Photodynamic therapy of adenoid hypertrophy in acute rhinosinusitis.

A first step for microorganisms to reach the respiratory system and cause infectious disease is colonization in the nasopharynx. Humans inhale a bacterial load of up to 106 per cubic meter of air per day [1], including transient microorganisms between the upper and lower airways. This can lead to lung infections, amounting to billions of dollars in annual direct treatment costs in the United States, depending on the etiologic agent [2,3]. Curcumin has been described as a photosensitizer (PS) that, activated at 450 nm, is efficient against planktonic bacteria [4] and biofilms [5]. At the same time, effects on microbial interactions are commonly detected in the upper respiratory tract and should be considered for the treatment of adenoids [6]. We, therefore, propose in this study to optimize photodynamic therapy (PDT) conditions in vitro by simulating bacterial coinfection conditions in nasal cavities evaluated by the response surface method, where we can evaluate interactions of treatment variables. From this, the clinical case of the treatment of rhinosinusitis was carried out using PDT with nasal lighting. The absence of symptoms that characterize the disease was monitored and evaluated by the Kepler Meyer method. The study points out considerations that can be evaluated for the treatment to be a possibility of clinical indication in the control of rhinosinusitis.

MICROBIAL CAUSATIVE AGENTS AND THEIR ANTIMICROBIAL SUSCEPTIBILITY PATTERNS IN CHRONIC RHINOSINUSITIS - IMPACT ON ANTIBIOTIC PROPHYLAXIS AND TREATMENT.

Chronic rhinosinusitis (CRS) is debilitating condition comprising inflammation of the mucosa of the nasal and paranasal sinuses, requiring conservative and often surgical treatment. Functional endoscopic sinus surgery (FESS) is a CRS treatment during which a microbiological diagnostic procedure may be conducted. Preoperative antibiotic prophylaxis is administrated before FESS. When indicated, the administered empiric antibiotic therapy must cover most common causing microbial agents. The aims of this study were to identify microbial pathogens isolated from sinonasal cavities in patients undergoing endoscopic sinus surgery, to determine bacterial antibiotic susceptibility patterns and compare them with guidelines for treatment and perioperative prophylactic use of antimicrobial agents. A retrospective cohort study on 456 samples collected between 2016 and 2019 was conducted at the Department of Otorhinolaryngology, Head and Neck Surgery and the Department of Microbiology, Parasitology and Hospital Infections in the Clinical University Centre Sestre milordnice, Zagreb. The most common isolated pathogens were Peptostreptococcus spp., Propionibacterium spp., Staphylococcus aureus, Pseudomonas spp., Fusobacterium spp. and Haemophilus influenzae. According to antibiotic susceptibility patterns, empiric antibiotic treatment with amoxicillin-clavulanic acid was appropriate. Due to high rates of antibiotic resistance of anaerobic bacterial isolates to metronidazole, it cannot be recommended in empirical antibiotic treatment or preoperative surgical antibiotic prophylaxis.

An open-label, multicentre, randomized comparative study of efficacy, safety and tolerability of the 5 plant - extract BNO 1012 in the Delayed Antibiotic Prescription Method in children, aged 6 to 11 years with acute viral and post-viral rhinosinusitis.

Acute rhinosinusitis (ARS) can be characterized as bacterial (ABRS) and require antibiotic therapy only in 0.5-5% of cases. In most cases, the disease is in a viral and post-viral form, which requires pathogenetic and symptomatic treatment. The study objective was to determine the efficacy of BNO 1012 extract in the technology of delayed antibiotic prescribing in children with acute rhinosinusitis. METHODS: 292 children aged 6 to 11 years with ARS were randomized in the multicenter, comparative study. They received an extract of five medicinal plants in addition to standard symptomatic therapy or standard therapy only. EVALUATION CRITERIA: reduction of the sinusitis severity according to a 4-point medical assessment scale (nasal congestion, severity of anterior and posterior rhinorrhea) at each visit, dynamics of self-scoring of rhinorrhea and headache (according to a 10-point visual analogue scale), "therapeutic benefit" in days, frequency of antibiotic prescriptions due to the use of an extract of five plants. RESULTS: The use of the 5-plant extract BNO 1012 in addition to the standard symptomatic treatment of acute rhinosinusitis provides a clinically significant, adequate reduction in the severity of rhinorrhea, nasal congestion and post-nasal drip, assessed by a physician at V2 (p < 0.005). Significant differences are noted in the patient's self-scoring of rhinorrhea on the second or third day in viral RS, and from the fourth to the eighth day in post-viral RS. Symptoms of similar intensity in control group were observed at V3. Thus, in the first week of treatment, the treatment group compared to the control one showed a "therapeutic benefit" of three days. The use of BNO 1012 in patients with acute rhinosinusitis can 1.81-fold reduce the prescription of antibacterial drugs. CONCLUSION: The combination of five medicinal plants is effective for the treatment of acute rhinosinusitis in children aged 6 to 11 years. Its use provides a significant "therapeutic benefit" when administered in addition to standard symptomatic therapy, reducing the need for antibiotic use.

An Up-to-Date Review on Bio-Resource Therapeutics Effective against Bacterial Species Frequently Associated with Chronic Sinusitis and Tonsillitis.

Upper respiratory tract infections include inflammations of the nose, sinuses (sinusitis), pharynx (tonsillitis, pharyngitis) and larynx (laryngitis) with bacteria or viruses as the main cause of these conditions. Due to their repetitive nature, chronic respiratory infections represent a global problem which is often a result of improper treatment. If not treated adequately, these conditions may have serious consequences. On the other hand, mis - and overuse of antibiotics has reduced their efficiency and accelerated the development of resistant bacterial strains, which further complicates the treatment of infections. This literature review will focus on current knowledge regarding medicinal plants and mushrooms which have been traditionally used in the treatment of infections caused by chronic sinusitis and tonsillitis commonly linked to bacteria - Staphylococcus aureus, Streptococcus pneumoniae, Streptococcus pyogenes, Fusobacterium nucleatum, Haemophilus influenzae and Moraxella catarrhalis. The present literature overview might be considered as a starting point for the development of novel, natural antimicrobial products with potential practical use in the treatment of chronic tonsillitis and sinusitis.

Manuka honey sinus irrigations in recalcitrant chronic rhinosinusitis: phase 1 randomized, single-blinded, placebo-controlled trial.

BACKGROUND: Manuka honey (MH) has significant antibiofilm activity in vitro and in vivo against Staphylococcus aureus, methicillin-resistant S aureus (MRSA), and Pseudomonas aeruginosa. This is the first randomized, single-blinded, placebo-controlled phase 1 clinical trial investigating the safety and preliminary efficacy of MH with augmented methylglyoxal (MGO) rinses in recalcitrant chronic rhinosinusitis (CRS). METHODS: Patients were included after previously undergoing endoscopic sinus surgery and presenting with signs and symptoms of sinus infection with positive bacterial cultures on sinus swabs. Patients were randomized to receive 14 days of twice-daily 16.5% MH + 1.3 mg/mL MGO sinonasal rinses and concurrent 10 days of placebo tablets (MH), or 14 days of twice-daily saline sinonasal rinses and concurrent 10 days of culture-directed antibiotic therapy (CON). Safety observations included the University of Pennsylvania Smell Identification Test (UPSIT) and adverse-event (AE) reporting. Efficacy was assessed comparing microbiology results, Lund-Kennedy scores (LKSs), and symptom scores using the visual analog scale (VAS) and 22-item Sino-Nasal Outcome Test (SNOT-22). RESULTS: Twenty-five patients completed the study. MH demonstrated a good safety profile with no major AEs and no changes in UPSIT. Six of 10 (60%) MH patients had a reduction in bacterial culture rate with 1 of 10 of those having negative cultures, compared with 12 of 15 (80%) in the control group with 7 of 15 having negative cultures upon completion of the study. CONCLUSION: This study concludes that twice-daily 16.5% MH augmented with 1.3 mg/mL MGO sinonasal rinses alone for 14 days is safe but not superior to culture-directed oral antibiotics and twice-daily saline rinses.

Histopathologic evaluation of Ecballium elaterium applied to nasal mucosa in a rat rhinosinusitis model.

This study aimed to evaluate the antimicrobial effects of the medicinal plant Ecballium elaterium, which is topically applied as a traditional medicine for the treatment of rhinosinusitis. Pure and extract forms of E elaterium were applied to the nasal cavity of rats for the treatment of Streptococcus-pneumoniae -induced rhinosinusitis. The nasal mucosa, soft palate, and trachea of the rats were harvested in the first hour, third day, and third week for histopathologic evaluation. This experiment revealed the anti-inflammatory effects of E elaterium and showed that it reduced fibrosis. The anti-inflammatory effect of all forms of E elaterium was found to reach its maximum level on the third day, decreasing by the third week. We also observed that the pure form of E elaterium caused severe epithelium loss in the first hour after application. The mechanism of the anti-inflammatory effect of different levels of extract forms needs to be further analyzed with different doses and duration of treatment.

Antibiofilm effects of amoxicillin-clavulanic acid and levofloxacin in patients with chronic rhinosinusitis with nasal polyposis.

PURPOSE: Microbial biofilms have been implicated in the pathogenesis of chronic rhinosinusitis with nasal polyposis (CRSwNP). The aim of our study was to evaluate in vitro effects of amoxicillin-clavulanic acid and levofloxacin on biofilm formation by bacterial species isolated from sinus tissue in patients with CRSwNP. METHODS: The sinus mucosal specimens were harvested from the upper parts and roof of ethmoid cavity of 48 patients with CRSwNP. Each sample was washed thoroughly in three separate beakers of sterile saline to remove any planktonic bacteria and further subjected to microbiology analysis. The biofilm-forming capacity of isolated strains was detected by microtiter-plate method and the effects of subinhibitory (1/2× to 1/16× MIC) and suprainhibitory concentrations (4, 8, 16, 32, and 64 µg/ml) of amoxicillin-clavulanic acid and levofloxacin on biofilm production were investigated. RESULTS: Bacterial strains were isolated in 42 (87.5%) patients: one microorganism in 80.9% and two microorganisms in 19.1% of patients. The most prevalent bacteria in CRSwNP biofilms were Staphylococcus epidermidis (34%) and S. aureus (28%) followed by S. haemolyticus (12%), Pseudomonas aeruginosa (8%), Moraxella catarrhalis (6%), Streptococcus pneumoniae (6%), and other staphylococci (6%). Subinhibitory concentrations of amoxicillin-clavulanic acid and levofloxacin significantly reduced biofilm formation (p < 0.01 and p < 0.05, respectively), with better efficacy of amoxicillin-clavulanic acid (1/2-1/8× MIC) on staphylococci and levofloxacin (1/2- 1/4× MIC) on M. catarrhalis and P. aeruginosa biofilm formation. Suprainhibitory concentrations of both tested antibiotics (4-64 µg/ml) significantly eradicated mature biofilms of staphylococci (p < 0.01). The effect of levofloxacin on eradication of staphylococcal biofilms was more noticeable, compared to the effect of amoxicillin-clavulanic acid (p < 0.01). Suprainhibitory concentrations of both tested antibiotics had no effect on eradication of previously formed M. catarrhalis and P. aeruginosa biofilms (p > 0.05). CONCLUSIONS: The amoxicillin-clavulanic acid and levofloxacin are shown to be potent antibiofilm agents in patients with CRSwNP. The effects of tested compounds depend on bacterial species and the volume of formed biofilm.

Anti-inflammatory and antibacterial evaluation of Thymus sipyleus Boiss. subsp. sipyleus var. sipyleus essential oil against rhinosinusitis pathogens.

Thymus sipyleus Boiss. subsp. sipyleus var. sipyleus of the Lamiaceae, locally known as thyme scented lemon, which is an endemic taxon collected from Sivas in Anatolia, was investigated in this study due to its folk medicine use against rhinosinusitis. The aromatic characteristics of the plant material gave the idea for the detailed evaluation of the volatiles and essential oil thereof. Consequently, the oil was obtained by Clevenger type hydrodistillation followed by gas chromatography-flame ionization detector (GC-FID) and gas chromatography/mass spectrometry (GC/MS) analyses for phytochemical characterization. To confirm the folk medicinal use against sinusitis, in vitro antimicrobial activities of the essential oil was evaluated by agar diffusion, microdilution and vapour diffusion methods against selected rhinosinusitis associated strains such as Staphylococcus aureus, methicillin-resistant S. aureus (MRSA), S. epidermidis, Streptococcus pyogenes, S. pneumoniae, Pseudomonas aeruginosa, Haemophilus influenzae and Moraxella catarrhalis. Additionally, the in vitro anti-inflammatory activity was evaluated by 5-lipoxygenase (5-LOX) inhibitory effect of the essential oil spectrophotometrically. Furthermore, the composition of the volatiles of the vapour phase of the oil was determined by headspace-solid phase microextraction (HS-SPME-GC/MS) after 15 min and 24 h in accordance with antimicrobial vapour diffusion method conditions, respectively. According to the analytical results, the main component was determined as thymol (66.2%). Whereas in the HS-SPME method p-cymene (26.1%) and γ-terpinene (26%) were identified as the main volatile components within the 15. min., and thymol (75.3%) after 24 h, respectively. The antibacterial activity against rhinosinusitis pathogens varied between 160 and 1250 µg/mL minimum inhibitory concentrations, with the best inhibitory effects observed against the S. aureus, S. pyogenes and M. catarrhalis. The anti-inflammatory activity of the oil was determined as 12.1 ±â€¯1.8% in 100 µg/mL. The results showed the in vitro antimicrobial and anti-inflammatory potential of the oil also in vapour phase against sinusitis supporting the traditional use.

High-dose versus standard-dose amoxicillin/clavulanate for clinically-diagnosed acute bacterial sinusitis: A randomized clinical trial.

BACKGROUND: The recommended treatment for acute bacterial sinusitis in adults, amoxicillin with clavulanate, provides only modest benefit. OBJECTIVE: To see if a higher dose of amoxicillin will lead to more rapid improvement. DESIGN, SETTING, AND PARTICIPANTS: Double-blind randomized trial in which, from November 2014 through February 2017, we enrolled 315 adult outpatients diagnosed with acute sinusitis in accordance with Infectious Disease Society of America guidelines. INTERVENTIONS: Standard-dose (SD) immediate-release (IR) amoxicillin/clavulanate 875 /125 mg (n = 159) vs. high-dose (HD) (n = 156). The original HD formulation, 2000 mg of extended-release (ER) amoxicillin with 125 mg of IR clavulanate twice a day, became unavailable half way through the study. The IRB then approved a revised protocol after patient 180 to provide 1750 mg of IR amoxicillin twice a day in the HD formulation and to compare Time Period 1 (ER) with Time Period 2 (IR). MAIN MEASURE: The primary outcome was the percentage in each group reporting a major improvement-defined as a global assessment of sinusitis symptoms as "a lot better" or "no symptoms"-after 3 days of treatment. KEY RESULTS: Major improvement after 3 days was reported during Period 1 by 38.8% of ER HD versus 37.9% of SD patients (P = 0.91) and during Period 2 by 52.4% of IR HD versus 34.4% of SD patients, an effect size of 18% (95% CI 0.75 to 35%, P = 0.04). No significant differences in efficacy were seen at Day 10. The major side effect, severe diarrhea at Day 3, was reported during Period 1 by 7.4% of HD and 5.7% of SD patients (P = 0.66) and during Period 2 by 15.8% of HD and 4.8% of SD patients (P = 0.048). CONCLUSIONS: Adults with clinically diagnosed acute bacterial sinusitis were more likely to improve rapidly when treated with IR HD than with SD but not when treated with ER HD. They were also more likely to suffer severe diarrhea. Further study is needed to confirm these findings. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02340000.

[Clinical research of different characteristics of fungal ball sinusitis].

Objective:The aim of this study is to investigate the clinical features of different subtypes of fungal ball sinusitis. Method:Four hundred and forty-nine cases with fungal ball rhinosinusitis (FBS) were involved in this retrospective analysis. The clinical features including symptoms, signs, and imaging scans, pathological results were all collected for each patient and the patients were classified into different subtypes according to these clinical features and the follow-up treatment. Result:In this retrospective study, 449 patients who diagnosed with fungal ball sinusitis were involved. According to clinical features, these patients were divided into 5 subtypes respectively: ①Subtype 1 simple FBS: there were 299 patients in this subtype. Main symptoms were one side headache, purulent rhinorrhea, nasal obstruction. CT scans showed the classical features of FBS. ②Subtype 2 FBS with nasal polyps: there were 78 patients in this subtype. Main symptoms were bilateral or unilateral nasal obstruction, purulent rhinorrhea. Histopathologic results showed nasal polyps with acute or chronic inflammation by inflammatory cell infiltration. Eosinophils infiltration was the most common phenomenon. Postoperative therapy was as same as the treatment to chronic rhinosinusitis. ③Subtype 3 FBS with allergic rhinitis:there were 51 patients in this subtype. During the operation, infected nasal sinus mucosa with serious edema could be found, often with asubmucosa cyst. Postoperative medical therapy with antihistamines during follow-up. ④Subtype 4 FBS with purulent cyst: there were 6 cases. Main symptoms were nasal obstruction, purulent rhinorrhea and facial pain. Sinus CT scans showed that the typical features of both fungal ball sinusitis and mucous cyst. Antibiotic saline nasal irrigation should be used intraoperatively and postoperatively, other than systemic antibiotic treatment. ⑤Subtype 5 mixed type: there were 15 cases. All of these patients were diagnosed with fungal ball sinusitis with nasal polyps combined with allergic rhinitis. The clinical features of diagnosis and treatment were combination of the two types. Conclusion:According to the different clinical features, fungal ball sinusitis could be classified with five different clinical features. This classification would help to standardize the treatment, reduce the postoperative recurrence rate, and improve the prognosis.

Failure of a Best Practice Alert to Reduce Antibiotic Prescribing Rates for Acute Sinusitis Across an Integrated Health System in the Midwest.

BACKGROUND: Antimicrobial resistance is a growing concern, and in recent years, there has been increased interest in ambulatory antimicrobial stewardship. Acute rhinosinusitis (ARS) is one of the most common outpatient diagnoses that results in an antibiotic prescription. OBJECTIVE: To determine if a best practice alert (BPA) will affect the percentage of oral antibiotic prescriptions for adults with ARS. METHODS: A prospective, pre/post study was initiated to evaluate the percentage of oral antibiotic prescriptions for ARS in 117 primary care clinics in the Midwest. Included in the study results were 16,570 adults who had an office visit for ARS: 8,106 patients from December 1, 2015, to February 28, 2016, were in the pre-intervention group without an active BPA, and 8,464 patients from December 1, 2016, to February 28, 2017, were in the post-intervention group when the BPA was active. The primary outcome was the number of oral antibiotic prescriptions for ARS compared with the number of office visits for ARS in the pre- and postintervention groups. RESULTS: The percentage of oral antibiotics prescribed for the pre- and postintervention groups were 94.8% and 94.3%, respectively (P = 0.152). The BPA displayed for 7,780 visits, prompting discontinuation of an antibiotic for 10 (0.1%) visits in the postintervention group. CONCLUSIONS: This study suggests that, although an electronic alert may be attractive to facilitate antimicrobial stewardship, it may be ineffective. These results warrant alternative measures to facilitate ambulatory antimicrobial stewardship. DISCLOSURES: No outside funding supported this study. The authors have no conflicts of interest to declare. Study concept and design were contributed by Hansen, D. Leedahl, and N. Leedahl. Hansen and N. Leedahl took the lead in data collection, with assistance from Carson and D. Leedahl. Data interpretation was performed by all the authors. The manuscript was written by Hansen, along with the other authors, and revised by all the authors.

Topical therapy for refractory rhinosinusitis caused by methicillin-resistant Staphylococcus aureus: First report in a prospective series.

OBJECTIVE: The incidence of refractory chronic rhinosinusitis (CRS) associated with methicillin-resistant Staphylococcus aureus (MRSA) is rising and remains a therapeutic challenge. The goal of this study is to demonstrate the efficacy of a non-invasive topical therapy against MRSA in these patients. METHODS: Seventeen patients with refractory CRS caused by MRSA were treated with a topical therapy protocol. Treatment consisted of weekly endoscopic sinus debridement followed by intra-sinus installation of a hydroxyl-ethylcellulose gel that releases mometasone and a culture-directed antibiotic for a period of 6 weeks, along with daily nasal nebulization of mometasone with the same antibiotic and saline rinses. Clinical outcome was assessed using the Lund-Kennedy (LK) symptom and endoscopic appearance scores. Sinus mucosal tissue was homogenized and cultured, and microbial biofilm burden was assessed based on colony forming units (CFUs) counts. RESULTS: Rhinotopic therapy resulted in clearance of MRSA in 13 of 16 patients (81.2%). Treated patients also demonstrated significant improvement clinically as measured by the LK scores. In addition, a significant decrease in mucosal CFUs was observed post-therapy. CONCLUSION: Our findings demonstrate that topical therapy is an effective method for treating MRSA-associated refractory CRS.

The value of Nigella sativa in the treatment of experimentally induced rhinosinusitis.

The aim of this study was to investigate the effect of Nigella sativa and cephalexin in the therapy of experimental bacterial rhinosinusitis. Bacterial rhinosinusitis was induced with Staphylococcus aureus. Rabbits were divided into five groups; control (n = 6), N. sativa 50 mg/ kg/d (n = 6), N. sativa 100 mg/kg/d (n = 6), N. sativa 200 mg/kg/d (n = 6), and cephalexin 20 mg/kg/d (n = 6) groups. N. sativa was given orally for 7 days. The same volume of normal saline (0.9% NaCl) was given as a vehicle to the control group for the same period. After treatment period, sinus mucosa samples were evaluated using stereological and histopathological methods. Half of the maxillary sinus mucosa samples were frozen at -800C for further analysis of NO levels. Pathology revealed a severe acute inflammatory process in rabbits treated with saline. Only mild inflammation was determined in cephalexin group, N. sativa 100 mg/kg/d and N. sativa 200 mg/kg/d groups. The level of NO increased in the saline group was significantly reduced in all treatment groups. N. sativa may prevent histopathological changes of rhinosinusitis via decreased NO levels in a dose dependent manner and can be used in the treatment of rhinosinusitis diseases.

Sinonasal methicillin-resistant Staphylococcus aureus: updates on treatment.

PURPOSE OF REVIEW: Over the past two decades, the management of methicillin-resistant Staphylococcus aureus (MRSA) in chronic rhinosinusitis has posed significant challenges. This document reviews current management techniques and novel treatment modalities for sinonasal MRSA infections. RECENT FINDINGS: Topical antibiotic therapy, that is, drops (ofloxacin) and ointments (mupirocin) as off-label use for the management of MRSA chronic sinusitis, has shown beneficial results. Other more recently trialed nonantibiotic modalities such as antimicrobial photodynamic therapy and colloidal silver irrigation are also showing promise. SUMMARY: Sinonasal MRSA is considered to be associated with recalcitrant chronic sinusitis. Advancements in systemic and local antibiotics in its management have been slow and unsatisfactory. Attention is shifting to the use of nonantibiotic antibacterial treatments. Knowledge of these options is critical to improve the overall management of these chronic patients.

Manuka honey sinus irrigation for the treatment of chronic rhinosinusitis: a randomized controlled trial.

BACKGROUND: Manuka honey (MH) has been shown in vitro to be effective against biofilm-producing bacteria. This study assessed the effectiveness of MH for patients with active chronic rhinosinusitis (CRS) and prior sinus surgery. METHODS: This prospective single-blinded (clinician only) randomized controlled trial recruited patients with active CRS and prior sinus surgery. Patients received either MH or saline (SAL) sinus irrigations twice daily for 30 days and were offered oral antibiotics and/or oral/topical steroids as indicated. Outcomes were 22-item Sino-Nasal Outcome Test (SNOT-22) change score (primary), culture negativity, and Lund-Kennedy endoscopic change score. RESULTS: Forty-two patients were analyzed (MH, n = 20; SAL, n = 22). The SNOT-22 change score achieved a clinically significant improvement in both groups but was similar between MH (median [interquartile range]: -12 [-20, -1]) and SAL (-12.5 [-22, -6]) (p = 0.57). Culture negativity was better on MH (8/19, 42%) compared to SAL (4/21, 19%), nearing statistical significance (p = 0.11). Lund-Kennedy endoscopic change score improved in both groups but was not statistically better on MH (-3 [-5, 0]) compared to SAL (-1 [-2, 0]) (p = 0.20). For patients not receiving oral antibiotics/steroids, culture negativity was statistically better on MH (5/10, 50%) compared to SAL (0/6, 0%) (p = 0.04). MH was well-tolerated. No adverse events were reported. CONCLUSION: In patients with active CRS and prior sinus surgery, both MH and SAL improved outcomes, but there was no statistically significant difference between these groups. However, in the subset that did not receive oral antibiotics/steroids, culture negativity was statistically better on MH, suggesting that MH alone may be effective for acute exacerbations of CRS.

Enumerating Virus-Like Particles and Bacterial Populations in the Sinuses of Chronic Rhinosinusitis Patients Using Flow Cytometry.

There is increasing evidence to suggest that the sinus microbiome plays a role in the pathogenesis of chronic rhinosinusitis (CRS). However, the concentration of these microorganisms within the sinuses is still unknown. We show that flow cytometry can be used to enumerate bacteria and virus-like particles (VLPs) in sinus flush samples of CRS patients. This was achieved through trialling 5 sample preparation techniques for flow cytometry. We found high concentrations of bacteria and VLPs in these samples. Untreated samples produced the highest average bacterial and VLP counts with 3.3 ± 0.74 x 10(7) bacteria ml(-1) and 2.4 ± 1.23 x 10(9) VLP ml(-1) of sinus flush (n = 9). These counts were significantly higher than most of the treated samples (p < 0.05). Results showed 10(3) and 10(4) times inter-patient variation for bacteria and VLP concentrations. This wide variation suggests that diagnosis and treatment need to be personalised and that utilising flow cytometry is useful and efficient for this. This study is the first to enumerate bacterial and VLP populations in the maxillary sinus of CRS patients. The relevance of enumeration is that with increasing antimicrobial resistance, antibiotics are becoming less effective at treating bacterial infections of the sinuses, so alternative therapies are needed. Phage therapy has been proposed as one such alternative, but for dosing, the abundance of bacteria is required. Knowledge of whether phages are normally present in the sinuses will assist in gauging the safety of applying phage therapy to sinuses. Our finding, that large numbers of VLP are frequently present in sinuses, indicates that phage therapy may represent a minimally disruptive intervention towards the nasal microbiome. We propose that flow cytometry can be used as a tool to assess microbial biomass dynamics in sinuses and other anatomical locations where infection can cause disease.

Alteration in Bacterial Culture After Treatment With Topical Mupirocin for Recalcitrant Chronic Rhinosinusitis.

IMPORTANCE: Topical mupirocin therapy is used to treat symptomatic chronic sinusitis (CRS). However, the potential adverse impact of this therapy on the sinus microbiota has not been well quantified. OBJECTIVE: To determine changes in microbiologic culture results before and after topical mupirocin therapy in patients with CRS with medically and surgically refractory disease. DESIGN, SETTING, AND PARTICIPANTS: We performed a retrospective medical chart review for 22 consecutive adults evaluated and treated between January 1, 2012, and January 1, 2014, at an otolaryngology-rhinology clinic at a regional academic medical center. The patients were 14 men and 8 women, who had undergone functional endoscopic sinus surgery for CRS, and in whom sinus aspirate cultures were performed before and after topical mupirocin therapy for symptomatic disease. Analyses were performed in April 2014. EXPOSURES: Patients underwent treatment with saline sinus rinse, with the addition of mupirocin, for at least 1 week. MAIN OUTCOMES AND MEASURES: Bacterial isolates from sinus aspirate culture. RESULTS: The patients included 14 men and 8 women, 18 to 75 years old, who underwent a mean of 1.9 functional endoscopic sinus surgical procedures. The mean (range) duration of mupirocin therapy was 6 (2-12) weeks. Before mupirocin therapy, cultures from symptomatic patients (14 men and 8 women, ages 18-75 years) revealed common bacteria implicated in CRS, which are characteristically gram-positive. After mupirocin therapy, cultures from symptomatic patients shifted significantly: 19 were gram-positive vs 3 gram-negative before treatment; 9 were gram-positive vs 13 gram-negative after treatment (P = .004), with increased growth of pathogenic gram-negative bacteria and Corynebacterium. CONCLUSIONS AND RELEVANCE: These data present evidence supporting the distinct abrogation of culturable sinus bacteria after mupirocin rinses, identifying a shift toward increased pathogenic bacteria. Consideration of healthy host microbiome and immune dysfunction should guide future treatment considerations.