[PAGID] Chronic rhinosinusitis in antibody deficiency diseases

[Berger, Melvin]

With patients that are actually chronically infected (rather than kids in which true "prophylaxis" is possible), I usually alternate months of full treatment antibiotics- like augmentin 875 or 1000 mg twice a day one month and zithomax every day the first week of the following month followed by alternate day the rest of that month. If patiebnts have chronic bronchitis and have ever had pseudomonas I add aerosolized tobramycin during the zithromax month. Then I reserve Quinolones for acute exacerbations. I am always wary that this may increase susceptbility to fungal infection and fluconazole or itraconazole are not far from mind. 
 
For prophylaxis in kids I agree with MaryEllen- bactrim is usyually my first choice. 
 
Most of our patients with chronic sinusitis who have crusty junk in their noses are on some kind of irrigation- eith with a water pik or similar device or the thing whixch looks like an aladdins lamp. The ENT guys usually recommend a slightly alkaline solution with sodium bicarb. 
 
Melvin Berger, M.D., Ph.D.
Professor of Pediatrics and Pathology
Case Western Reserve University
phone 216 844 3237
 
Director, Jeffrey Modell Center for Primary Immune Deficiencies
Division of Allergy-Immunology
Rainbow, Babies and Children's Hospital
University Hospitals of Cleveland
RB&C Rm 504, MS 6008B
11100 Euclid Ave.
Cleveland, OH 44106

________________________________

From: pagid-bounces at list.clinimmsoc.org on behalf of Conley, Mary-Ellen
Sent: Wed 6/4/2008 9:51 AM
To: pagid at list.clinimmsoc.org
Subject: Re: [PAGID] Chronic rhinosinusitis in antibody deficiency diseases


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
	 
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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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