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Myrianthefs P, Zakynthinos GE, Tsolaki V, Makris D. Aerosolized Antibiotics to Manage Ventilator-Associated Infections: A Comprehensive Review. Antibiotics (Basel) 2023; 12:antibiotics12050801. [PMID: 37237704 DOI: 10.3390/antibiotics12050801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 04/18/2023] [Accepted: 04/20/2023] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND Ventilator-associated lower respiratory tract infectious complications in critically ill patients cover a wide spectrum of one disease process (respiratory infection), initiating from tracheal tube and/or tracheobronchial colonization, to ventilator associated tracheobronchitis (VAT) and ventilator-associated pneumonia (VAP). VAP occurence has been associated with increased intensive care unit (ICU) morbidity (ventilator days, as well as length of ICU and hospital stay) and ICU mortality. Therefore, treatments that aim at VAP/VAT incidence reduction are a high priority. AIM The aim of the present review is to discuss the current literature concerning two major aspects: (a) can aerosolized antibiotics (AA) administered in a pre-emptive way prevent the occurrence of ventilator-associated infections? and (b) can VAT treatment with aerosolized avert the potential evolution to VAP? RESULTS There were identified eight studies that provided data on the use of aerosolized antibiotics for the prevention of VAT/VAP. Most of them report favorable data on reducing the colonisation rate and the progression to VAP/VAT. Another four studies dealt with the treatment of VAT/VAP. The results support the decrease in the incidence to VAP transition and/or the improvement in signs and symptoms of VAP. Moreover, there are concise reports on higher cure rates and microbiological eradication in patients treated with aerosolized antibiotics. Yet, differences in the delivery modality adopted and resistance emergence issues preclude the generalisability of the results. CONCLUSION Aerosolized antibiotic therapy can be used to manage ventilator-associated infections, especially those with difficult to treat resistance. The limited clinical data raise the need for large randomized controlled trials to confirm the benefits of AA and to evaluate the impact on antibiotic selection pressure.
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Affiliation(s)
- Pavlos Myrianthefs
- "Agioi Anargyroi" General Hospital, School of Health Sciences, Department of Nursing, National and Kapodistrian University of Athens, 14564 Athens, Greece
| | - George E Zakynthinos
- Third Cardiology Clinic, University of Athens, Sotiria Hospital, 11526 Athens, Greece
| | - Vasiliki Tsolaki
- Department of Intensive Care Medicine, University Hospital of Larissa, 41110 Larissa, Greece
| | - Demosthenes Makris
- Department of Intensive Care Medicine, University Hospital of Larissa, 41110 Larissa, Greece
- Faculty of Medicine, University of Thessaly, 41110 Larissa, Greece
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Dhanani JA, Goodman S, Ahern B, Cohen J, Fraser JF, Barnett A, Diab S, Bhatt M, Roberts JA. Comparative lung distribution of radiolabeled tobramycin between nebulized and intravenous administration in a mechanically-ventilated ovine model, an observational study. Int J Antimicrob Agents 2020; 57:106232. [PMID: 33232733 DOI: 10.1016/j.ijantimicag.2020.106232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 09/15/2020] [Accepted: 11/14/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Ventilator-associated pneumonia is common and is treated using nebulized antibiotics. Although adequate pulmonary biodistribution is important for antibiotic effect, there is a lack of data for both intravenous (IV) and nebulized antibiotic administration during mechanical ventilation. OBJECTIVE To describe the comparative pulmonary regional distribution of IV and nebulized technetium-99m-labeled tobramycin (99mTc-tobramycin) 400 mg in a mechanically-ventilated ovine model. METHODS The study was performed in a mechanically-ventilated ovine model. 99mTc-tobramycin 400 mg was obtained using a radiolabeling process. Computed tomography (CT) was performed. Ten sheep were given 99mTc-tobramycin 400 mg via either an IV (five sheep) or nebulized (five sheep) route. Planar images (dorsal, ventral, left lateral and right lateral) were obtained using a gamma camera. Blood samples were obtained every 15 min for 1 h (4 time points) and lung, liver, both kidney, and urine samples were obtained post-mortem. RESULTS Ten sheep were anesthetized and mechanically ventilated. Whole-lung deposition of nebulized 99mTc-tobramycin 400 mg was significantly lower than with IV (8.8% vs. 57.1%, P<0.001). For both administration routes, there was significantly lower deposition in upper lung zones compared with the rest of the lungs. Dorsal deposition was significantly higher with nebulized 99mTc-tobramycin 400 mg compared with IV (68.9% vs. 58.9%, P=0.003). Lung concentrations of 99mTc-tobramycin were higher with IV compared with nebulized administration. There were significantly higher concentrations of 99mTc-tobramycin in blood, liver and urine with IV administration compared with nebulized. CONCLUSIONS Nebulization resulted in lower whole and regional lung deposition of 99mTc-tobramycin compared with IV administration and appeared to be associated with low blood and extra-pulmonary organ concentrations.
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Affiliation(s)
- Jayesh A Dhanani
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Australia; Department of Intensive Care Medicine, Royal Brisbane & Women's Hospital, Brisbane, Australia; Critical Care Research Group, The University of Queensland, Brisbane, Australia.
| | - Steven Goodman
- Department of Nuclear Medicine and Specialised PET Services Queensland, The Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Benjamin Ahern
- School of Veterinary Science, Faculty of Science, University of Queensland, Gatton, Australia
| | - Jeremy Cohen
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Australia; Department of Intensive Care Medicine, Royal Brisbane & Women's Hospital, Brisbane, Australia
| | - John F Fraser
- Critical Care Research Group, The University of Queensland, Brisbane, Australia
| | - Adrian Barnett
- Institute of Health and Biomedical Innovation & School of Public Health and Social Work, Queensland University of Technology, Kelvin Grove, Brisbane, Australia
| | - Sara Diab
- Critical Care Research Group, The University of Queensland, Brisbane, Australia
| | - Manoj Bhatt
- Department of Nuclear Medicine and Specialised PET Services Queensland, The Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Jason A Roberts
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Australia; Department of Intensive Care Medicine, Royal Brisbane & Women's Hospital, Brisbane, Australia; Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, Australia; Department of Pharmacy, Royal Brisbane & Women's Hospital, Brisbane, Australia
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Elnadoury O, Beattie J, Lubinsky AS. Uninterrupted Continuous and Intermittent Nebulizer Therapy in a COVID-19 Patient Using Sequential Vibratory Mesh Nebulizers: A Case Report. J Aerosol Med Pulm Drug Deliv 2020; 33:357-360. [PMID: 32852238 DOI: 10.1089/jamp.2020.1636] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Interruptions in continuous nebulized pulmonary vasodilators, such as epoprostenol, can potentially result in clinical deterioration in respiratory status. Coadministration of other intermittent nebulized therapies may require opening the ventilator circuit to facilitate administration. However, in patients with SARS-CoV2 infection, it is preferred to avoid opening the circuit whenever feasible to prevent aerosolization of the virus and exposure of health care workers. In this study, we describe a unique method of administering continuous epoprostenol nebulization and intermittent nebulized antibiotics, mucolytics, and bronchodilators, using Aerogen vibrating mesh nebulizers without interruptions in epoprostenol or opening the ventilator circuit. This technique set up consisted of stacking two Aerogen nebulizer cups, each with its own controller. This approach was successful in allowing concomitant delivery of intermittent and continuous nebulized therapy without interruptions. To our knowledge, this method has not been previously described in the literature and may be helpful to bedside clinicians facing a similar clinical scenario.
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Affiliation(s)
- Ola Elnadoury
- Department of Pharmacy, NYU Langone Hospital-Brooklyn, Brooklyn, New York, USA
| | - Jason Beattie
- Department of Medicine-Pulmonary, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Anthony S Lubinsky
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, NYU Langone Health, New York, New York, USA
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Bruguera-Avila N, Marin A, Garcia-Olive I, Radua J, Prat C, Gil M, Ruiz-Manzano J. Effectiveness of treatment with nebulized colistin in patients with COPD. Int J Chron Obstruct Pulmon Dis 2017; 12:2909-2915. [PMID: 29042767 PMCID: PMC5634377 DOI: 10.2147/copd.s138428] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Objectives To analyze whether the introduction of nebulized colistin in patients with chronic obstructive pulmonary disease (COPD) and infection with Pseudomonas aeruginosa (PA) is associated with a decrease of the number and duration of severe exacerbations. Materials and methods Thirty six patients with COPD and infection with PA treated with nebulized colistin attending a day hospital during a 5-year (January 2010–December 2014) period were prospectively included. Repeated-measures t-tests were used to assess whether the introduction of colistin was associated with changes in the number of exacerbations or the length of the hospitalizations, comparing for each patient the year prior to the introduction of colistin with the year after. Results After the introduction of colistin, the number of admissions decreased from 2.0 to 0.9 per individual year (P=0.0007), and hospitalizations were shorter (23.3 vs 10.9 days, P=0.00005). These results persisted when patients with and without bronchiectasis or with and without persistence of Pseudomonas were separately analyzed. No pre–post differences were detected in the number of exacerbations not requiring admission. Conclusion Nebulized colistin seems associated with a strong decrease in the number and duration of hospitalizations due to exacerbation in patients with COPD and infection with PA. Clinical trials with a larger number of patients are needed in order to confirm these results.
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Affiliation(s)
- Nuria Bruguera-Avila
- Department of Medicine, Hospital Sant Jaume de Calella, Calella, Barcelona, Spain.,Department of Medicine, Universitat Autònoma de Barcelona, Bellatera, Spain.,Department of Pulmonary Medicine, Hospital Universitari Germans Trias i Pujol, Carretera del Canyet sn, Badalona, Barcelona, Spain
| | - Alicia Marin
- Department of Pulmonary Medicine, Hospital Universitari Germans Trias i Pujol, Carretera del Canyet sn, Badalona, Barcelona, Spain.,Ciber de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain.,Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Carretera del Canyet sn, Badalona, Barcelona, Spain
| | - Ignasi Garcia-Olive
- Department of Pulmonary Medicine, Hospital Universitari Germans Trias i Pujol, Carretera del Canyet sn, Badalona, Barcelona, Spain.,Ciber de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain.,Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Carretera del Canyet sn, Badalona, Barcelona, Spain
| | - Joaquim Radua
- Department of Statistics, FIDMAG Germanes Hospitalaries Research Unit, Sant Boi de Llobregat, Barcelona, Spain.,CiberSam - Ciber de Salud Mental, Madrid, Spain.,Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Cristina Prat
- Ciber de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain.,Department of Microbiology, Hospital Universitari Germans Trias i Pujol, Carretera del Canyet sn, Badalona, Barcelona, Spain.,Department of Genetics and Microbiology of Universitat Autònoma de Barcelona, Bellatera, Spain
| | - Montserrat Gil
- Department of Pulmonary Medicine, Hospital Universitari Germans Trias i Pujol, Carretera del Canyet sn, Badalona, Barcelona, Spain
| | - Juan Ruiz-Manzano
- Department of Medicine, Universitat Autònoma de Barcelona, Bellatera, Spain.,Department of Pulmonary Medicine, Hospital Universitari Germans Trias i Pujol, Carretera del Canyet sn, Badalona, Barcelona, Spain.,Ciber de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain.,Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Carretera del Canyet sn, Badalona, Barcelona, Spain
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Solé-Lleonart C, Roberts JA, Chastre J, Poulakou G, Palmer LB, Blot S, Felton T, Bassetti M, Luyt CE, Pereira JM, Riera J, Welte T, Qiu H, Rouby JJ, Rello J. Global survey on nebulization of antimicrobial agents in mechanically ventilated patients: a call for international guidelines. Clin Microbiol Infect 2015; 22:359-364. [PMID: 26723563 DOI: 10.1016/j.cmi.2015.12.016] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Revised: 11/26/2015] [Accepted: 12/12/2015] [Indexed: 01/07/2023]
Abstract
Nebulized antimicrobial agents are increasingly administered for treatment of respiratory infections in mechanically ventilated (MV) patients. A structured online questionnaire assessing the indications, dosages and recent patterns of use for nebulized antimicrobial agents in MV patients was developed. The questionnaire was distributed worldwide and completed by 192 intensive care units. The most common indications for using nebulized antimicrobial agent were ventilator-associated tracheobronchitis (VAT; 58/87), ventilator-associated pneumonia (VAP; 56/87) and management of multidrug-resistant, Gram-negative (67/87) bacilli in the respiratory tract. The most common prescribed nebulized agents were colistin methanesulfonate and sulfate (36/87, 41.3% and 24/87, 27.5%), tobramycin (32/87, 36.7%) and amikacin (23/87, 26.4%). Colistin methanesulfonate, amikacin and tobramycin daily doses for VAP were significantly higher than for VAT (p < 0.05). Combination of parenteral and nebulized antibiotics occurred in 50 (86%) of 58 prescriptions for VAP and 36 (64.2%) of 56 of prescriptions for VAT. The use of nebulized antimicrobial agents in MV patients is common. There is marked heterogeneity in clinical practice, with significantly different in use between patients with VAP and VAT. Randomized controlled clinical trials and international guidance on indications, dosing and antibiotic combinations to improve clinical outcomes are urgently required.
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Affiliation(s)
- C Solé-Lleonart
- UHN and Mount Sinai Hospital, University of Toronto, Canada; Universitat Autonoma de Barcelona, Barcelona, Spain
| | - J A Roberts
- Burns Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, Australia
| | - J Chastre
- Service de Réanimation Médicale, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Université Pierre et Marie Curie of Paris, Paris, France
| | - G Poulakou
- 4th Department of Internal Medicine, Athens University School of Medicine, Attikon University General Hospital, Athens, Greece
| | - L B Palmer
- Pulmonary, Critical Care, and Sleep Division, Department of Medicine, State University of New York at Stony Brook, Stony Brook, NY, USA
| | - S Blot
- Department of Internal Medicine, Faculty of Medicine and Health Science, Ghent University, Ghent, Belgium
| | - T Felton
- Acute Intensive Care Unit, University Hospital of South Manchester, Manchester, UK
| | - M Bassetti
- Infectious Diseases Division, Santa Maria Misericordia University Hospital, Udine, Italy
| | - C-E Luyt
- Service de Réanimation Médicale, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Université Pierre et Marie Curie of Paris, Paris, France
| | - J M Pereira
- Emergency and Intensive Care Department, Centro Hospitalar S. João EPE, University of Porto, Porto, Portugal
| | - J Riera
- Critical Care Department, Vall d'Hebron University Hospital, CIBERES, Vall d'Hebron Institute of Research, Barcelona, Spain
| | - T Welte
- Department of Pulmonary Medicine, Hannover Medical School, Hannover, Germany
| | - H Qiu
- Critical Care Department, Zhong Da Hospital, School of Medicine, Southeast University, Nanjing, China
| | - J-J Rouby
- Department of Anesthesiology and Critical Care, Multidisciplinary Intensive Care Unit, La Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, University Pierre et Marie Curie (UPMC) of Paris 6, Paris, France
| | - J Rello
- CIBERES, Universitat Autonoma de Barcelona, Spain.
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Tridello G, Volpi S, Assael BM, Meneghelli I, Passiu M, Circelli M. Lung function comparison between two decades in cystic fibrosis children: A single centre study. Pediatr Pulmonol 2015; 50:1237-43. [PMID: 26422228 DOI: 10.1002/ppul.23314] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Revised: 08/03/2015] [Accepted: 08/28/2015] [Indexed: 11/06/2022]
Abstract
OBJECTIVES The purpose of this study was to compare two cohorts of cystic fibrosis (CF) patients born and treated in two different decades, diagnosed through a CF neonatal screening program. METHODOLOGY We compared pulmonary function decline from 10 to 15 years of age in patients with cystic fibrosis born between 1979 and 1984 (Cohort 1) and between 1991 and 1996 (Cohort 2). Forced expiratory volume in 1 sec (FEV1%) and forced expiratory flow from 25% to 75% (FEF 25-75%) were analyzed by a linear mixed model approach. The differences between the two cohorts were estimated and the overall cohort effect was tested. RESULTS Ninety-two patients (51 males, 41 females) fulfilled the selection criteria. Pancreatic insufficiency and CF related diabetes were present in 91% and 20% of patients, respectively. The mean absolute decrement of FEV1% was 9.2 (standard deviation [SD] 11.2) in Cohort 1 and 0.6 (SD 10.4) in Cohort 2 (P < 0.001). The mean decrement of FEF 25-75% was 16.3 (SD 19.5) in Cohort 1 and 1.3 (SD 16.8) in Cohort 2 (P < 0.001) and the Pseudomonas aeruginosa (Pa) colonization was 28% and 15% respectively (P = 0.1). CONCLUSIONS Our results show that pulmonary function has clearly ameliorated over a decade in young CF patients, in a period during which several significant therapeutic changes have been introduced, such as dornase alfa, tobramycin and hypertonic saline. To our knowledge this is the first study showing a cohort effect in patients diagnosed after neonatal screening.
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Haworth CS, Foweraker JE, Wilkinson P, Kenyon RF, Bilton D. Inhaled colistin in patients with bronchiectasis and chronic Pseudomonas aeruginosa infection. Am J Respir Crit Care Med 2014; 189:975-82. [PMID: 24625200 PMCID: PMC4098097 DOI: 10.1164/rccm.201312-2208oc] [Citation(s) in RCA: 180] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Accepted: 03/08/2014] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Chronic infection with Pseudomonas aeruginosa is associated with an increased exacerbation frequency, a more rapid decline in lung function, and increased mortality in patients with bronchiectasis. OBJECTIVES To perform a randomized placebo-controlled study assessing the efficacy and safety of inhaled colistin in patients with bronchiectasis and chronic P. aeruginosa infection. METHODS Patients with bronchiectasis and chronic P. aeruginosa infection were enrolled within 21 days of completing a course of antipseudomonal antibiotics for an exacerbation. Participants were randomized to receive colistin (1 million IU; n = 73) or placebo (0.45% saline; n = 71) via the I-neb twice a day, for up to 6 months. MEASUREMENTS AND MAIN RESULTS The primary endpoint was time to exacerbation. Secondary endpoints included time to exacerbation based on adherence recorded by the I-neb, P. aeruginosa bacterial density, quality of life, and safety parameters. All analyses were on the intention-to-treat population. Median time (25% quartile) to exacerbation was 165 (42) versus 111 (52) days in the colistin and placebo groups, respectively (P = 0.11). In adherent patients (adherence quartiles 2-4), the median time to exacerbation was 168 (65) versus 103 (37) days in the colistin and placebo groups, respectively (P = 0.038). P. aeruginosa density was reduced after 4 (P = 0.001) and 12 weeks (P = 0.008) and the St. George's Respiratory Questionnaire total score was improved after 26 weeks (P = 0.006) in the colistin versus placebo patients, respectively. There were no safety concerns. CONCLUSIONS Although the primary endpoint was not reached, this study shows that inhaled colistin is a safe and effective treatment in adherent patients with bronchiectasis and chronic P. aeruginosa infection. Clinical trial registered with http://www.isrctn.org/ (ISRCTN49790596).
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Affiliation(s)
| | | | | | - Robert F. Kenyon
- Profile Pharma Ltd., Tangmere, Chichester, West Sussex, United Kingdom; and
| | - Diana Bilton
- Host Defence Unit, Royal Brompton Hospital, London, United Kingdom
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Abstract
Chronic rhinosinusitis, one of the most common chronic medical complaints in the United States, seems to be increasing in incidence and prevalence, and has a significant impact on quality of life. Topical forms of medical therapy represent an attractive alternative for drug delivery to the nasal cavity and paranasal sinuses. Topical drug delivery has the advantage of directly acting on the site of inflammation, producing a higher concentration at the target site while avoiding systemic side effects. Although considerable research has been undertaken into improving nasal formulations in order to enhance absorption, little attention has so far been directed to upgrading the delivery devices. The aim of this review is to present current knowledge on the novel drug-delivery devices in use in the management of chronic rhinosinusitis patients, and to present the current available knowledge on topical drug penetration into the sinuses using various delivery devices. Additionally, methods used to enhance fluid sinus deposition are presented and the published clinical studies on the results of nebulized antibiotics in the treatment of chronic rhinosinusitis patients are discussed.
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Affiliation(s)
- Silviu Albu
- Department of Otolaryngology, University of Medicine and Pharmacy Cluj-Napoca, Cluj-Napoca, Romania.
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