Clinical practice guideline (update): adult sinusitis.

OBJECTIVE: This update of a 2007 guideline from the American Academy of Otolaryngology--Head and Neck Surgery Foundation provides evidence-based recommendations to manage adult rhinosinusitis, defined as symptomatic inflammation of the paranasal sinuses and nasal cavity. Changes from the prior guideline include a consumer added to the update group, evidence from 42 new systematic reviews, enhanced information on patient education and counseling, a new algorithm to clarify action statement relationships, expanded opportunities for watchful waiting (without antibiotic therapy) as initial therapy of acute bacterial rhinosinusitis (ABRS), and 3 new recommendations for managing chronic rhinosinusitis (CRS). PURPOSE: The purpose of this multidisciplinary guideline is to identify quality improvement opportunities in managing adult rhinosinusitis and to create explicit and actionable recommendations to implement these opportunities in clinical practice. Specifically, the goals are to improve diagnostic accuracy for adult rhinosinusitis, promote appropriate use of ancillary tests to confirm diagnosis and guide management, and promote judicious use of systemic and topical therapy, which includes radiography, nasal endoscopy, computed tomography, and testing for allergy and immune function. Emphasis was also placed on identifying multiple chronic conditions that would modify management of rhinosinusitis, including asthma, cystic fibrosis, immunocompromised state, and ciliary dyskinesia. ACTION STATEMENTS: The update group made strong recommendations that clinicians (1) should distinguish presumed ABRS from acute rhinosinusitis (ARS) caused by viral upper respiratory infections and noninfectious conditions and (2) should confirm a clinical diagnosis of CRS with objective documentation of sinonasal inflammation, which may be accomplished using anterior rhinoscopy, nasal endoscopy, or computed tomography. The update group made recommendations that clinicians (1) should either offer watchful waiting (without antibiotics) or prescribe initial antibiotic therapy for adults with uncomplicated ABRS; (2) should prescribe amoxicillin with or without clavulanate as first-line therapy for 5 to 10 days (if a decision is made to treat ABRS with an antibiotic); (3) should reassess the patient to confirm ABRS, exclude other causes of illness, and detect complications if the patient worsens or fails to improve with the initial management option by 7 days after diagnosis or worsens during the initial management; (4) should distinguish CRS and recurrent ARS from isolated episodes of ABRS and other causes of sinonasal symptoms; (5) should assess the patient with CRS or recurrent ARS for multiple chronic conditions that would modify management, such as asthma, cystic fibrosis, immunocompromised state, and ciliary dyskinesia; (6) should confirm the presence or absence of nasal polyps in a patient with CRS; and (7) should recommend saline nasal irrigation, topical intranasal corticosteroids, or both for symptom relief of CRS. The update group stated as options that clinicians may (1) recommend analgesics, topical intranasal steroids, and/or nasal saline irrigation for symptomatic relief of viral rhinosinusitis; (2) recommend analgesics, topical intranasal steroids, and/or nasal saline irrigation) for symptomatic relief of ABRS; and (3) obtain testing for allergy and immune function in evaluating a patient with CRS or recurrent ARS. The update group made recommendations that clinicians (1) should not obtain radiographic imaging for patients who meet diagnostic criteria for ARS, unless a complication or alternative diagnosis is suspected, and (2) should not prescribe topical or systemic antifungal therapy for patients with CRS.

Otitis media: an update on current pharmacotherapy and future perspectives.

INTRODUCTION: Acute otitis media (AOM) is the most common childhood bacterial infection and also the leading cause of conductive hearing loss in children. Currently, there is an urgent need for developing novel therapeutic agents for treating AOM. AREAS COVERED: Structured search of current literature. PubMed was searched for published literature in areas of pharmacotherapeutics, preventive therapies and complementary treatments for OM. The intent of this review is to provide a comprehensive evaluation of therapeutics for AOM, including preventive modalities and complementary medicine. EXPERT OPINION: the management of AOM in young children is still evolving and depends on patterns of bacterial colonization and antimicrobial resistance in the community. The introduction of vaccinations against potential respiratory tract pathogens has altered the frequency of recovery of pathogens causing ear infections in children. Even though not all patients require antimicrobial therapy to overcome their infection, these agents improve symptoms faster and lead to fewer treatment failures. Further studies are warranted to evaluate which patients would best benefit from antimicrobial therapy.

Acute sinusitis in children.

Acute rhinosinusitis is a common illness in children. Viral upper respiratory tract infection is the most common presentation of rhinosinusitis. Most children resolve the infection spontaneously and only a small proportion develops a secondary bacterial infection. The proper choice of antibiotic therapy depends on the likely infecting pathogens, bacterial antibiotic resistance, and pharmacologic profiles of antibiotics. Amoxicillin-clavulanate is currently recommended as the empiric treatment in those requiring antimicrobial therapy. Isolation of the causative agents should be considered in those who failed the initial treatment. In addition to antibiotics, adjuvant therapies and surgery may be used in the management of acute bacterial rhinosinusitis.

Antimicrobial treatment of anaerobic infections.

INTRODUCTION: Anaerobes are the most predominant components of normal human skin and mucous membrane bacterial flora and are, therefore, a common cause of endogenous bacterial infections. Because of their fastidious nature, they are difficult to isolate from infectious sites and are often overlooked. Anaerobic infections can occur at all body sites, including the central nervous system, oral cavity, head and neck, chest, abdomen, pelvis, skin and soft tissues. AREAS COVERED: This up-to-date review describes the antimicrobials available for the treatment of anaerobic infections and the advantages in using them according to the site of infection and expected antimicrobial susceptibility. EXPERT OPINION: Treatment of anaerobic infection is complicated by the slow growth of these organisms, their polymicrobial nature and the growing resistance of anaerobes to antimicrobials. Antimicrobial therapy is often the only therapy required, or it is an important adjunct to a surgical approach. Because anaerobes generally are recovered mixed with aerobic organisms, the choice of appropriate antimicrobial should provide adequate coverage of both types of pathogen. The most effective antimicrobials against anaerobes are: metronidazole, the carbapenems, chloramphenicol, the combinations of a penicillin and a beta-lactamase inhibitor, and tigecycline.

The effects of treatment of acute otitis media with a low dose vs a high dose of amoxicillin on the nasopharyngeal flora.

OBJECTIVE: To compare the effects on the nasopharyngeal flora of therapy of acute otitis media in children with either a low dose or a high dose of amoxicillin. DESIGN: Retrospective study. PATIENTS: Of 50 children diagnosed as having acute otitis media, 25 received a low dose of amoxicillin (45 mg/kg/d) (group 1) and 25 received a high dose of amoxicillin (90 mg/kg/d) (group 2) for 10 days, and both groups were evaluated. INTERVENTION: Antimicrobial treatment. RESULTS: Before therapy, potential pathogens (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and Staphylococcus aureus) were isolated from the nasopharynx of 15 children in group 1 (60%) and 13 in group 2 (52%). The number of penicillin-susceptible isolates was equally reduced after both therapies. However, an increase was noted in the recovery of S aureus only in group 2 (from 2 to 6 organisms). A greater eradication rate of interfering organisms following therapy was noted in group 2 (from 86 to 36) than in group 1 (from 92 to 60) (P < .001). These organisms include alpha-hemolytic streptococci, and Peptostreptococcus and Prevotella species. CONCLUSIONS: The oral flora at the end of therapy with a high dose of amoxicillin is more depleted of organisms with interfering capability than following treatment with a low dose of amoxicillin. These changes may contribute to the greater recovery rate of patients infected with S aureus who received a high dose of amoxicillin.

Treatment of anaerobic infection.

Anaerobic bacteria are the predominant flora in the normal human skin and mucous membranes and are, therefore, a common cause of endogenous infections. Since anaerobic infections are generally polymicrobial, where anaerobes are mixed with aerobic organisms, therapy should provide coverage of both types of pathogens. The isolation of anaerobes requires appropriate methods of collection, transportation and cultivation of specimens. The lack of use of any of these methods can lead to inadequate recovery of anaerobes and inappropriate therapy. Treatment of anaerobic infection is complicated by the slow growth of these organisms and the growing resistance of anaerobic bacteria to antimicrobials. The primary role of antimicrobials is to limit the local and systemic spread of infection. Surgical drainage is of primary importance. This includes debriding of necrotic tissue, draining the pus, improving circulation, alleviating obstruction and increasing tissue oxygenation. The most effective antimicrobials against anaerobic organisms are metronidazole, the carbapenems (imipenem, meropenem and ertapenem), chloramphenicol, the combinations of a penicillin and a beta-lactamase inhibitor (ampicillin or ticarcillin plus clavulanate, amoxicillin plus sulbactam, and piperacillin plus tazobactam), tigecycline and clindamycin.

Comparison of clarithromycin and ciprofloxacin therapy for Bacillus anthracis Sterne infection in mice with or without (60)Co gamma-photon irradiation.

Biological agents and ionizing radiation lead to more severe clinical outcomes than either insult alone. This study investigated the survival of non-irradiated and (60)Co-gamma-irradiated mice given therapy for inhalation anthrax with ciprofloxacin (CIP) or a clinically relevant mixture of clarithromycin (CLR) and its major human microbiologically important metabolite 14-hydroxy clarithromycin (14-OH CLR). All B6D2F1/J 10-week-old female mice were inoculated intratracheally with 3 x 10(8) c.f.u. of Bacillus anthracis Sterne spores 4 days after the non-lethal 7 Gy dose of (60)Co gamma radiation. Twenty-one days of treatment with CLR/14-OH CLR, 150 mg kg(-1) twice daily, or CIP, 16.5 mg kg(-1) twice daily, began 24 h after inoculation. Pharmacokinetics indicate that the area under the curve (AUC) for 14-OH CLR on the concentration-versus-time graph was slightly higher in gamma-irradiated than non-irradiated animals. Neither drug was able to increase survival in gamma-irradiated animals. CIP and CLR/14-OH CLR therapies in non-irradiated animals increased survival from 49 % (17/35 mice) in buffer-treated animals to 94 % (33/35) and 100 %, respectively (P < 0.001). B. anthracis Sterne only was isolated from 25-50 % of treated mice with or without irradiation. Mixed infections with B. anthracis Sterne were present in 50-71 % of gamma-irradiated mice but only in 5-10 % of mice without irradiation.

Eradication of pathogens from the nasopharynx after therapy of acute maxillary sinusitis with low- or high-dose amoxicillin/clavulanic acid.

The growing resistance of Streptococcus pneumoniae to penicillin can be overcome by increasing the dose of the penicillin administered. This generated the recommendation that the adult dose of amoxicillin for the treatment of acute maxillary sinusitis (AMS) be increased from 1.5 g/day to 4.0 g/day. The objective of this study was to investigate whether the higher dose of amoxicillin is more effective than the previously recommended dose in eradicating S. pneumoniae from the nasopharynx of patients who present with AMS. Nasopharyngeal cultures obtained from 58 patients with AMS were studied: 30 received amoxicillin 1.5 g/day given in divided doses three times a day for 10 days (amoxicillin/clavulanic acid 4:1 formulation) and 28 were treated with amoxicillin 4.0 g/day given in divided doses twice a day for 10 days (amoxicillin/clavulanic acid 16:1 formulation). Seventy-one potentially pathogenic organisms were isolated: S. pneumoniae (27 isolates), Haemophilus influenzae non-type b (25), Moraxella catarrhalis (5), Streptococcus pyogenes (5) and Staphylococcus aureus (9). The number of S. pneumoniae isolates in the 1.5 g/day group was reduced from 14 to 9 (2 intermediately resistant and 3 highly resistant). In contrast, the number of S. pneumoniae isolates in the 4.0 g/day group was reduced from 13 to 2 (1 highly resistant) (P<0.05). No differences were noted in the eradication rate of other groups of isolates, which were all susceptible to amoxicillin/clavulanic acid. These data illustrate the superiority of 4.0 g/day amoxicillin/clavulanic acid compared with 1.5 g/day amoxicillin/clavulanic acid in the eradication of S. pneumoniae from the nasopharynx.

Minimum inhibitory concentrations of herbal essential oils and monolaurin for gram-positive and gram-negative bacteria.

New, safe antimicrobial agents are needed to prevent and overcome severe bacterial, viral, and fungal infections. Based on our previous experience and that of others, we postulated that herbal essential oils, such as those of origanum, and monolaurin offer such possibilities. We examined in vitro the cidal and/or static effects of oil of origanum, several other essential oils, and monolaurin on Staphylococcus aureus, Bacillus anthracis Sterne, Escherichia coli, Klebsiella pneumoniae, Helicobacter pylori, and Mycobacterium terrae. Origanum proved cidal to all tested organisms with the exception of B. anthracis Sterne in which it was static. Monolaurin was cidal to S. aureus and M. terrae but not to E. coli and K. pneumoniae. Unlike the other two gram-negative organisms, H. pylori were extremely sensitive to monolaurin. Similar to origanum, monolaurin was static to B. anthracis Sterne. Because of their longstanding safety record, origanum and/or monolaurin, alone or combined with antibiotics, might prove useful in the prevention and treatment of severe bacterial infections, especially those that are difficult to treat and/or are antibiotic resistant.

Antimicrobial resistance in the nasopharyngeal flora of children with acute otitis media and otitis media recurring after amoxicillin therapy.

The objective of this study was to investigate the antimicrobial susceptibility of the organisms isolated from the nasopharynx of children who presented with acute otitis media (AOM) or otitis media that recurred after amoxicillin therapy. Nasopharyngeal cultures obtained from 72 patients, 40 with AOM and 32 with recurrent otitis media (ROM), were analysed. Thirty-six potentially pathogenic organisms were recovered in 34 (85 %) of the children from the AOM group, and 42 were isolated from 29 (91 %) of the children from the ROM group. The organisms isolated were Streptococcus pneumoniae (n = 26), Haemophilus influenzae non-type b (n = 22), Moraxella catarrhalis (n = 13), Streptococcus pyogenes (n = 8) and Staphylococcus aureus (n = 9). Resistance to the eight antimicrobial agents used was found in 37 instances in the AOM group as compared to 99 instances in the ROM group (P < 0.005). The difference between AOM and ROM was significant with Streptococcus pneumoniae resistance to amoxicillin (P < 0.005), to amoxicillin/clavulanate (P < 0.005), to trimethoprim/sulfamethoxazole (P < 0.01), to cefixime (P < 0.01) and to azithromycin (P < 0.01), and for H. influenzae resistance to amoxicillin (P < 0.025). These data illustrate the higher recovery rate of antimicrobial-resistant Streptococcus pneumoniae and H. influenzae from the nasopharynx of children who had otitis media that recurred after amoxicillin therapy than those with AOM.

Management of anaerobic infection.

The management of anaerobic infection needs to be prompt and appropriate in order to ensure recovery. Management includes the use of hyperbaric oxygen, surgical methods and antimicrobial therapy. Various factors, such as efficacy, bacterial antimicrobial resistance, ability to reach appropriate antimicrobial levels at the infected site, toxicity and stability need to be taken into account in choosing antimicrobial agents. Some antimicrobials have poor activity against anaerobic bacteria. The more suitable agents include penicillins, cephalosporins, carbapenems, chloramphenicol, clindamycin, metronidazole, macrolides, glycopeptides, tetracyclines and quinolones.

Eradication of Streptococcus pneumoniae in the nasopharyngeal flora of children with acute otitis media after amoxicillin-clavulanate therapy.

Nasopharyngeal cultures were obtained from 60 children with acute otitis media before and after treatment with either 45 or 90 mg of amoxicillin (given as amoxicillin-clavulanate) per kg of body weight per day for 10 days. The number of Streptococcus pneumoniae isolates in the 45-mg/kg group was reduced from 12 to 6 and was reduced from 14 to 1 (P = 0.0261) in the 90-mg/kg group.

Joint and bone infections due to anaerobic bacteria in children.

The current review describes the microbiology, diagnosis and management of septic arthritis and osteomyelitis due to anaerobic bacteria in children. Staphylococcus aureus, Haemophilus influenzae type-b, and Group A streptococcus, Streptococcus pneumoniae, Kingela kingae, Neisseria meningiditis and Salmonella spp are the predominant aerobic bacteria that cause arthritis in children. Gonococcal arthritis can occur in sexually active adolescents. The predominant aerobes causing osteomyelitis in children are S. aureus, H. influenzae type-b, Gram-negative enteric bacteria, beta-hemolytic streptococci, S. pneumoniae, K. kingae, Bartonella henselae and Borrelia burgdorferi. Anaerobes have rarely been reported as a cause of these infections in children. The main anaerobes in arthritis include anaerobic Gram negative bacilli including Bacteroides fragilis group, Fusobacterium spp., Clostridium spp. and Peptostreptococcus spp. Most of the cases of anaerobic arthritis, in contrast to anaerobic osteomyelitis, involved a single isolate. Most of the cases of anaerobic arthritis are secondary to hematogenous spread. Many patients with osteomyelitis due to anaerobic bacteria have evidence of anaerobic infection elsewhere in the body, which is the source of the organisms involved in osteomyelitis. Treatment of arthritis and osteomyelitis involving anaerobic bacteria includes symptomatic therapy, immobilization in some cases, adequate drainage of purulent material and antibiotic therapy effective to these organisms.

Antibacterial therapy for acute group a streptococcal pharyngotonsillitis: short-course versus traditional 10-day oral regimens.

The objective of this review is to examine the use of short-course antibacterial therapy of group A beta-hemolytic streptococcal (GABHS) pharyngotonsillitis, compared with traditional 10-day therapy. In preparing this paper we reviewed the medical literature of studies comparing 10 days of penicillin with shorter courses of antibacterial therapy. Short-course therapy of 6 days of amoxicillin, 4 to 5 days of cephalosporins, and 5 days of azithromycin was found to be as, or more effective than traditional 10-day penicillin therapy. The benefits of short-course therapy include superior compliance and adherence, lower incidence of adverse effects, less effect on the bacterial flora, improved patient and parent satisfaction, and lower drug costs. In conclusion, short courses of amoxicillin, cephalosporins, and macrolides provide superior or equal efficacy to a 10-day course of penicillin therapy in the treatment of GABHS pharyngotonsillitis.

Antimicrobial therapy for bacillus anthracis-induced polymicrobial infection in (60)Co gamma-irradiated mice.

Challenge with both nonlethal ionizing radiation and toxigenic Bacillus anthracis spores increases the rate of mortality from a mixed bacterial infection. If biological weapons, such as B. anthracis spores, and nuclear weapons were used together, casualties could be more severe than they would be from the use of either weapon alone. We previously discovered that a polymicrobial infection developed in B6D2F(1)/J mice after nonlethal (7-Gy) (60)Co gamma irradiation and intratracheal challenge with B. anthracis Sterne spores 4 days after irradiation. In this present study, we investigated the survival of mice and the response of the polymicrobial infection during the course of antimicrobial therapy with penicillin G procaine, ofloxacin, trovafloxacin, or gatifloxacin. Survival was prolonged, but not ensured, when the mice were treated with either broad-spectrum ofloxacin or narrow-spectrum penicillin G for 7 days beginning 6 or 24 h after challenge. Survival was not prolonged when therapy was delayed more than 24 h after challenge. When these two antimicrobial agents were given for 21 days, the survival rate was increased from 0% for the controls to 38 to 63% after therapy. Therapy with trovafloxacin or gatifloxacin reduced the incidence of mixed infection and improved the rate of survival to 95% (trovafloxacin) or 79% (gatifloxacin), whereas the rate of survival for the controls was 5%. We conclude that the mixed infection induced by B. anthracis in irradiated mice complicates effective therapy with a single antimicrobial agent. To limit mortality following nonlethal irradiation and challenge with B. anthracis spores, antimicrobial therapy needs to be initiated within a few hours after challenge and continued for up to 21 days.