Sinusitis, antibiotic treatment

It is likely that the patient s sinusitis has an infective element and therefore a referral to the GP for antibiotic treatment is the next step. 

First mentioned by others (H13, Sll), this has been studied in detail (H32). After exclusion of known causes (catabolic, etc., Section 4.4), isolated IgG deficiency is occasionally found in infants, children, and adults. The genetics are unknown. Some are sporadic without known consanguinity. Others are found in families with other immunological abnormalities (B29). It is very similar to Bruton s disease. In six of the author s cases, the accent has been on pyogenic infections of the lungs and soft tissues. There has been no diarrhea or malabsorption, no sinusitis, and no septicemia. During episodes of pus formation the patients have been very febrile and ill, with only a slow amelioration following correct antibiotic treatment. Some patients develop the hemolytic uremic syndrome. 

This chapter will focus primarily on otitis media, pharyngitis, and sinusitis because these infectious entities are frequently bacterial in origin, and apprpriate antibiotic treatment can minimize morbidity and potentially prevent comphcations. 

Although many clinical studies have been performed evaluating antibiotics for ABRS, no randomized, double-blind, placebo-controlled studies have used pre- and posttreatment sinus aspirate cultures as an outcome measure. Despite this, antibiotics appear to resolve symptoms more quickly and reduce failure rates and complications compared with no treatment.35-37 Since diagnosis usually is based on clinical presentation and not sinus aspirate cultures, clinicians must attempt to differentiate ABRS from viral rhinosinusitis. Therefore, it is important to limit antibiotic use to cases where infection is unlikely to resolve without causing prolonged disease patients with mild to moderate symptoms that persist for 10 days or worsen over 5 to 7 days and patients with severe symptoms,31,34... 

Treatment guidelines developed by the Sinus and Allergy Health Partnership reflect antibiotic choices that are likely to result in favorable clinical and bacteriologic outcomes based on pathogen distribution, spontaneous resolution rates, and nationwide resistance patterns.310 These guidelines (Figs. 69-3 and 69-4) stratify therapy based on severity of disease and risk of infection with resistant organisms, defined as mild disease in patients with prior antibiotic use within 4 to 6 weeks. Other risk factors for resistance include day-care attendance or frequent... 

Oral beta-lactam antibiotics such as amoxycillin, cotrimoxazole or doxycycline for 7-10 days are suitable for the treatment of bacterial sinusitis. Furuncles of the nose should be treated with an anti-staphyloccal drug for 5 days. Standard treatment for streptococcal pharyngitis consists of 10 days of penicillin. Malignant otitis externa responds to high dose quinolone therapy (e.g. ciprofloxacin 750 mg 2 t.d.) administered orally. For parapharyngeal abscess, high dose penicillin plus beta-lactamase inhibitors such as amoxycillin-clavulanic acid can be used. Duration of treatment is guided by clinical and parameters of inflammation, and abscesses often need several weeks to resolve by conservative treatment. 

Erythromycin is effective in the treatment and prevention of S. pyogenes and other streptococcal infections, but not those caused by the more resistant fecal streptococci. Staphylococci are generally susceptible to erythromycin, so this antibiotic is a suitable alternative drug for the penicillin-hypersensitive individual. It is a second-line drug for the treatment of gonorrhea and syphilis. Although erythromycin is popular for the treatment of middle ear and sinus infections, including H. influenzae, possible erythromycin-resistant S. pneumoniae is a concern. 

Amoxicillin is the first-line treatment as it treats most pathogens involved in sinusitis. However, Mr JC is allergic to penicillin and therefore alternative antibiotics are indicated doxycycline or a macrolide antibiotic would be a suitable alternative in this patient. 

A 56-year-old chronic intranasal cocaine abuser with a visible nasal defect presented with a hole in the roof of his mouth. He had been reportedly drug free for 2 weeks. He had an oronasal fistula with adjacent black necrotic areas and erosive destruction of the nasal septum, turbinates, and antrum, with mucoperiosteal thickening of the sphenoid and maxillary sinuses. Treatment included antibiotics and a prosthesis plate construction... 

Piccirillo JF, Mager DE, Frisse ME, et al. Impact of first-line vs second-line antibiotics for the treatment of acute uncomplicated sinusitis. JAMA 2001 286 1849-1856. 

Ciprofloxacin is a fluoroquinolone antibiotic that interferes with microbial DNA synthesis. It is indicated in the treatment of infections of the lower respiratory tract, skin and skin structure, bones and joints, urinary tract gonorrhea, chancroid, and infectious diarrhea caused by susceptible strains of specific organisms typhoid fever uncomplicated cervical and urethral gonorrhea women with acute uncomplicated cystitis acute sinusitis nosocomial pneumonia chronic bacterial prostatitis complicated intra-abdominal infections reduction of incidence or progression of inhalational anthrax following exposure to aerosolized Bacillus anthracis. Cipro IV Used for empirical therapy for febrile neutropenic patients. 

Levofloxacin is a fluoroquinolone/ophthalmic/antibiotic that interferes with microbial DNA synthesis. It is indicated in the treatment of acute maxillary sinusitis, acute bacterial exacerbation of chronic bronchitis, nosocomial pneumonia, community-acquired pneumonia, skin and skin structure infections, chronic bacterial prostatitis, urinary tract infection (UTI), inhalational anthrax (postexposure), and acute pyelonephritis caused by susceptible strains of specific microorganisms. Ophthalmic use is for the treatment of conjunctivitis caused by susceptible strains of aerobic Gram-positive and aerobic Gram-negative microorganisms. 

Loracarbef, a synthetic beta lactam antibiotic of the car-bacephem class (200 to 400 mg p.o. q. 12 hours), is used in the treatment of secondary bacterial infections of acute bronchitis, acute bacterial exacerbations or chronic bronchitis, of pneumonia, pharyngitis, tonsillitis, sinusitis, acute otitis media, uncomplicated skin and skin-structure infections, impetigo, uncomplicated cystitis, and in uncomplicated pyelonephritis. 

The goal in treatment of sinusitis is eradication of infection with clearance of the infected material from the sinuses. While the use of an appropriate antibiotic is necessary, the use of ancillary therapy is also of utmost importance. Steam and nasal saline, decongestants, topical corticosteroids, and mucoevacuants are given in an attempt to reduce nasal obstruction, increase sinus ostia size, promote improved mucociliary function, decrease mucosal inflammation, and thin secretions. In selected patients who fail to respond to aggressive medical therapy, functional endoscopic surgery can often provide relief. In patients with poorly controlled asthma, treatment of underlying sinusitis has been shown to dramatically improve the asthmatic state. 

Erythromycin is a macrolide antibiotic widely used for the treatment of upper and lower respiratory tract infections. Recent reports further showed that EM and its analogues are effective for the treatment of chronic airway diseases such as DPB, bronchial asthma, and chronic sinusitis [5, 15, 32]. This effectiveness is considered to be apart from their antimicrobial actions, because they are effective at half of the recommended dosage and even in cases without concomitant infection. Its precise mechanisms, however, remain unclear. Several cytokines including IL-1, TNF-a, and IL-8 have been reported to be elevated in HALF from patients with such airway inflammatory diseases (Table II), and to be decreased... 

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