itisnot
cleariftherewasanimportantdifferenceindisease-specificHRQLaftertreatment(threemonths)oratthreemonthsaftertreatment
wascompleted(lowqualityevidence).Theremayhavebeenmorepeopleintheantibioticsgroupwhofelttheyhad’improved’atthe
endoftreatment,buttherewerealsopeoplewhohadworsesymptomsinbothgroups(verylowqualityevidence).Itisveryuncertain
iftherewasadifferenceingastrointestinaldisturbancesbetweengroups.
Whencompared with intranasal steroids inpeople with chronic rhinosinusitis (without polyps), itwas veryuncertain if therewas
adifferenceindiseaseseverity(usingacombinedscoreforfourdifferentsymptoms)betweentheantibiotics andintranasalsteroids
groupsinonestudy(lowqualityevidence).Noinformationwasgivenaboutadverseevents.
Theone studythatcomparedantibiotics withoralsteroids(inpeoplewithchronicrhinosinusitis withpolyps)didnotpresentany
effectivenessresultsthatwecoulduse.Itwasuncertainiftherewasanydifferenceingastrointestinaldisturbancesorskinirritationin
theantibioticsgroup(verylowqualityevidence).
Therewerenoreportsofanyseriousadverseeffectsinanyofthestudies.
Conclusions
Wefoundverylittleevidencethatoralantibioticsareeffectiveinpatientswithchronicrhinosinusitis.Wedidfindmoderatequality
evidenceofamodestimprovementindisease-specificqualityoflifeinadultswithchronicrhinosinusitiswithoutpolypsreceivingthree
monthsofamacrolideantibiotic.Thesizeoftheimprovementwasmoderate(0.5pointsonafive-pointscale)andonlyseenatthe
endofthethree-monthtreatment;bythreemonthslaternodifferencewasfound.
Systemicandtopicalantibioticsforchronicrhinosinusitis(Review) 3
Copyright©2016TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
Despite ageneral understanding that antibiotics can be associated with adverse effects,including gastrointestinal disturbances, the
resultsinthisreviewwereveryuncertainbecausethestudiesweresmallandfeweventswerereported.
Moreresearchinthisarea,particularlyevaluatinglonger-termoutcomesandadverseeffects,isrequired.
Systemicandtopicalantibioticsforchronicrhinosinusitis(Review) 4
Copyright©2016TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
CopySyste SUMMARY OF FINDINGS FOR THE MAIN COMPARISON [Explanation]
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ollaboratiorchronicrh (Osutoutfcdopiemasret)iscipants R(9e5la%tiCveI)effect Anticipatedabsoluteeffects∗(95%CI) Quality Whathappens
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lishedusitis Disease-specificHRQL - • At3months:the • At3months:the • At3months:MD ⊕⊕⊕(cid:13) • SNOT-20was
by(Re assessed with: SNOT- meanSNOT-20score meanSNOT-20scorein 0.54lower(0.98lower MODERATE1 scoredwitha
Johnview) 20 was2.88 theinterventiongroup to0.1lower) maximum of 5points.
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ile Follow-up: after treat- meanSNOT-20score lowerto0.1lower) 35lower(0.81lowerto groupwithmacrolide
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& ment (3 months) and 3 was2.84 • At6months:the 0.11higher) antibioticsindicatea
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ubsin bances (0.22to8.50) VERYLOW2 there is an increase in
lishedbusitis(R Foollfopwa-rutpic:i3pamnotsn:t3h3s 105per1000 143per1000 38moreper1000 gbaasntcreosinwteitshtiannatlibdiiosttiucrs-
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. tation) skin irritation with an-
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of participants:33 No events were re-
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0per1000 arm.
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very serious reactions
(e.g. Stevens-Johnson
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(1RCT)
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ranetics GRADEWorkingGroupgradesofevidence
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llaboratiochronicrh sLMuoobwdseqtaruanattleiiatyqll:yuOadluiiftrfyec:roeWnnfetidaernecmeoindtehreateeflfyeccotnefsitdiemnatteinisthleimeitfefedc:tTehsetitmruaetee:ffTehcetmtruaeybeeffseucbtsistalniktiealyllytodibffeercelnotsferotomtthheeeessttiimmaatteeooff tthheeeeffffeecctt,but there is a possibility that it is
n.Pubinosin Verylowquality:Wehaveverylittleconfidenceintheeffectestimate:Thetrueeffectislikelytobesubstantiallydifferentfrom theestimateof effect
lishedusitis 1Downgradedtomoderatequalityduetoimprecision:smallsamplesize(n=64)leadingtoimpreciseresults.
b(R 2Downgradedtolowqualityduetolimitationsofstudydesign(lackofinformationaboutrandomisation,allocationconcealment
ye
Johnview) aconndfibdleinndciengin,theirgvhalrsis).k of reporting bias) and imprecision (small study (n = 33) with low number of events leading to large
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ile 3Downgraded to very low quality due to limitations of study design (lack of information about randomisation, allocation
y
& concealmentandblinding,highriskofreportingbias),indirectnessoftheincludedpopulationandintervention(studyincluded
So apopulationwhoweremoreseverelyaffected;thosewithrecurrentpolypsorrecalcitrantdisease;andtheinterventionwasa
n
s, 20-daycourseof antibiotics)andimprecision(smallstudy(n=33)withnoeventsineitherarm).
L
td
.
7
BACKGROUND knowledgeofthepolypstatus,particularlyinprimarycare.This
review(andmostofitscompanionreviews)considerpatientswith
andwithoutpolypstogetherintheinitialevaluationoftreatment
Descriptionofthecondition effects.However,subgroupanalysesexplorepotentialdifferences
betweenthem.
Chronicrhinosinusitisisdefinedasinflammationofthenoseand
Themostcommonlyusedinterventionsforchronicrhinosinusitis
paranasal sinuses. Itischaracterisedby twoor more symptoms,
areusedeithertopically(sprayedintothenose)orsystemically(by
one of which must be nasal blockage/obstruction/congestion or
mouth)andincludesteroids,antibioticsandsaline.
nasaldischarge(anterior/posteriornasaldrip).Theotherpossible
symptomsincludefacialpain/pressure,reductionorlossofsense
ofsmell(inadults)orcough(inchildren).Symptomsmusthave
continued for at least 12 weeks. In addition, people must have Descriptionoftheintervention
eithermucosalchangeswithintheostiomeatalcomplexorsinuses
Various groups of systemic antibiotics have been studied in
(orboth)asevidencedbyacomputerisedtomography(CT)scan
the treatment of chronic rhinosinusitis, including penicillins,
and/or endoscopic signs of at least one of the following: nasal
cephalosporins,quinolones,tetracyclinesandmacrolides.Thedu-
polyps,mucopurulentdischargeprimarilyfromthemiddlemeatus
ration of antibiotic courses ranges from nine days to 12 weeks.
or oedema/mucosal obstruction primarilyinthemiddlemeatus
Topical antibiotics havealsobeenusedtotreatchronicrhinosi-
(EPOS2012).
nusitis.Thesehavebeendeliveredasantibioticnasalwashesand
Chronicrhinosinusitisrepresentsacommonsourceofillhealth;
sprays.
11%ofUKadultsreportedchronicrhinosinusitissymptomsina
worldwidepopulationstudy(Hastan2011).Symptoms,including
nasalobstruction,nasaldischarge,facialpain,anosmiaandsleep
Howtheinterventionmightwork
disturbance, have a major impact on quality of life, reportedly
greaterinseveraldomainsoftheSF-36thananginaorchronicres- Systemicandtopicalantibioticsareusedinchronicrhinosinusitis
piratorydisease(Gliklich1995).Acuteexacerbations,inadequate withtheaimofeliminatinginfectionandinflammation,normal-
symptom control and respiratory disease exacerbation are com- isingtherheologyandcohesivityofnasalmucus(Hatipoglu2005;
mon.Complicationsarerare,butmayincludevisualimpairment Inamura2000;Miyanohara2000;Wallwork2006),alteringbac-
andintracranialinfection. terialbiofilmformation (Wozniak 2004),reversingostial occlu-
Twomajorphenotypesofchronicrhinosinusitishavebeeniden- sionandimprovingsymptoms.Themacrolideclassofantibiotics
tified based on the presence or absence of nasal polyps on ex- hasbeenspecificallyidentifiedaspotentiallyusefulinchronicrhi-
amination.Nasalpolypsaretumour-likehyperplasticswellingsof nosinusitisduetothewell-documentedanti-inflammatoryeffects
the nasal mucosa, most commonly originating fromwithin the ofreducingcytokineactivityandinturnreducingairwayinflam-
ostiomeatalcomplex(Larsen2004).Chronicrhinosinusitis with mationandmucusproduction(Tamaoki 2004),ratherthanfor
nasal polyps(CRSwNP) is diagnosed whenpolyps are seen(on itsantibacterialaction.Topicalantibioticshavethetheoreticalad-
directorendoscopicexamination)bilaterallyinthemiddlemea- vantage of acting directly on the site of infection/inflammation
tus.TheacronymCRSsNPisusedfortheconditioninwhichno and providing ahigher concentration of antibiotic atthe target
polypsarepresent. site,buttheyhavelimitedpenetrationintothesinusesintheun-
Althoughtheaetiologyofchronicrhinosinusitis isnotfullyun- operatednose.
derstood,itmayinvolveabnormalitiesinthehostresponsetoir- However,unnecessaryantibioticprescriptionsshouldbeavoided.
ritants,commensalandpathogenicorganismsandallergens,ob- Adverse effects are not uncommon, including allergy (
structionofsinusdrainagepathways,abnormalitiesofnormalmu- MacLaughlin2000);thesearecommonlymanifestedasskinirri-
cociliaryfunction,lossofthenormalmucosalbarrierorinfection. tationorrashes(andinseverecasesasanaphylaxis,Stevens-John-
Twotypicalprofilesmaybeobservedwithrespecttoinflammatory sonsyndromeetc.),diarrhoeaandabdominalpain(Bucher2004).
mediators; in eosinophilic chronic rhinosinusitis, which is typi- Oneofthemainconcernswithantibioticsisthatoveruseisassoci-
callyassociatedwithnasalpolyps,highlevelsofeosinophils,im- atedwithincreasingresistancetoantibioticsamongcommunity-
munoglobulinE(IgE)andinterleukin(IL)-5maybefound,while acquiredpathogens.
inneutrophilicchronicrhinosinusitis,moreoftenassociatedwith
chronicrhinosinusitis withoutpolyps,neutrophilspredominate,
withelevatedinterferon(IFN)gamma,IL-8andtumournecrosis
Whyitisimportanttodothisreview
factor(TNF)(EPOS2012).
While treatment decisions should be made based on an under- Antibioticsarestillfrequentlyusedtotreatpatientswithchronic
standing of the patient’s chronic rhinosinusitis phenotype and rhinosinusitis. This may be in the mistaken belief thatin some
likely aetiology, in practice treatment may be initiated without patientswithchronicrhinosinusitissomeoralloftheirsymptoms
Systemicandtopicalantibioticsforchronicrhinosinusitis(Review) 8
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