Staphylococcus aureus on Sinus Culture Is Associated With Recurrence of Chronic Rhinosinusitis After Endoscopic Sinus Surgery

Abstract

Objectives: Identify whether identification of S. aureus on conventional culture is a predictor of success or failure after ESS followed by budesonide nasal irrigations (BUD) in chronic rhinosinusitis (CRS) patients at high risk of recurrence.Methodology: Prospective clinical trial including 116 patients from a tertiary care center at high-risk of disease recurrence following ESS+BUD. Blood samples, microbial swabs, and SNSS/SNOT-22 were taken on the day of surgery (Visit-1) and 4 months postoperatively (Visit-2). Outcomes were evaluated using symptoms and mucosal status as assessed by the Lund-Kennedy endoscopic score.Results: Seventy-five patients (69.4%) attained SNOT-22 MCID or higher. (Mean = 33.4, range 9–75). Objective documentation of recurrence of disease, as defined by combined endoscopic/symptomatic criteria, was noted in 58/116 patients (50%). Revision surgery was associated with a significantly higher rate of disease recurrence (60.0 vs. 28.0%; p < 0.001). Culture for Staphylococcus aureus was associated with disease recurrence, preoperatively and at 4 months post-surgery (p = 0.020; p < 0.001). This was restricted to post-operative cultures in the revision group (10.0 vs. 48.8%; p < 0.001). Other factors associated with poor outcome included intolerance to non-steroidal anti-inflammatory drugs (NSAID) (p = 0.036). Significantly higher Lund-Kennedy scores in the recurrence groups despite similar symptom intensity, emphasizing the importance of considering objective outcome in addition to patient-reported ones.Conclusion: Patients undergoing revision ESS are at high risk of disease recurrence, even when budesonide irrigations are used post operatively. Presence of S. aureus on culture pre-operatively or at 4 months post-ESS is associated with a negative outcome. This suggests that S. aureus negatively influences outcome, possibly via a number of mechanisms, including interactions with the (i) immune system, (ii) regeneration and repair of the sinus epithelium, or (iii) via interference with the sinus microbiome. This suggests that S. aureus may be a simple and inexpensive biomarker for disease severity and indicates a clear need to better appreciate S. aureus on how it contributes mechanistically to disease development and persistence in order to develop targeted therapeutic strategies.

Azithromycin in high‐risk, refractory chronic rhinosinusitus after endoscopic sinus surgery and corticosteroid irrigations: a double‐blind, randomized, placebo‐controlled trial

“…Using our group's criteria for high-risk patients, 5 we demonstrated through a prospective clinical trial that presence of pre-and post-ESS Staphylococcus aureus was a negative microbiologic biomarker for disease recurrence in patients having undergone ESS followed by saline irrigations with budesonide respules (BNI). 6 We further demonstrated S aureus's deleterious effect on epithelial repair, 7 which was in concordance with the clinical findings of the prospective trial.…”

“…The mechanism behind S aureus ’s CRS pathogenesis and tendency for poor prognosis has been described through various hypotheses, whether it be its biofilm‐forming capacities, 34 its intraepithelial presence, 35 its potential for immunity reduction, 36 or its impairment of epithelial repair, 7 among others. What remains evident is that S aureus is a strong marker for CRS outcome, both pre‐ and post‐ESS. 6 The benefit of adding AZI, and its capacity to influence S aureus clearance, is demonstrated clinically in this study, whereas our group also previously showed that the mechanism behind this effect may be associated with the CRS epithelium healing properties AZI has through its rho‐kinase inhibitor‐like properties, even in the presence of S aureus .…”

“…What remains evident is that S aureus is a strong marker for CRS outcome, both pre-and post-ESS. 6 The benefit of adding AZI, and its capacity to influence S aureus clearance, is demonstrated clinically in this study, whereas our group also previously showed that the mechanism behind this effect may be associated with the CRS epithelium healing properties AZI has through its rho-kinase inhibitorlike properties, even in the presence of S aureus. 7 Furthermore, we recently reported with an in-depth 16S rRNA microbiome analysis that patients on a low-dose AZI regimen showed a significant decrease in the abundance of sinonasal S aureus variants, whereas patients on placebo instead showed a decrease in key species regulating a healthy sinonasal microbiome, such as Bacteroides vulgatus and Lachnospiraceae spp, resulting in a significant decrease in microbial diversity, which may in part be responsible for disease persistence.…”

Low‐dose and long‐term azithromycin significantly decreases Staphylococcus aureus in the microbiome of refractory CRS patients

“…aureus has often been reported and associated with refractory CRS. [47][48][49] It is interesting to see that azithromycin may play a role in decreasing this pathogen in such a difficult-to-treat population. Its underlying anti-staphylococcal mechanism of action remains to be clarified.…”

“…S. aureus has often been reported and associated with refractory CRS 47‐49 . It is interesting to see that azithromycin may play a role in decreasing this pathogen in such a difficult‐to‐treat population.…”