[PAGID] Chronic rhinosinusitis in antibody deficiency diseases

[Conley, Mary-Ellen]

As many of you know, I am a STRONG believer in chronic prophylactic antibiotics in XLA and other antibody deficiencies.  I usually tell families that every infection may cause a little scarring that makes the patient more vulnerable to the next infection.  Ken brings up a concern that is shared by many people - the development of resistance to oral antibiotics.  I think this is more likely to occur when you start and stop antibiotics or when you give a borderline low dose, than it is if you give hefty doses every day.  We have minimal problems with resistance.  I have a patient who has been on Bactrim for 13 years and has never needed a change because of infection.  Most of our patients "graduate" to Augmentin within a few years but most stay on that drug.  Chronic antibiotics are cheaper and more efficient than increasing the dose of gammaglobulin.  As Ken says, the gammaglobulin is not going to get into the nose.

Ashish is right - there is no consensus on this topic and it is important enough that we would like an answer.  However, designing a good study would be difficult.  Many people would not be willing to randomize their patients and the important outcome measures, such as chronic lung disease would take many years to develop.  Luigi Notarangelo (Gigi) and I have discussed a study in which we compare chest CTs from adolescent or adult XLA patients treated under a philosophy of chronic prophylactic antibiotics vs antibiotics with acute infections.

When a family (rather than the bacteria) expresses resistance, I generally make a deal.  I suggest that if the patient requires two or more courses of antibiotics in a six month period, we start the chronic antibiotics.  Teenagers tend to be a compliance problem.  If they are not compliant, we tend to stop the antibiotics.  Usually they get sick within a few months and then compliance improves.

Mary Ellen






Mary Ellen Conley, MD
Department of Immunology
St. Jude Children's Research Hospital
332 N. Lauderdale
Memphis, TN 38105-2794
FAX  901-495-3977
TEL  901-495-2576



________________________________
From: pagid-bounces at list.clinimmsoc.org [mailto:pagid-bounces at list.clinimmsoc.org] On Behalf Of Paris, Kenneth
Sent: Tuesday, June 03, 2008 8:19 PM
To: pagid at list.clinimmsoc.org
Subject: Re: [PAGID] Chronic rhinosinusitis in antibody deficiency diseases

Ashish,

At our center we use daily intranasal mupirocin ointment in this situation.  It may help extend the asymptomatic intervals.  Our thoughts are that it may help reduce colonization with pathogenic bacteria that can cause sinusitis.  Prolonged use may contribute to some resistance, but the same risk occurs with prophylactic oral abx.  We sometimes enlist help from our ENT colleagues to help identify the pathogen and get resistance profiles, especially if we suspect a resistant bacteria  (we always specify that we do not want procedures that may disrupt normal anatomy).   Many, if not all of our XLA patients have had issues with chronic/recurrent sinusitis despite adjustments in dose of IgG.  Lack of mucosal IgA isn't overcome by IVIG, so these types of infections are common.

Kenneth Paris MD, MPH
Assistant Professor of Pediatrics
Division of Allergy and Immunology
LSU Health Sciences Center
Children's Hospital of New Orleans

Mail:
200 Henry Clay Avenue
Children's Hospital
Research Institute for Children 4th Floor
New Orleans, LA 70118

Phone:  504-896-9589
Fax:  504-896-9311
Email:  kparis at lsuhsc.edu<mailto:kparis at lsuhsc.edu>

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________________________________
From: pagid-bounces at list.clinimmsoc.org on behalf of Ashish Kumar
Sent: Tue 6/3/2008 9:53 AM
To: Pagid
Subject: [PAGID] Chronic rhinosinusitis in antibody deficiency diseases


The mother of one one of my patients with XLA does not want to use
prolonged antibiotics for the management of his chronic rhinosinusitis.
His symptoms disappear while on he is on Augmentin but reappear when
stopped. Has anyone tried nasal steroids alone or in combination with
antibiotics/higher dose of IVIG successfully?
Is there published consensus on the appropriate management of chronic
rhinosinusitis in patients with antibody deficiency diseases - most of
what I found suggest that there is none. Maybe an opportunity for a
collaborative group trial?

--
Ashish Kumar, MD, PhD
Assistant Professor of Pediatrics
Division of Hematology/Oncology/Blood and Marrow Transplantation
University of Minnesota

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