Efficacy of a 5-day course of telithromycin in the treatment of acute maxillary sinusitis caused by drug-resistant Streptococcus pneumoniae

VOLUME 109, NUMBER 1 883 Efficacy nfa 5-Day Course of Telithromycin in the Treatment of Acute Maxillary Sinusitis Caused by Drug-Resistant Streptococcus Pneumoniae Patricia Buchanan*, Thad Stephens§, Hal Galbraith~, Carolyn Andrade¥, Bruno Leroy• *River Road Medical Group, Eugene, OR §ForeSite, LLC, Kansas City, MO YQuintiles, Incorporated, Kansas City, MO CAventis Pharmaceuticals, Bridgewater, NJ BACKGROUND: Most clinicians are in agreement that allergies can contribute to the development of sinusitis. In addition, effective treatment of sinusitis leads to improved asthma symptoms. Available options for empiric treatment of acute maxillary sinusitis (AMS) are increasingly limited by the rising prevalence of antibacterial resistance among common respiratory pathogens. The results of a study of short-course (5-day) therapy with telithromycin (TEL), the first ketolide antibacterial, in patients with AMS caused by drug-resistant Streptococcus pneumoniae are presented. METHODS: A total of 252 adults and adolescents with clinical signs and symptoms of AMS (>2 purulent/pain symptoms present for >7 days at entry; confirmed by radiology [presence of air fluid level and/or total sinus opacity and/or mucosal thickening >-10 mm] and sinus puncture/ endoscopy) were treated with TEL 800 mg once daily for 5 days in a phase 3, multicenter, double-blind study. Clinical and bacteriologic outcomes (per protocol) were assessed at the post-therapy/test-of-cure visit (days 17-21). RESULTS: In 27 patients with Spneumoniae isolates (single + multiple pathogens), the eradication rate was 88.9%. In total, 14 patients had pretreatment isolates resistant to penicillin G (MIC >2.0 mg/L) and/or erythromycin A (MIC >1.0 rag/L). A total of 93% (13/14) of isolates had telithromycin MICs _<0.5 mg/L. The erythromycin A-resistant isolates included 5 ermB+ and 7 merlE+ strains. In these patients, satisfactory clinical and bacteriologic outcomes were achieved in 85.7 % (12/14). CONCLUSION: A convenient 5-day course of TEL 800 mg once daily is an effective treatment for patients with AMS, achieving high clinical cure and eradication rates even in patients with infections caused by drug-resistant S pneumoniae, 8 Q A Actinomycosis of the Frontal Sinus: An Uncommon Cause of l ~ ' l t Chronic Sinusitis D Pattanaik, JU Coniglio, D Pulver University of Rochester Medical Center, Rochester, NY Actinomycosis of the paranasal sinuses is extremely rare. Involvement of the frontal sinus has never been reported before. There have been isolated case reports of actinomycosis involving the maxillary and ethmoidal sinuses only. We report here a case of 47-year-old man who presented to us with history of recurrent sinusitis of 1-year duration. He also had bilateral endoscopic sinus surgery of maxillary and ethmoidal sinuses along with septoplasty. In the past he was treated with several courses of oral antibiotics, antihistaminics and topical nasal steroids. He was referred to rule out allergies and immunodeficiency. He tested negative for any underlying primary immunodeficiency state mad Wegener's granulomatosis. The skin test was positive to multiple aeroallergens and allergen immunotherapy was started. How ever he had multiple relapses of acute sinusitis in next six to twelve months. Repeat CT scan of the sinuses showed significant disease of the frontal sinuses. This led to further surgery of the ethmoidal and frontal sinuses (bilateral ethmoidectomy revision with left frontal osteoblastic trephination and indwelling stent placement). Culture of the drained sinus fluid grew Pseudomonas aeruginosa that was sensitive to ciprofloxacin. He was treated appropriately with antibiotics and the stent was removed. He did relatively well for few months. Then he emergently presented to the ENT clinic with severe headache and left frontal swelling. The swelling was aspirated and sent for culture and sensitivity. CT scan of the head revealed complete opacification of the frontal sinuses, but there was no intracranial extension. He was taken urgently to the operating room and bilateral frontal sinus obliteration with iliac crest bone was done. Post operatively he was started empirically on ceftriaxone, ciprofloxacin and clindamycin. Later both the sinus biopsy tissue and the aspirated pus grew actinomyces on culture. Currently, five months after surgery he is asymptomatic with no further relapse. To the best of our knowledge, this is the first case report of actinomycosis involving the frontal sinus. Surgery combined with prolonged course of treatment with antibiotics is recommended for actinomycosis involving the sinuses. 8 8 5 Specific Inflammatory Cel, Types and Disease Severity as Pro dictors of Post Surgical Outcomes in Patients With Chronic Sinusitis Jaqueline Moran, DB Conley, LC Grammer, GK Haines, Anne Marie Ditto Northwestern University Medical School, Chicago, IL Chronic Sinusitis is a common condition which is frequently refractory to medical and surgical intervention. It has not been well defined which patient subgroups benefit from surgical intervention and which do not. We have reported experience with endoscopic sinus surgery in patients with asthma and sinusitis, as well as the magnitude of local tissue inflammation in these patients despite corticosteroid therapy. We now present data on the significance of specific markers of inflammation, as well as the amount of required perioperative antibiotic therapy as potential predictors of postoperative outcomes. Improvement was defined as a decrease in the number of antibiotic courses for 1 year post-operatively, when compared with 1 year pre-operatively. Patients were selected via retrospective chart review of 75 patients who underwent endoscopic sinus surgery or polypectomy between 1994 and 1997. Some of these patients underwent their first surgery, while others underwent revision of a previous surgery. Fifteen patients met the following selection criteria: chronic sinusitis, one year preoperative and one year post-operative follow up for endoscopic sinus surgery or polypectomy and asthma requiring inhaled or oral corticosteroids. Sections of sinus tissue obtained at surgery for 10 of the patients were H&E stained and evaluated for lymphocytes, plasma cells, eosinophils, neutrophils and macrophages. Immunostains for T cells, B cells and macrophages were also performed. Total number of antibiotic courses were enumerated in 6 month blocks for I year pre-operatively and 1 year post-operatively as markers of disease activity. Neither total magnitude of inflammation or specific inflammatory cell types were predictors of surgical outcome. The patients who did not improve post-operatively had a statistically significant lower number of pre-operative antibiotics than the patients who improved. These findings are important because they may indicate patients with less severe disease are less likely to benefit from sinus surgery. Additional medical intervention may be indicated in this group of patients prior to consideration for operative intervention. Future prospective studies of specific select patient populations will help further delineate these groups.