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Azithromycin add-on therapy in high-risk postendoscopic sinus surgery patients failing corticosteroid irrigations: A
Anastasios Maniakas1, Martin Desrosiers
1Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, PQ, Canada.
Background:
Chronic rhinosinusitis (CRS) has a high potential for recurrence after endoscopic sinus surgery (ESS), despite a postoperative therapy of topical corticosteroid irrigations. Azithromycin (AZI) is a macrolide antibiotic with anti-inflammatory properties that may be of benefit in such steroid-unresponsive patients. Follow-up study was performed to (1) review the effectiveness of the management strategy of adding AZI in high-risk post-ESS patients failing standard management and (2) identify predictive factors for steroid nonresponsiveness.
Methods:
A retrospective audit of the postoperative evolution of all patients undergoing ESS for CRS in 2010 by a single surgeon was undertaken. Patients deemed at high risk of recurrence based on preoperative history and/or perioperative findings received nasal irrigation with 0.5 mg of budesonide (BUD) in 240 mL of saline twice daily after ESS. Patients showing signs of endoscopic recurrence at 4 months, despite BUD, had AZI at 250 mg three times a week added to their treatment regimen.
Results:
A total of 57 high-risk patients underwent ESS during this period. At 4 months, 63.2% (36/57) had a favorable outcome solely with BUD. Twelve of the 21 nonresponders received AZI, with an additional 66.7% (8/12) subsequently showing a favorable response. Failure of BUD was associated with female gender (p = 0.048), having elevated alpha-1-antitrypsin levels (p = 0.037) and lower recovery rates of Staphylococcus aureus (p = 0.063). Although the AZI subgroup was too small for statistical analysis, female gender was more frequently associated with failure of both BUD and AZI, while IgE was not useful.
Conclusion:
A significant subgroup of high-risk patients showing disease recurrence after ESS despite topical corticosteroid therapy may respond to the addition of AZI as part of their therapy. These findings suggest that topical steroid-unresponsive CRS may represent a distinct entity and that alternate anti-inflammatory agents may be required for optimal management.
Insights
Adding azithromycin (AZI) to budesonide (BUD) irrigation improved outcomes for high-risk chronic rhinosinusitis patients after surgery who did not respond to steroids. Female gender and elevated alpha-1-antitrypsin levels predicted poor response to BUD.
Area of Science:
- Otolaryngology
- Pharmacology
- Immunology
Background:
- Chronic rhinosinusitis (CRS) frequently recurs after endoscopic sinus surgery (ESS).
- Standard postoperative care includes topical corticosteroid irrigations, but some patients remain steroid-unresponsive.
- Azithromycin (AZI), a macrolide antibiotic, possesses anti-inflammatory properties beneficial for steroid-resistant cases.
Purpose of the Study:
- To evaluate the effectiveness of adding AZI to budesonide (BUD) irrigation for high-risk post-ESS CRS patients.
- To identify predictors of steroid nonresponsiveness in this patient population.
Main Methods:
- A retrospective audit of 57 high-risk CRS patients undergoing ESS in 2010.
- High-risk patients received BUD irrigation post-ESS.
- Nonresponders at 4 months received adjunctive AZI therapy.
Main Results:
- 63.2% of patients achieved favorable outcomes with BUD alone.
- An additional 66.7% of BUD nonresponders responded favorably after adding AZI.
- Female gender, elevated alpha-1-antitrypsin, and lower Staphylococcus aureus recovery predicted BUD failure.
Conclusions:
- Adjunctive AZI therapy can be effective for high-risk CRS patients with recurrent disease despite topical corticosteroids.
- Topical steroid-unresponsive CRS may be a distinct entity requiring alternative anti-inflammatory agents.
- Further research into alternative treatments for steroid-resistant CRS is warranted.
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