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Acute Bacterial Rhinosinusitis

Acute Bacterial Rhinosinusitis. Brief Background. Typically follows viral infection Dx is by clinical manifestations Streptococcus pneumoniae , Haemophilus influenzae and, to a lesser degree , Moraxella catarrhalis. Treatment. Medical therapy

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Acute Bacterial Rhinosinusitis

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  1. Acute BacterialRhinosinusitis

  2. Brief Background • Typically follows viral infection • Dx is by clinical manifestations • Streptococcus pneumoniae, Haemophilusinfluenzae and, to a lesser degree, Moraxellacatarrhalis

  3. Treatment • Medical therapy • Fluoroquinolones: highly ranked among antibacterials • Surgery • For recurrent or persistent rhinosinusitis

  4. The Evidence • “Fluoroquinolonescompared with β-lactam antibiotics for the treatment of acute bacterial sinusitis: a meta-analysis of randomized controlled trials” • Screened 191 trials • Used 11 trials

  5. The Evidence • Validity • Meta-analysis ofRCTs comparing the effectiveness and safety of fluoroquinolonesand β-lactams in acute bacterial sinusitis • Inclusion criteria • Diagnosis based on clinical criteria • RCTs in other languages excluded • RCTs comparing fluoroquinolones with beta lactams

  6. Outcomes of the Meta-Analysis • Primary comparison • Respiratory fluoroquinolones vs. beta lactams • Secondary comparison • All fluoroquinolones vs. beta lactams • Effectiveness and safety outcomes • intention to treat population • clinically evaluable population • Bacteriologically evaluable population

  7. Assessing Methodology of the RCTs • reporting of adequate randomization procedures • allocation concealment • masking of the intervention • reporting of study withdrawals • reporting of patient crossovers between treatment arms • reporting of violation of the inclusion criteria

  8. Data Analysis • calculated pooled odds ratios (ORs) and 95% confidence intervals (CIs) • assessed publication bias

  9. Results • Primary effectiveness analysis • extent of clinical cure and improvement did not differ between fluoroquinolones and β-lactams (odds ratio [OR] 1.09, 95% confidence interval [CI] 0.85–1.39) at the test-of-cure assessment, which varied from 10 to 31 days after the start of treatment

  10. Results • Fluoroquinolones were associated with an increased chance of clinical success among the clinically evaluable patients in all of the randomized controlled trials (OR 1.29, 95% CI 1.03–1.63) and in 4 blinded randomized controlled trials (OR 1.45, 95% CI 1.05–2.00)

  11. Results • no statistically significant difference between fluoroquinolones and amoxicillin–clavulanate (OR 1.24, 95% CI 0.93–1.65).

  12. Results • Eradication or presumed eradication of the pathogens isolated before treatment was more likely with fluoroquinolone treatment than with β-lactam treatment (OR 2.11, 95% CI 1.09–4.08)

  13. Results • adverse events did not differ between treatments (OR 1.17, 95% CI 0.86–1.59) • In 2 blinded RCTs: more adverse events occurred with fluoroquinoloneuse than with β-lactamuse

  14. Applicability • Treatment is feasible since both are easily available • Benefit vs harm • Adverse events did not greatly differ between the two • Fluoroquinolones: diarrhea • Beta lactams: nausea • propensity for more adverse events in association with fluoroquinolone use was observed in sensitivity and exploratory analyses

  15. Main Findings • respiratory fluoroquinolones did not prove superior to β- lactams for the treatment of acute bacterial sinusitis in terms of clinical cure or total adverse events • marginal benefit of fluoroquinolones over β-lactams in terms of rapidity of symptom resolution • respiratory fluoroquinolones as a valuable therapeutic option for cases resistant to β-lactams

  16. Main Findings • use of respiratory fluoroquinolones as first-line therapy in the vast majority of patients with bacterial sinusitis, in whom the condition often has a benign clinical course, is not supported by the available evidence.

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