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News -> November, 2001 News
James A. Hadley, MD
ARS First Vice-President
Rochester, NY
A host of material has surfaced in the medical literature regarding appropriate antibiotic treatment for Acute Bacterial Rhinosinusitis (ABRS) and Chronic Rhinosinusitis (CRS). Disregarding the fact that our Society still does not have a true definition of CRS, there are several different classes of antimicrobials from which to choose. What, then, should the majority of Rhinologic surgeons choose as their primary and secondary antimicrobial for these common respiratory illnesses?
Antibiotics are designed to kill bacterial pathogens (beta-lactams, fluoroquinolones) or prevent their growth (sulfas, macrolides) and studies prove that their use shortens the course of an infection and helps to prevent complications. However, excessive and inappropriate use has lead to the development of resistance. Pathogens have become adept at mutation, transformation, conjugation, and plasmid development to promote prolongation of their species. The result is that Streptococcus pneumoniae and Haemophilus influenzae are no longer readily eradicated by the usual course of therapy with antibiotics.
Guidelines promoted by our Society and the Sinus & Allergy Health Partnership (Otolaryngol Head Neck Surg June 2000) established a new methodology of dealing with this problem. Proper use of these guidelines should improve patient care enhancing cost savings. They recognize that patients exposed to an antibiotic within 4 to 6 weeks of their current infection are likely to be infected with a resistant pathogen. Using the Poole Therapeutic Outcome Model, clinicians may now predict the therapeutic effectiveness of various antimicrobial agents for ABRS or CRS. The model is available at the Sinus & Allergy Health Partnership website, www.allergysinus.org.
Thus, for patients who are evaluated for ABRS who have not been exposed to antibiotics within the previous 4 to 6 weeks, first-line therapy is limited to high-dose amoxicillin, amoxicillin-clavulanate, cefpodoxime proxetil, and cefuroxime axetil. For adult patients with moderate infection and prior antibiotic use the agents that are indicated are amoxicillin-clavulanate, or one of the fluoroquinolones (gatifloxacin, levofloxacin or moxifloxacin), or combination therapy--amoxicillin or clindamycin for gram-positive coverage plus cefixime or cefpodoxime proxetil for gram-negative coverage. Very similar first line agents are recommended in the pediatric population with the exception of the fluoroquinolones, which still have no pediatric indication. Despite the recent reports of shorter-course therapy, the guidelines still recommend 10-14 days of therapy.
Issuing guidelines on appropriate antibiotic use for treatment of ABRS and CRS is only the first step in ensuring that rational principles are adopted and followed in clinical practice. It remains up to us, as rhinologists to get this message out to our primary care physicians, our associates in health care and especially our patients. We need to curtail the prevalence of resistance before we no longer have available medications to treat these infections.
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