Culture‐inappropriate antibiotic therapy decreases quality of life improvement after sinus surgery

Abstract

Background Despite their widespread use, antibiotics have not been shown to improve chronic rhinosinusitis (CRS) outcomes. We aimed to determine whether culture-inappropriate postoperative antibiotic therapy was associated with less quality of life (QOL) improvement following functional endoscopic sinus surgery (FESS). Methods This retrospective cohort study recruited 376 adult CRS patients undergoing FESS between 10/1/2007 to 12/31/2011. Patient demographics, comorbidities and medications were collected at baseline. Trimethoprim-sulfamethoxazole and clindamycin were administered for 2 weeks postoperatively. The antibiotic appropriateness was determined based on bacterial resistance profile of organisms identified during intraoperative culture. The QOL outcome was defined as change of 22 item Sinonasal Outcome Test scores from preoperative visit to 1-, 3- and 6-month post-FESS. Clinically significant difference was defined as at least ½ SD of baseline QOL score in the reference group. Mixed-effects regression models were performed. Results Seven percent of patients (n=27) had culture-inappropriate antibiotic therapy, and additional 5% (n=19) had culture-specific antibiotic adjustment. Compared to patients with culture-appropriate antibiotics, patients with culture-inappropriate antibiotics had significantly less improvement of QOL from baseline to postoperative 1-month and 3-month follow-up where the difference became clinically significant; patients with antibiotic adjustment had more QOL improvement from baseline to 1-month follow-up, but their QOL worsened at 3-month follow-up, and these changes were not clinically significant. However, all effects washed out at 6-month follow-up with no significant differences. Conclusions Culture-inappropriate postoperative antibiotic therapy decreased short-term QOL improvement to a clinically meaningful level after FESS. Culture guided selection of antibiotics may improve short-term FESS outcome.

Comparison of outcomes following culture‐directed vs non–culture‐directed antibiotics in treatment of acute exacerbations of chronic rhinosinusitis

“…A prior study suggested that in the short term, patients who receive culture‐inappropriate antibiotics have less QOL improvement based on change in SNOT‐22 score compared to those who receive culture‐appropriate antibiotics . However, this difference was insignificant after a 6‐month follow‐up.…”

“…In a study by Zhang et al., only 7% of patients treated empirically with trimethoprim/sulfamethoxazole and clindamycin were found to have culture‐inappropriate antibiotics. This is far less than 2 other studies that reported a 51.4% and 77% change in antibiotics based on culture results .…”

“…Endoscopic‐guided cultures and use of culture‐directed antibiotics result in improved sinonasal symptoms and QOL outcome scores, although this has not been directly compared to empiric antibiotics . In previous studies, patients treated with culture‐ inappropriate antibiotics (eg, those not covered by culture sensitivity profiles) have decreased QOL improvement compared to those treated with culture‐appropriate antibiotics, but this difference was no longer apparent at 6‐month follow‐up …”

Quality of life improvement from sinus surgery in chronic rhinosinusitis patients with asthma and nasal polyps

“…For example, history of prior FESS was not significantly associated with the changes of SNOT-22 scores in our study, which was consistent with our previous study. 27 Smith et al 26 found patients undergoing primary surgery were significantly more likely to improve on the QOL measured by RSDI and CSS after an average of 17.4 months postoperative follow-up. The differences in our findings can be due to many reasons, such as the different QOL instruments, different clinical factors collected and evaluated as potential confounders, and different lengths of follow-up.…”

Are multiple sinus cultures necessary during sinus surgery for chronic rhinosinusitis?

“…As mentioned in the introduction culture‐directed antibiotics have demonstrated improvement in quality of life measures in patients with CRS. Additionally, previous studies have demonstrated the importance of postoperative antibiotic adjustment based on culture results to facilitate recovery following ESS . This study did not seek to evaluate the effect of antibiotic treatment on long‐term effect of culture‐directed antibiotic treatments on patients’ clinical course.…”