Erythromycin stearate in acute maxillary sinusitis

The use of macrolides in respiratory tract infections

Macrolides have enjoyed continued use for over 40 years, being increasingly usedfor the treatment of respiratory tract infections. Newer macrolides have been introduced that show improved absorption after oral administration, better gastrointestinal tolerance, and delivery of increased amounts of drug to the infection site. Macrolides are commonly used in community-acquired pneumonia, as well as in atypical pneumonia and legionellosis. The newer macrolides, in comparative studies, have been shown to be as effective as the conventional therapies for treating acute otitis media, acute sinusitis and acute pharyngitis, with a low incidence of side-effects. However, dosing can be simplified because of their unique pharmacokinetic properties. Limitations in the use of macrolides for respiratory infections include rather marginal activity in the most severe cases of Haemophilus influenzae infections, lack of activity against Klebsiella and other coliforms, which precludes their use as single agents in the therapy of pneumonia in patients with significant underlying disease or in the elderly, and development of resistance in streptococci and staphylococci.

Antibiotics for acute maxillary sinusitis

BACKGROUND

For adults seeking care in ambulatory medical practices, sinusitis is the most common diagnosis treated with antibiotics.

OBJECTIVES

We examined whether antibiotics are indicated for acute sinusitis, and if so, which antibiotic classes are most effective.

SEARCH STRATEGY

Relevant studies were identified from searches of MEDLINE and EMBASE in December 2001, contacts with pharmaceutical companies and bibliographies of included studies.

SELECTION CRITERIA

Randomized trials were eligible that compared antibiotic to control or antibiotics from different classes, for acute maxillary sinusitis. Additional criteria for inclusion were diagnostic confirmation by radiograph or sinus aspiration, outcomes that included clinical cure or improvement, and a sample size of 30 or more adults. Of 2058 potentially relevant studies, two or more reviewers identified 49 studies meeting selection criteria.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by two persons and synthesized descriptively. Some data were analyzed quantitatively using a random effects model. Primary outcomes were: a) clinical cure, and b) clinical cure or improvement. Secondary outcomes were radiographic improvement, relapse rates, and dropouts due to adverse effects.

MAIN RESULTS

Forty-nine trials, involving 13,660 participants, evaluated antibiotic treatment for acute maxillary sinusitis. Major comparisons were antibiotic versus control (n of 5); newer, non-penicillin antibiotic versus penicillin class (n of 10); and amoxicillin-clavulanate versus other extended spectrum antibiotics (n of 17), where n is the number of trials. Most trials were conducted in otolaryngology settings. Only 8 trials described adequate allocation and concealment procedures; 20 were double-blind. Compared to control, penicillin improved clinical cures [relative risk (RR) 1.72; 95% CI 1.00 to 2.96]. Treatment with amoxicillin did not significantly improve cure rates (RR 2.06; 95% CI 0.65 to 6.53) but there was significant variability between studies. Radiographic outcomes were improved by antibiotic treatment. Comparisons between classes of antibiotics showed no significant differences: newer non-penicillins versus penicillins (RR for cure 1.07; 95% CI 0.99 to 1.17); newer non-penicillins versus amoxicillin-clavulanate (RR for cure 1.03; 95% CI 0.96 to 1.11). Compared to amoxicillin-clavulanate, dropouts due to adverse effects were significantly lower for cephalosporin antibiotics (RR 0.47; 95% CI 0.30 to 0.73). Relapse rates within one month of successful therapy were 7.7%.

REVIEWER'S CONCLUSIONS

For acute maxillary sinusitis confirmed radiographically or by aspiration, current evidence is limited but supports the use of penicillin or amoxicillin for 7 to 14 days. Clinicians should weigh the moderate benefits of antibiotic treatment against the potential for adverse effects.

Outbreaks of infections with erythromycin-resistant group A streptococci in child day care centres

Erythromycin-resistant group A streptococci (ERGAS) are considered rare in Sweden. In the county of Halland (240,000 inhabitants) in southern Sweden, we had 294 isolates of ERGAS between January 1984 and June 1985. Almost all strains were of T-type 12 and only resistant to erythromycin (MIC values approximately 8 g/l). Seven child day care centres (DCC) were involved in the outbreaks and on average 49% of all children were infected in each outbreak. Employees were seldom infected (8%), but parents and siblings more often (23% and 36%). One course of phenoxymethylpenicillin succeeded in eradicating ERGAS from 75% of those infected. The ERGAS strains are now established in southern Sweden and account for about 2% of all group A streptococcal infections in the county of Halland.

Occipito-mental side projection radiography in childhood maxillary sinusitis

152 sinuses of children with acute maxillary sinusitis were roentgenographically examined with both a standard occipito-mental (OM) and an occipito-mental side (OMS) projection. In the acute phase of the disease the OMS projection was superior in 13% of sinuses in demonstrating the presence of retained maxillary secretion. When the result of medical treatment was controlled after two weeks the superiority was seen only in 1% of sinuses due to the major difference between the subgroups' 'mucosal thickening'. The clinical importance of the OM finding 'mucosal thickening' seems to be different in the acute and in the follow-up phase. From the clinical point of view single OM projection seems to be sufficient in most cases. However, the OMS projection seems to be a useful adjunct to or replacement of the standard OM radiogram in the acute phase of childhood maxillary sinusitis, if it is felt necessary to demonstrate the presence of retained secretion in spite of the increased radiation. When the result of treatment is evaluated, in unilateral cases OMS projection can replace OM projection.

Increased use of erythromycin causes resistance in Haemophilus influenzae

The use of erythromycin in Sweden has increased since 1975. An increasing prevalence of Haemophilus influenzae (H.i.) with reduced susceptibility to erythromycin has been noted in our laboratory during the years 1980 to 1985. The largest consumers of erythromycin were found to be children less than 4 years of age. Variations in resistance level of H.i. isolated from patients within this age group and variations in consumption of erythromycin were analysed for each year. The highest prevalence of resistant strains was found during spring and summer. The consumption of the antibiotic was highest during the first quarter of the year, gradually decreasing, and increasing sharply again during the fourth quarter of the year. Judging also from deviations from this pattern there seems to be an association between consumption and resistance. The different levels of resistance reported in the literature may reflect different populations of patients with different consumption of erythromycin, and different levels at different time of the year. Considering the present high level of H.i. with decreased susceptibility to erythromycin the drug is not likely to have clinical effect in H.i. infections.

Erythromycin: a microbial and clinical perspective after 30 years of clinical use (1)

Erythromycin is a macrolide that acts by inhibiting the translocation reaction during protein synthesis. Erythromycin is inactive against the Enterobacteriaceae and Pseudomonas aeruginosa except under alkaline conditions. Erythromycin is active against most gram-positive bacteria; some gram-negative bacteria, including Neisseria, Bordetella, Brucella, Campylobacter, and Legionella; and Treponema, Chlamydia, and Mycoplasma. The emergence of resistance to erythromycin is closely associated with its use and is often plasmid mediated. After its oral or parenteral administration, erythromycin diffuses readily into intracellular fluids and is actively concentrated intracellularly by polymorphonuclear leukocytes and alveolar macrophages.

The effect of erythromycin on the nasopharyngeal pathogens in children with secretory otitis media

Seventy-five children not older than 11 years, with secretory otitis media of more than 3 months' duration were randomly divided into two groups prior to myringotomy. One group remained untreated, whereas the other received erythromycin ethylsuccinate (Abboticin) in standard dosage for the last 10 days before surgery. Nasopharyngeal cultures were taken under general anaesthesia, which ensured an uniform mode of sampling. In the erythromycin-treated group the occurrence of Streptococcus pneumoniae (3%) and Branhamella catarrhalis (0%) was significantly lower than in the control group (35% and 32%, respectively); and the frequency of cultures with no pathogen was significantly higher in the treated group. The occurrence of Haemophilus influenzae remained essentially unchanged.

Activity of common antibiotics against Branhamella catarrhalis, Haemophilus influenzae, pneumococci, group A streptococci and Staphylococcus aureus in 1983

The activity of phenoxymethylpenicillin (PcV), ampicillin, cefaclor, cefuroxime, chloramphenicol, co trimoxazole, doxycycline and erythromycin against clinical isolates of Branhamella catarrhalis, Haemophilus influenzae, pneumococci, group A streptococci and Staphylococcus aureus in 1983 was investigated with the MIC-method (plate-dilution technique). Forty-six percent of B. catarrhalis, 2% of H. influenzae and 78% of S. aureus were beta-lactamase producing and had high MIC-values for penicillin and ampicillin. Thus MIC for 90% of all strains of B. catarrhalis was 32 mg/l and 8 mg/l for penicillin and ampicillin while MIC for 90% of non beta-lactamase producing Branhamella strains was 2 mg/l and 0.25 mg/l respectively. This indicates a high susceptibility of penicillins to the action of Branhamella beta-lactamase. Almost all strains of B. catarrhalis, pneumococci, group A streptococci and S. aureus were inhibited at low concentrations of erythromycin. However, 4 mg/l was required to inhibit 90% of H. influenzae. Co-trimoxazole and doxycycline had good activity against all B. catarrhalis and H. influenzae strains while a few pneumococci, streptococci and staphylococci had intermediate sensitivity or were resistant. Essentially all strains were sensitive to cefuroxime and chloramphenicol.

Penetration of erythromycin in respiratory tract infections

Successful treatment of respiratory tract infections with erythromycin may depend upon adequate penetration of the drug to the site of infection. The delivery of antibiotics into respiratory tract secretions is a simple passive diffusion process along a concentration gradient according to Fick's principle. A number of other factors including physicochemical characteristics of the drug and host defence mechanisms may further modify the tissue penetration. A common feature of penetration studies in respiratory tract infections is the wide range of results. This is due to the numerous variables involved in this kind of study. However, the studies performed at steady state, and after oral administration of erythromycin, show a rapid increase in drug concentrations in adenoid and tonsillar tissue homogenates and sustained levels equal to or higher than in serum. In secretions of the middle ear, paranasal sinuses and bronchiae the penetration and elimination of erythromycin is much slower. The drug levels were equal to--or in some cases even higher than--steady state serum concentrations. Fluctuations, however, were less pronounced. In lung tissue homogenates erythromycin concentrations higher than the serum levels have generally been found. In respiratory tract secretions and tissues the penetration of erythromycin is good. Sufficient levels are reached to inhibit in vitro the growth of most common pathogens involved in respiratory tract infections with the exception of some strains of Haemophilus influenzae.

Efficacy and tolerance of enteric-coated erythromycin base (Ery-Max) administered twice or four times daily in patients with acute bronchitis

We performed a double-blind trial of a new formulation of erythromycin base as enteric-coated pellets (Ery-Max) in the treatment of acute bronchitis in 220 patients. Subjects were randomized to receive either 500 mg twice or 250 mg four times a day for 10 days. The response to treatment as assessed clinically and by changes in sputum purulence was the same in the two groups. Thus 97% and 98% of the patients had a good or improved clinical effect. Treatment was well tolerated, but side-effects were encountered more often in the q.i.d. group (p greater than 0.05). In conclusion, the study showed that the enteric-coated erythromycin as pellets, given twice or four times daily for 10 days, was well tolerated and equally effective in acute bronchitis. Hence, the more convenient b.i.d. regimen can be recommended.

Erythromycin binding to human serum

Erythromycin binding to human serum was measured under conditions of binding equilibrium. The binding is sensitive to pH changes, decreasing at acid pH. Over a great range of serum dilution, the bound fraction is semilogarithmically related to serum concentration. Binding is shown to be completely reversible. With increasing erythromycin concentration a specific part of binding is saturable and specifically displaceable by erythromycin is specifically bound to a single class of noninteracting binding sites with an apparent dissociation constant Kd = 5.9 microM (38 degrees C). The kinetic and thermodynamic parameters at 25 degrees are: Kd = 8.4 microM, delta H degrees = +4.4 X 10(3) cal per mole, delta G degrees = 6.9 X 10(3) cal per mole, delta S degrees = +38 e.u.

[Binding, distribution and efficacy of erythromycin (author's transl)]

The significance of the binding of antibiotics in humans in still a controversial question. In principle, only free, unbound antibiotic is considered to be diffusible and biologically active. With unimpaired measurements and a binding balance within the normal therapeutic concentration range, the free portion of erythromycin in the human serum is found to depend significantly on the total concentration of erythromycin. For example, for concentrations of 1, 16 and 24 mg/l, approx. 74%, 54% and 46% are bound (+38 degrees C). binding is temperature-dependent and decreases with decreasing temperature. At +4 degrees C, 44% of 1 mg/l and 30% of 16 mg/l are bound. These binding characteristics are based in part on the properties of erythromycin's major binding partner in the serum - acidic alpha1-glycoprotein. Albumin only contributes slightly to the overall binding and is not concentration-dependent in the therapeutic range, i.e. it cannot be saturated. Binding phenomena have a decisive influence on the distribution of an antibiotic within an organism. In the case of erythromycin, the tissue levels in nearly every organ are higher, sometimes considerably higher, than the corresponding serum levels. We have shown the binding of erythromycin to cytosol and particle fractions in certain organs and compared this to the binding in the serum. The antibacterial principle regarding the efficacy of erythromycin is also based primarily on a binding reaction which maintains the concentration gradient for the intake of erythromycin in microorganisms. The kinetics ofintake (microorganism) are compared to those of binding (macroorganism) and referred to the minimum inhibitory concentration.

The penetration of erythromycin into the middle ear

The penetration of erythromycin was studied in 108 cases of secretory otitis media. Erythromycin ethylsuccinate was given orally in a dosage of 30-60 mg/kg/day and samples of middle ear effusion were obtained at different intervals. The concentration of erythromycin in the middle ear effusions reached the plasma level (1.1-1.2 mg/l) after 26 hours. The plateau levels were maintained during the steady state. Elimination was slow; 14 hours after the last dose of a ten-day treatment, the concentration of erythromycin in the middle ear effusions was still as high as 0.9 mg/l, compared to 0.2 mg/l in plasma. The concentration of erythromycin in the middle ear effusions surpassed the MICs of most respiratory pathogens. Erythromycin can thus be regarded as a suitable drug in the treatment of otitis media. Furthermore, since the respiratory mucosa reacts in a uniform manner to an inflammatory stimulus, the result of this penetration study is valid for inflammatory diseases in any area lined with respiratory epithelium.

[Concentrations of erythromycin and amoxicillin in tonsil and sinus tissues of patients with tonsillitis and sinusitis. A comparison (author's transl)]

Thirty male patients with chronic tonsillitis and 30 male patients with chronic Sinusitis maxillaris were pre-treated for four days with either 2 X 1 g erythromycin daily per os or 3 X 0.75 g amoxicillin daily per os in an open and randomised comparative study. MIC values for the relevant bacteria were determined beforehand. The intended tonsillectomy or radical operation was performed on the third day of pre-treatment, circa 1.5 h after the final administration of antibiotics. The tonsils or the sinus membrane were examined bacteriologically; the concentrations of erythromycin or amoxicillin were determined. At the same time, the concentration of the antibiotic administered was determined in the serum. The average concentration of erythromycin in the tonsil tissue was 1.24 micrograms/g; it was 1.21 micrograms/g in the sinus membrane. Amoxicillin was found at a concentration of 0.17 microgram/g in the tonsil tissue, and 0.1 microgram/g in the sinus membrane. While the levels of erythromycin in the tissue generally equalled or exceeded the MIC value for the pathogen in question, the levels of amoxicillin only reached the relevant MIC value for the given pathogen in a few cases since the concentration in the tissue was insufficient. The clinical tolerance of both antibiotics was good.

Haemophilus influenzae, Pneumococci, group A streptococci and Staphylococcus aureus: sensitivity of outpatient strains to commonly prescribed antibiotics

The degree of resistance of Haemophilus influenzae, pneumococci, group A streptococci and Staphylococcus aureus to phenoxymethylpenicillin, ampicillin, doxycycline, erythromycin and chloramphenicol was investigated with the MIC-method (plate-dilution technique). Each bacterial group consisted of 100 outpatient strains. Seven strains of H. influenzae were beta-lactamase-producing. Of the 100 haemophilus strains, 58% were sensitive and the rest intermediate sensitive to erythromycin. 99% were sensitive to doxycycline and all strains were sensitive to chloramphenicol. Essentially all pneumococcal strains were sensitive to the antibiotics tested. However, a few strains demonstrated diminished sensitivity to penicillins. All group A streptococci were sensitive to ampicillin, penicillin and chloramphenicol, and 98% were sensitive to erythromycin. Approximately 1 strain out of 5 was resistant to doxycycline. 75% of S. aureus were beta-lactamase producers. Four of the S., aureus strains were resistant to erythromycin and 8 to doxycycline. The results presented indicate a better antibiotic situation than in some other countries, but suggest the need for a more extensive antibiotic sensitivity examination of isolated bacteria.

Absorption of erythromycin from pediatric suspension in infants and children

The absorption of erythromycin in infants and children was estimated after the administration of an erythromycin suspension. The subjects were divided into 3 age groups: 0-1 month, 1-6 months and 6 months-6 years. The absorption was lower in infants less than 1 month of age than in the older children. Erythromycin ethylsuccinate and erythromycin stearate were equally well absorbed in the fasting state in subjects 6 months-6 years of age. Administration of the drug at mealtimes considerably increased the absorption of erythromycin ethylsuccinate but had little effect on the absorption of erythromycin stearate. The absorption of erythromycin stearate in the fasting state was much lower than that of erythromycin ethylsuccinate in infants 1-6 months of age. None of the infants given erythromycin ethylsuccinate because of an outbreak of whooping-cough on the neonatal ward showed evidence of liver toxicity, nor did they develop symptoms of whooping-cough.

Discrimination of purulent from nonpurulent maxillary sinusitis. Clinical and radiographic diagnosis

For the rational treatment of sinusitis, it is essential to distinguish sinusitis of bacterial origin from that of other etiologies. In maxillary sinusitis, antral purulence indicates a significant amount of pathogenic bacteria, whereas the presence of bacteria seems to be of less or no relevance in nonpurulent sinusitis. Hence, from a therapeutic point of view one important diagnostic goal is the differentiation of purulent from nonpurulent sinusitis. In this respect clinical examination is fairly reliable. Sinus radiography cannot distinguish purulent from nonpurulent sinusitis and offers few advantages when deciding on antibiotic therapy. Antral aspiration offers the most comprehensive information on which to base a reliable diagnosis.

Antibiotic sensitivity of Haemophilus influenzae strains including three recent chloramphenicol-resistant isolates

The antibiotic sensitivity of 100 recent isolates of Haemophilus influenzae was determined. Three strains were resistant to chloramphenicol with minimal inhibitory concentrations of 16 microgram/ml. Of these three resistant strains, one produced betalactamase and one was resistant to sulfamethoxazole-trimethoprim. The remaining strains were inhibited by 0.25-2.0 microgram/ml of chloramphenicol. Ampicillin and benzylpenicillin were found to inhibit all but the betalactamase-producing strains at low concentrations. Regarding sulfamethoxazole-trimethoprim 96% had minimal inhibitory concentrations of 2.5-0.12 microgram/ml or less, while two strains were resistant. The invitro efficacy of erythromycin against H. influenzae was low. The majority of the strains was inhibited by low concentrations of doxycycline and cefuroxime while cefoxitin exhibited minimal inhibitory concentrations values usually exceeding 1 microgram/ml. The minimal inhibitory concentrations registered are compared to the concentrations of the different antibiotics attainable in certain body fluids.

[Tissue penetration of erythromycin (author's transl)]

Although erythromycin has been used in therapy for more than 25 years, until now there has been no paper summarizing the data on tissue penetration. The present review documents in detail dose- and time-related peak serum levels of erythromycin derivatives after oral administration, in addition to the erythromycin tissue levels. The erythromycin tissue levels often manifoldly exceed the corresponding MIC values of pathogens sensitive to erythromycin. However, erythromycin does not penetrate the central nervous system, or only penetrates in small, incalculable amounts. The same applies for the placental passage of erythromycin. The tissue levels confirm, with respect to the MIC values of the pathogen spectrum, clinical experience with erythromycin in the treatment of ear, nose and throat infections, respiratory tract infections and, with some limitations Chlamydia urethritis.

Penetration of erythromycin through respiratory mucosa. A study using secretory otitis media as a model

This study is based upon the concept that the respiratory mucosa reacts in a uniform manner to an inflammatory stimulus. Secretory Otitis Media (SOM) may be used as a model to disclose some aspects of antibiotic penetration. Erythromycin was given for different periods of time to 108 cases of SOM where myringotomy was indicated. The middle ear effusion was aspirated and blood samples were obtained simultaneously. The concentration of erythromycin was determined by microbiological procedures. Erythromycin penetrated into the middle ear effusion. After the fourth dose the concentration was at the same level as the plasma peak level. The elimination of the drug from the middle ear secretion was considerably prolonged compared with the rapid elimination from plasma. This implies that erythromycin attains a steady state in the middle ear effusion with concentrations equal to the plasma peak level.

The microbiology of paranasal sinus infections: diagnosis and management

Study of the bacteriology of sinusitis and its diagnosis and treatment has been difficult. One problem is the anatomy of the paranasal sinuses; all communicate with a bacteriologically contaminated cavity. Access to all but the frontal sinus involves traversing either the nasal or oral cavity, both of which are teeming with aerobic and anaerobic bacteria. The criteria used to establish the diagnosis of sinusitis has varied widely. There are a number of examination techniques available, but none are foolproof. Therefore, patient populations may not be comparable. The absolute elimination of the possibility of contamination of culture specimens is impossible. Investigators have taken cultures in several ways: of the purulent secretions within the nose, of the contents lavaged from the sinus into the nose, of material aspirated from the sinus, and of tissue removed from the sinus. In most studies prior to 1974, anaerobic cultures were not performed. Studies of various treatment programs have used differing criteria to monitor the progress of treatment. No single method is completely reliable. Clinical signs and symptoms, radiologic appearance, the results of irrigation, and thermography have been used to follow patients. Many studies have used multiple therapeutic maneuvers concurrently, for example, antibiotics, lavage, and a decongestant. In some there were no controls. Because of these problems, as is true in many clinical areas of investigation, meaningful comparisons of various studies are difficult. Despite this, there are some areas of consensus in the literature.

Penetration of erythromycin stearate into maxillary sinus mucosa and secretion in chronic maxillary sinusitis

The penetration of oral erythromycin stearate (Abboticin), administered in a dosage of 500 mg three times a day, into the maxillary sinus mucosa and secretion was studied in 15 patients (22 sinuses) operated on for chronic maxillary sinusitis. The average concentration in serum was 2.3 microgram/ml, 1.2 microgram/ml in secretion, and 1.8 microgram/ml in mucosa. These concentrations are highly effective against diplococci and most aerobic and anaerobic streptococci (MIC value 0.06 microgram/ml) but not against Haemophilus influenzae (MIC value for 80% of 2 microgram/ml).