Current management of upper respiratory tract and head and neck infections

The objective of this study is to present the antimicrobial management modalities of treating upper respiratory tract (URT) and head and neck infections. This article discusses the current antimicrobial treatment strategies of URT and head and neck infections. The increasing antimicrobial resistance of many bacterial pathogens has made the treatment of URT and head and neck infections more difficult. This review summarizes the aerobic and anaerobic microbiology and antimicrobials therapy of acute and chronic URT and head and neck infections. These infections include dental (gingivitis, periodontitis, necrotizing ulcerative gingivitis, and periodontal abscess), acute and chronic otitis media, mastoiditis and sinusitis, pharyngo-tonsillitis, peritonsillar, retropharyngeal and parapharyngeal abscesses, suppurative thyroiditis, cervical lymphadenitis, parotitis, siliadenitis, and deep neck infections including Lemierre syndrome. In conclusion, the proper management of these infections requires an accurate clinical and bacteriological diagnosis.     

Microbiology and antimicrobial management of sinusitis

Sinusitis generally develops as a complication of viral or allergic inflammation of the upper respiratory tract. The bacterial pathogens in acute sinusitis are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis, while anaerobic bacteria and Staphylococcus aureus are predominant in chronic sinusitis. Pseudomonas aeruginosa has emerged as a potential pathogen in immunocompromised patients and in those who have nasal tubes or catheters, or are intubated. Many of these organisms recovered from sinusitis became resistant to penicillins either through the production of beta-lactamase (H. influenzae, M. catarrhalis, S. aureus, Fusobacterium spp., and Prevotella spp) or through changes in the penicillin-binding protein (S. pneumoniae). The pathogenicity of beta-lactamase-producing bacteria is expressed directly through their ability to cause infections, and indirectly through the production of betalactamase. The indirect pathogenicity is conveyed not only by surviving penicillin therapy, but also by 'shielding' penicillin-susceptible pathogens from the drug. The direct and indirect virulent characteristics of these bacteria require the administration of appropriate antimicrobial therapy directed against all pathogens in mixed infections. The antimicrobials that are the most effective in management of acute sinusitis are amoxycillin-clavulanate (given in a high dose), the newer quinolones (gatifloxacin, moxifloxacin) and the second generation cephalosporins (cefuroxime, cefpodoxime, cefprozil or cefdinir). The antimicrobials that are the most effective in management of chronic sinusitis are amoxycillinclavulanate, clindamycin and the combination of metronidazole and a penicillin.     

The effects of antimicrobials and exposure to smoking on bacterial interference in the upper respiratory tract of children

Interactions between micro-organisms that include antagonism (interference) and synergism maintain balance between members of the normal endogenous flora, and play a role in preventing colonization by potential pathogens. Bacteria with interference capability of potential respiratory tract pathogens include alpha-hemolytic streptococci, non-hemolytic streptococci, Prevotella spp. and Peptostreptococcus spp. The role of bacterial interference in the occurrence of upper respiratory tract infections and its effect on their eradication is discussed. The infections include otitis media, sinusitis and pharyngo-tonsillitis. Treatment with antimicrobial agents and direct and indirect exposure to smoking, can affect the balance between the interfering organisms and potential pathogens. Introduction into the indigenous microflora of low virulence bacterial strains that are capable of interfering with colonization and infection with virulent organisms has been used to prevent the failure of antimicrobials in the treatment of pharyngo-tonsillitis and otitis media.     

Effect of telithromycin and azithromycin on nasopharyngeal bacterial flora in patients with acute maxillary sinusitis

OBJECTIVE: To explore the efficacy of the ketolide telithromycin compared with azithromycin in eradicating S pneumoniae from the nasopharynx of adults with acute maxillary sinusitis. The growing resistance of Streptococcus pneumoniae to penicillin and macrolides brought about the development of a new class of antibiotics-the ketolides-that are effective against resistant pneumococci. SETTING: Otolaryngology clinic. PATIENTS: One-hundred five patients with acute maxillary sinusitis. INTERVENTIONS: Nasopharyngeal cultures were obtained before therapy and 10 to 12 days after initiation of treatment. Fifty-nine patients were treated with 500 mg of azithromycin daily for 3 days and 46 were treated with 800 mg of telithromycin daily for 5 days. RESULTS: Sixty-seven potential pathogens were recovered prior to initiation of therapy in 57 patients, 32 treated with telithromycin and 25 treated with azithromycin: S pneumoniae (31 isolates), Haemophilus influenzae (non-type b) (13), Staphylococcus aureus (8), Streptococcus pyogenes (8), and Moraxella catarrhalis (7). The distribution of the pathogens was similar in both groups. The number of S pneumoniae isolates in the azithromycin group was reduced following treatment from 14 to 8 (43% reduction), and 5 of these 8 isolates were resistant to azithromycin. In contrast, the number of S pneumoniae isolates in the telithromycin group was reduced following treatment from 17 to 1 (94% reduction) (P < .01). This isolate was susceptible to azithromycin and telithromycin. No differences were noted in the eradication rate of all of the other potential pathogens, which were all susceptible to both azithromycin and telithromycin. Development of resistance to the antimicrobial agents used (defined as increase in the minimal inhibitory concentration by at least 2 tubes) was found only in 5 isolates (4 S pneumoniae and 1 H influenzae) recovered only from patients who received azithromycin (P < .05). CONCLUSION: These data illustrate the superiority of telithromycin to azithromycin in the eradication of S pneumoniae from the nasopharynx.     

Nonsurgical treatment of sinusitis

Acute infections of the paranasal sinuses is an infrequent complication of viral upper respiratory infections. Prolonged or repeated episodes of acute sinusitis may lead to irreversible changes in the mucosa, resulting in chronic sinusitis. In hospitalized and immunocompromised patients sinusitis may be caused by unusual and resistant bacteria or fungi. Although sinusitis is often considered as merely an annoyance, complications can be associated with significant morbidity and mortality. Therapy of acute sinusitis is often empiric and directed against the most common pathogens. Fungal infections of the sinuses often require surgery as well as amphotericin-B therapy. In hospitalized or immunocompromised patients therapy should be directed at suspected nosocomial pathogens or be based on appropriate culture material.     

Group C streptococcal sinusitis

The group C streptococci have emerged as important human pathogens. A case of group C streptococcal sinusitis in a 6-year-old girl is reported and four cases of group C streptococcal sinusitis are reviewed. Age less than 18 years, central nervous system complications, and a delay in the institution of adequate therapy were features common to all five cases. Three patients were bacteremic with group C streptococci and two patients died. These cases suggest that when beta-hemolytic streptococci are isolated from sinus culture, serogrouping should be performed. When group C streptococci are identified, appropriate antimicrobial therapy should be instituted and one should be alert for suppurative intracranial complications.     

Microbiology and antimicrobial treatment of orbital and intracranial complications of sinusitis in children and their management

This review describes the microbiology, and medical management of orbital and intracranial complications of sinusitis in children. The most common complications are orbital cellulitis, subperiosteal abscess, orbital abscess, brain abscess, subdural empyema and meningitis. The predominate organisms recovered from these infection are anaerobic, aerobic, and microaerophilic bacteria of oral flora origin. Establishing the microbiology by obtaining appropriate cultures for both aerobic and anaerobic bacteria are essential for proper antimicrobial selection. Early recognition and appropriate surgical and medical therapy are essential to ensure recovery.     

The role of bacteria in chronic rhinosinusitis

Sinusitis generally develops as a complication of viral or allergic inflammation of the upper respiratory tract. The bacterial pathogens in acute sinusitis are S. pneumoniae, H. influenzae, and M. catarrhalis, while anaerobic bacteria and S. aureus predominant in CRS.     

Humoral immunodeficiency in recurrent upper respiratory tract infections. Some basic, clinical and therapeutic features

Adequate surface protection of the upper airway tract depends on intimate co-operation between natural non specific defence mechanisms such as ciliary function and acquired adaptative immunity. The latter is mediated by specific antibodies mainly belonging to secretory immunoglobulin A (SIgA) and to lesser extent secretory IgM (SigM) as well as by serum derived and locally produced IgG. Immunoglobulin's deficiency may exist in a significant percentage of patients with chronic or recurrent infections of the upper respiratory tract. So an immunologic screening should be extended to patients who have persistent sinus infection, despite normal mucocilary and ventilation patterns, inadequate response to antimicrobial therapy, culture of unusual pathogens from the upper respiratory tract or history of infection at other side, mainly bronchopulmonary. The therapeutic aspects include immunoglobulin replacement or mucosal immunogens whose efficacy is related with both an unspecific and a specific way. In the future, cytokines will probably become the strongest therapy of the immunoglobulin's deficiency.     

Sinusitis--judicious antibiotic treatment

The paper presents different forms of sinusitis in children and adults as well as the patomechanism of sinusitis of infective and non-infective origin. The role of bacterial infection has been discussed. Participation of major pathogens of URTI such as S. pneumoniae, H. influenzae and M. catarrhalis has been highlighted and the factors influencing growth of their antibiotic-resistant stains. Guidelines concerning antibiotic therapy in children and adults, depending on disease course, age and factors influencing growth of resistant stains have been presented. Causes of failure in treatment of sinusitis have been analysed eg. in case of bacterial biofilm growth or non-neutrophilic inflammation forms. Antimicrobial treatment concerns mainly acute and aggravated infections. In case of chronic sinusitis, antibiotic therapy is complementary to surgical treatment.     

beta-Lactamase-producing bacteria recovered after clinical failures with various penicillin therapy

The presence of beta-lactamase-producing bacteria in clinical specimens was investigated in 185 children with orofacial or respiratory tract infections. All of these patients failed to respond to antimicrobial therapy, including penicillins, that was administered to 148 (80%) of them. beta-Lactamase-producing aerobic and anaerobic bacteria were detected in 75 (40.5%) of the 185 children. The beta-lactamase-producing strains included all 11 strains of the Bacteroides fragilis group, 30 (45.4%) of the 66 strains of Bacteroides melaninogenicus group, five (41.7%) of the 12 strains of Bacteroides oralis, and 41 (97.6%) of 42 strains of Staphylococcus aureus. All beta-lactamase-producing Bacteroides strains were resistant to penicillin as compared with the non-beta-lactamase-producing strains. Clinical cure was achieved after surgical drainage and a change in antimicrobial therapy in most of the patients. In treatment of orofacial and respiratory tract infections, the clinician should consider the presence of beta-lactamase-producing Bacteroides sp and S aureus as a possible cause of clinical failure with various penicillin therapies.     

Efficacy and safety of garenoxacin in the treatment of upper respiratory tract infections

Objective

To determine the efficacy and safety of garenoxacin, a new generation of quinolone antimicrobial agent, in the treatment of adult upper respiratory tract infections.

Methods

A total of 113 subjects were enrolled in this study. Garenoxacin (400 mg/day) was administered to patients with pharyngolaryngitis, tonsillitis, and otitis media for 5–7 days and to those with sinusitis for 7–10 days. Clinical symptoms and findings were examined and quantitatively evaluated using a scoring system.

Results

We found 80 to 100% improvement rate in symptoms and findings for each infection. In addition, we found significant improvement in subjective evaluations from patient questionnaires even in the early stage of the treatment. X-ray examination for acute sinusitis demonstrated that the clinical efficacy was 84% (27/32) and 76% (19/25) patients were already improved within seven days. Among the detected 84 bacteria, 75 (89%) were identified as the major pathogenic bacteria of respiratory tract infections such as Streptococcus pneumoiae (27 strains) and Haemophillus influenzae (14 strains). Garenoxacin administration completely eradicated bacteria in 53 out of 54 cases (98%). There were 8 adverse events (8.3%) including 3 diarrhea cases (3.1%).

Conclusion

These results suggest that garenoxacin is a highly effective and safe antimicrobial agent in the treatment of community-acquired upper respiratory infections. Additionally, garenoxacin did not induce the growth of resistant bacteria because of its strong antimicrobial activity.     

Use of a new antimicrobial preparation baliz-2 in inflammatory diseases of paranasal sinuses

Conservative therapy of 104 patients with acute and chronic sinusitis included a new antimicrobial drug--Balis-2--administered into the affected sinuses. After 1 to 3 punctures the recovery was observed in all patients (34 patients) with acute sinusitis and in 54 out of 70 patients (77.1%) with chronic sinusitis. Balis-2 is recommended for a wide application in the therapy of sinusitis.     

Pott's Puffy Tumor and Epidural Abscess Arising From Dental Sepsis: A Case Report

Objective To present an unusual case of two uncommon cranial complications of frontal sinusitis: Pott's puffy tumor and epidural abscess arising from frontal sinusitis of dental origin, and also two systemic complications of sinusitis: septicemia and empyema, all occurring in an immunocompetent patient. Study Design A 21‐year‐old man presented with a scalp swelling and epidural abscess. Magnetic resonance imaging and computed tomographic scans revealed unilateral opacification of the frontal sinus and an epidural abscess with a direct connection to the scalp abscess. Further history revealed that his symptoms occurred coincidentally with a tooth extraction 2 months before, and he was hospitalized soon after the tooth extraction for sepsis and a lung abscess. Methods A combined neurosurgical and otolaryngologic approach was required to treat the sinusitis and the associated epidural and scalp abscess. Results Cultures returned as Streptococcus intermedius from all three sites. The patient was free of disease at the 3‐month follow‐up. Conclusions Odontogenic maxillary sinusitis is well documented; however, there is little reported of frontal sinusitis arising from dental disease. The prevalence of sinusitis of dental origin will be reviewed, including the microbiology of this particularly virulent organism that persisted despite earlier treatment with ampicillin. Also, the current thoughts on management of these cases will be discussed with particular reference to local therapy for sinusitis in addition to systemic treatment with antibiotics.     

An antimicrobial peptide modulates epithelial responses to bacterial products

INTRODUCTION: Changes in the respiratory epithelium and chronic and recurrent infections are thought to play a central role in the pathogenesis of otitis media and sinusitis. The airway epithelium is the primary defense system of the respiratory tract. Bacterial cell membrane components like lipopolysaccharide (LPS) and lipoteichoic acid (LTA) can affect the mucociliary clearance function of the respiratory epithelium. P60.4-Ac is a synthetic antimicrobial peptide based on the structure of the cathelicidin LL-37 that neutralizes the pro-inflammatory activity of LPS and LTA. MATERIALS AND METHODS: Normal respiratory sinus epithelium was cultured at the air liquid interface. The cells were incubated with LPS or LTA in the presence or absence of P60.4-Ac. RESULTS: P60.4-Ac neutralized the LPS- and LTA- induced effect on air-liquid interface cultured epithelial cells. P60.4-Ac significantly inhibited the increase in the epithelial layer caused by LPS or LTA. CONCLUSION: These data demonstrate that P60.4-Ac might be of clinical benefit in the management of otitis media with effusion and sinusitis.     

Resistant microorganisms in head and neck infections

The key pathogens most commonly associated with acute infections in the upper respiratory tract include Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis and Streptococcus pyogenes. Antimicrobial resistance amongst these organisms to many of the commonly used agents for treatment continues to evolve. S. pneumoniae is probably the most important pathogen in the respiratory tract and antimicrobial resistance of this organism to many drugs appears to be rising. For some organisms, such as S. pyogenes, resistance to standard therapy such penicillin has not been described. For others, such as M. catarrhalis, beta-lactamase production has become the norm, with over 90% of isolates now producing this enzyme. One of the major drivers of resistance continues to be the overuse and misuse of antibiotics in the community. This is complicated by the fact that most therapy is empiric and the exact etiology of a patient's infection is not known. Despite the fact that the clinical impact of antibiotic resistance on patient outcomes is not always clear, it remains prudent to consider the issue of resistance when selecting therapy for a patient and to continue to strive for appropriate antibiotic use as a means to stem the tide of evolving resistance.     

A treatment for primary ciliary dyskinesia: Efficacy of functional endoscopic sinus surgery

Primary ciliary dyskinesia (PCD) is an inherited disorder manifested in children as chronic otomastoiditis, recurrent pneumonia, and chronic sinusitis. The failure of the ciliary beat pattern to effectively function in the respiratory tract produces stasis of secretions with secondary inflammation, edema, and infection. The authors report three young children with PCD who presented with variable severities of symptoms. Each had the aforementioned respiratory tract problems. The child with the most severe symptomatology was treated with a variety of medical options, including long-term gamma globulin injections, but hospitalizations persisted twice per month because of severe sinopulmonary illness. All three of the children underwent functional endoscopic sinus surgery (FESS). In addition, two children received pressure equalization (PE) tubes. One child required a revision procedure. Their surgical outcomes are discussed. Follow-up of FESS in three children with this disorder shows a marked improvement in symptomatology with a decreased incidence of hospitalization and a somewhat decreased need for medical therapy.     

Chronic sinusitis and the yellow nail syndrome

Diagnosing syndromes that include chronic sinusitis can expedite the management of both conditions. Yellow nail syndrome is usually described as the combination of yellow nails, lymphoedema and often respiratory manifestations such as chronic sinusitis, bronchiectasis and pleural effusions. The pathology responsible for the syndrome is believed to be lymphatic hypoplasia. Diagnosis of yellow nail syndrome is clinical not requiring any specialized tests. In the two cases described, the respiratory tract manifestations required the most active investigation and management. The significance of this syndrome to the otolaryngologist is discussed.     

Microbiology of acute exacerbation of chronic sinusitis

OBJECTIVES: We undertook to evaluate the microbiology of acute exacerbation of chronic sinusitis (AECS). METHODS: Repeated aspirations of maxillary sinus secretions by endoscopy were performed in 7 patients over a period of 125 to 242 days. RESULTS: Bacteria were recovered for all 22 aspirates, and the number of isolates was between 2 and 4. A total of 54 isolates were isolated: 16 aerobic and facultative bacteria and 38 anaerobic bacteria. The aerobic bacteria were Haemophilus influenzae (7 isolates), Streptococcus pneumoniae (3), Moraxella catarrhalis (3), Staphylococcus aureus (2), and Klebsiella pneumoniae (1). The anaerobic bacteria included pigmented Prevotella and Porphyromonas spp (19), Peptostreptococcus spp (9), Fusobacterium spp (8), and Propionibacterium acnes (2). A change in the types of isolates was noted in all consecutive cultures obtained from the same patients as different organisms emerged and previously isolated bacteria were no longer recovered. An increase in antimicrobial resistance was noted in 6 instances. CONCLUSIONS: This study illustrates the microbial dynamics of AECS in which anaerobic and aerobic bacteria prevail, and highlights the importance of obtaining cultures from patients with AECS for guidance in selection of proper antimicrobial therapy.     

Tuberculosis of the nasopharynx: clinicopathological features

The clinicopathological features of 10 adult patients with nasopharyngeal tuberculosis (TB) are presented. 9 patients had no evidence of chest or systemic disease. 7 patients presented with cervical lymphadenopathy, and only 4 had nasal symptoms. Examination of the nasopharynx showed no abnormality in 2 patients, lymphoid hyperplasia in 4 patients, and a tumour-like mass in 4 patients. These findings suggest that nasopharyngeal TB may occur more frequently as part of an isolated upper respiratory tract infection than as secondary to pulmonary infection. The nasopharynx may be a portal of entry for tubercle bacilli in patients who develop cervical lymphadenitis. Involvement of the nasopharynx by TB may be underdiagnosed because it does not produce obvious symptoms or physical signs in all cases.