The Laryngoscope C 2014 The American Laryngological, V
Rhinological and Otological Society, Inc.
Should Topical Antibiotics Be Routinely Used Following Sinus Surgery? Mohammad H. Al-Bar, MD; Arjuna Kuperan, MD; Roy R. Casiano, MD BACKGROUND The role of bacterial infections in the etiology of stable chronic rhinosinusitis (CRS) is unclear. The advantages of nasal saline irrigation following endoscopic sinus surgery (ESS) are well documented. Nasal irrigation is also superior to nebulizers and sprays.1 Adding topical antibiotics to saline irrigation theoretically confers the additional advantages of direct delivery of antibiotics in high concentrations to the diseased mucosa with a low risk of systemic adverse effect. In addition, ESS provides abundant sinus mucosal access and allows increased distribution of the topical antibiotic, improved aeration of the sinuses, and return of normal mucociliary clearance function.
LITERATURE REVIEW The large majority of studies focus on nonsurgical patients. Analysis and review of these studies to determine the efficacy of topical antibiotic use after ESS is challenging because these studies differ in design, patient characteristics, types of antibiotic used, duration of treatment, outcome measures, and level of evidence. It is also important to know that there is not enough data on using topical antibiotics during the perioperative period; thus, this literature review focuses on the present data on using topical antibiotics for the acute exacerbation of CRS in post-ESS patients. A recent systematic review shows that there are three randomized control trials (levels of evidence 1b and 2b) studying the effectiveness of topical antibiotic therapies in patients with CRS using bacitracin/ colimycin, neomycin, and tobramycin; and it showed that the addition of antibiotics
From the Department of Otolaryngology–Head and Neck Surgery, University of Miami Miller School of Medicine, Miami, Florida, U.S.A. Editor’s Note: This Manuscript was accepted for publication March 10, 2014. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Roy R. Casiano, MD, Department of Otolaryngology–Head and Neck Surgery, University of Miami Miller School of Medicine, 1120 NW 14th St, CRB 5th Floor, Miami, FL 33136. E-mail: [email protected] DOI: 10.1002/lary.24673
Laryngoscope 124: December 2014
to topical solution failed to demonstrate clinical improvement.2 In 2008, Lim et al. performed a literature review of a wide variety of topical antimicrobials used in the management of CRS.1 Both subjective and objective outcome measures were used in the studies examined. Both postsurgical and nonsurgical studies analyzed in the review showed efficacy for the use of topical antimicrobials; however, the study quality is higher in the postsurgical group containing mostly level 2a and 2b evidence. Fourteen studies were included in the review, with eight focusing on acute exacerbations of CRS in post-ESS patients. Of those eight studies, only two did not have a positive outcome. The remaining six studies showed a beneficial effect for topical antimicrobials, with levels of evidence ranging from 2a to 4. The role of empiric treatment versus culture-directed therapy was also discussed in the review, with varying levels of evidence ranging from 2a to 4. Ten of the 14 studies investigated empiric therapy, and six of these 10 studies showed efficacy with topical antimicrobials. In contrast, all four culturedirected analyses displayed treatment benefits. They authors concluded that there is a low level of evidence for the efficacy of topical antimicrobials in CRS treatment. Higher level of evidence exists for studies analyzing postsurgical outcomes using culture-directed therapy.1 The topical antibiotic mupirocin (bactroban) exhibits high efficacy in the postsurgical patient with recalcitrant CRS due to Staphylococcus aureus (SA), which is the most commonly cultured organism in patient with post-ESS CRS. SA is related to biofilm formation, intracellular residence, and super-antigen production. Patients who have persistent CRS despite ESS can also present with methicillin-resistant staphylococcus aureus and other concomitantly strong-resistance patterns. A 2012 article by Jervis-Bardy et al., which was a prospective, double-blinded, placebo-controlled study (level 1b) analyzed patients who had persistent CRS with a positive sinonasal culture for SA sensitive to mupirocin and amoxicillin/clavulanic acid.3 All patients had ESS at least one time, more than 12 weeks prior to their enrollment. Nine patients received 1 month of mupirocin rinses compared to 13 patients in the control group who also received one month of saline rinses topically and Al-Bar et al.: Topical Antibiotics Following Sinus Surgery
2653
amoxicillin with clavulanic acid tablets orally. After 1 month of follow-up, zero of 13 patients (0.0%) in the control group returned SA negative cultures at 1 month, compared to eight of nine patients (88.9%) in the mupirocin group (P
Rhinological and Otological Society, Inc.
Should Topical Antibiotics Be Routinely Used Following Sinus Surgery? Mohammad H. Al-Bar, MD; Arjuna Kuperan, MD; Roy R. Casiano, MD BACKGROUND The role of bacterial infections in the etiology of stable chronic rhinosinusitis (CRS) is unclear. The advantages of nasal saline irrigation following endoscopic sinus surgery (ESS) are well documented. Nasal irrigation is also superior to nebulizers and sprays.1 Adding topical antibiotics to saline irrigation theoretically confers the additional advantages of direct delivery of antibiotics in high concentrations to the diseased mucosa with a low risk of systemic adverse effect. In addition, ESS provides abundant sinus mucosal access and allows increased distribution of the topical antibiotic, improved aeration of the sinuses, and return of normal mucociliary clearance function.
LITERATURE REVIEW The large majority of studies focus on nonsurgical patients. Analysis and review of these studies to determine the efficacy of topical antibiotic use after ESS is challenging because these studies differ in design, patient characteristics, types of antibiotic used, duration of treatment, outcome measures, and level of evidence. It is also important to know that there is not enough data on using topical antibiotics during the perioperative period; thus, this literature review focuses on the present data on using topical antibiotics for the acute exacerbation of CRS in post-ESS patients. A recent systematic review shows that there are three randomized control trials (levels of evidence 1b and 2b) studying the effectiveness of topical antibiotic therapies in patients with CRS using bacitracin/ colimycin, neomycin, and tobramycin; and it showed that the addition of antibiotics
From the Department of Otolaryngology–Head and Neck Surgery, University of Miami Miller School of Medicine, Miami, Florida, U.S.A. Editor’s Note: This Manuscript was accepted for publication March 10, 2014. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Roy R. Casiano, MD, Department of Otolaryngology–Head and Neck Surgery, University of Miami Miller School of Medicine, 1120 NW 14th St, CRB 5th Floor, Miami, FL 33136. E-mail: [email protected] DOI: 10.1002/lary.24673
Laryngoscope 124: December 2014
to topical solution failed to demonstrate clinical improvement.2 In 2008, Lim et al. performed a literature review of a wide variety of topical antimicrobials used in the management of CRS.1 Both subjective and objective outcome measures were used in the studies examined. Both postsurgical and nonsurgical studies analyzed in the review showed efficacy for the use of topical antimicrobials; however, the study quality is higher in the postsurgical group containing mostly level 2a and 2b evidence. Fourteen studies were included in the review, with eight focusing on acute exacerbations of CRS in post-ESS patients. Of those eight studies, only two did not have a positive outcome. The remaining six studies showed a beneficial effect for topical antimicrobials, with levels of evidence ranging from 2a to 4. The role of empiric treatment versus culture-directed therapy was also discussed in the review, with varying levels of evidence ranging from 2a to 4. Ten of the 14 studies investigated empiric therapy, and six of these 10 studies showed efficacy with topical antimicrobials. In contrast, all four culturedirected analyses displayed treatment benefits. They authors concluded that there is a low level of evidence for the efficacy of topical antimicrobials in CRS treatment. Higher level of evidence exists for studies analyzing postsurgical outcomes using culture-directed therapy.1 The topical antibiotic mupirocin (bactroban) exhibits high efficacy in the postsurgical patient with recalcitrant CRS due to Staphylococcus aureus (SA), which is the most commonly cultured organism in patient with post-ESS CRS. SA is related to biofilm formation, intracellular residence, and super-antigen production. Patients who have persistent CRS despite ESS can also present with methicillin-resistant staphylococcus aureus and other concomitantly strong-resistance patterns. A 2012 article by Jervis-Bardy et al., which was a prospective, double-blinded, placebo-controlled study (level 1b) analyzed patients who had persistent CRS with a positive sinonasal culture for SA sensitive to mupirocin and amoxicillin/clavulanic acid.3 All patients had ESS at least one time, more than 12 weeks prior to their enrollment. Nine patients received 1 month of mupirocin rinses compared to 13 patients in the control group who also received one month of saline rinses topically and Al-Bar et al.: Topical Antibiotics Following Sinus Surgery
2653
amoxicillin with clavulanic acid tablets orally. After 1 month of follow-up, zero of 13 patients (0.0%) in the control group returned SA negative cultures at 1 month, compared to eight of nine patients (88.9%) in the mupirocin group (P
