© Borgis - New Medicine 4/2013, s. 114-119
Magdalena Frąckiewicz1, *Lidia Zawadzka-Głos1, Elżbieta Podsiadły2, Lechosław P. Chmielik1, Joanna Rogulska2
Bacteriological aetiology of chronic rhinosinusitis in children; a study from the pediatric otolaryngology clinic of the warsaw medical university
1Department of Pediatric Otolaryngology, Medical University of Warsaw, Poland
Head of Department: Lidia Zawadzka-Głos, MD, PhD
2Department of Laboratory Diagnostics and Clinical Immunology of Development Age, Poland
Head of Department: prof. Urszula Demkow, MD, PhD
Introduction. Chronic rhinosinusitis (CRS) is a long-lasting inflammation whose aetiology is multifactorial. In the majority of patients, the disease develops from an existing impaired patency of the nose or ostia of paranasal sinuses. Such patients require surgical treatment, however almost always the disease is accompanied by bacterial infection of this region.
Aim. To identify and estimate the sensitivity of pathogens to drugs through bacteriological testing of samples from children surgically treated for chronic rhinosinusitis or those where preliminary treatment of such diseases has been proposed.
Material and methods. The study was performed on children who had undergone the initial stage of conservative treatment at the Department of Paediatric Otolaryngology, Warsaw Medical University between 2007 and 2010. Samples for bacteriological examination were collected during the endoscopic sinus surgery from under the middle nasal turbinates and maxillary sinuses.
Results. Pathogens that either most frequently caused or co-existed with chronic rhinosinusitis were determined in samples taken from the maxillary sinuses and from under the middle nasal turbinates. Staphylococcus aureus was found to be the most frequently cultured.
Discussion. Chronic rhinosinusitis develops as a result of composite and multistage inflammatory process. At least one component of the CRS pathogenesis is through chronic or recurrent bacterial infection. Our study demonstrated in many cases a lack of correlation between the results from under the nasal turbinates and maxillary sinuses.
Conclusions. 1. Our screening tests have a different bacterial aetiology for rhinosinusitis than those patients seen by their family doctor. 2. In most cases results from under the middle nasal turbinate differ from the lumen of maxillary sinuses. 3. Examining samples taken from under the middle nasal turbinates and maxillary sinuses plays a vital role in establishing the aetiology of rhinosinusitis and in choosing the appropriate treatment if a recurrence of rhinosinusitis occurs. 4. On basis of this study, the authors suggest amoxicillin and amoxicillin with clavulanate acid be used as first line treatment agents in cases of exacerbated chronic rhinosinusitis.
In essence, chronic rhinosinusitis is a long-lasting mucosal inflammation of the nose and paranasal sinuses that cannot be cured by pharmacological treatment (1, 3, 4). Its most frequent cause in children is an impaired patency of the nose or of the ostia of paranasal sinuses together with local immunological disorders. Factors that predispose children to chronic rhinosinusitis are adenoids, nasal septum deviation, tumor of the nasopharynx, retained foreign bodies in the nose, unilateral or bilateral choanal atresia. Its main symptoms are: a dense muco-purulent discharge retained in the nasal cavities, impaired nasal patency and others including a productive cough, (mainly in the morning), a clearing one’s throat, halitosis, loss of appetite and smell, morning vomiting and in older children recurrent headaches.
Regardless of the cause, bacterial infection almost always plays role in the pathomechanism of chronic rhinosinusitis (1-3). Antibiotic therapy is seen to be vital regarding the frequency in which of chronic rhinosinusitis occurs. Family doctors usually do not make a bacteriological examination because the plain nasal culture, available in a surgery, has little diagnostic value. However, bacteriological testing of samples taken from under the middle nasal turbinates and lumen of maxillary sinuses can be important although this is basically inaccessible for family doctors, paediatricians or even otorhinolaryngologists from out-patient clinic. For these doctors, whose role is to administer antibiotic therapy, a knowledge of the most frequent pathogens in this disease is thereby important. The compositions of pathogens changes over time and will depend on local living conditions of the population. Therefore, adequately equipped clinical centers should monitor on their region for the most frequent bacteriologic agents in cases of chronic rhinosinusitis.
To identify and estimate the sensitivity of pathogens to drugs through bacteriological testing of samples taken from under the middle turbinates and lumen of maxillary sinuses from children surgically treated for chronic rhinosinusitis or those where preliminary treatment of such diseases has been proposed.
MATERIAL AND METHODS
The study was performed on 230 patients with chronic rhinosinusitis (107 females, 123 males) aged 5 to 17, where conservative treatment had been ineffective and who underwent endoscopic surgery at the Clinical Department of Pediatric Otolaryngology, of Warsaw Medical University in the period between January 2007 and May 2010. Before surgery, patients were treated with antibiotics and 36 (15.65%) of patients received antibiotics during the surgery. Samples for bacteriological examination were collected during the surgical procedure from under both middle nasal turbinates using a swab and from maxillary sinuses using a suction assembly. The material was cultured on TSA medium containing 5% defibrinated mutton-blood, chocolate agar with bacitracin (HAEM, Biomerieux), Chapman’s medium (MSA2, Biomerieux), MacConkey’s medium (MCK, Biomerieux), whereas sample material from the sinuses was additionally cultured on a medium for the isolation of anaerobic bacteria (SCS, Biomerieux). The cultures were incubated at a temperature 37°C and in the case of the chocolate medium in an atmosphere of 5% CO2, whereas anaerobic cultures were contained within an atmosphere of 10% CO2, 85% N2, 5% H2. Identification of pathogens was performed by ATB Expression System (Biomerieux). The sensitivity to drugs of bacteriological strains was determined using the diffuse-discoid method or E-tests. Determinations and interpretation were carried out according to recommendations of National Drug-sensitiveness Centre and Clinical Laboratory Standards Institute (CLSI). In all cases where results of microbiological examination were positive, antibiograms were performed. Results with antibiograms were attached to the patient’s records in the out-patient clinic for cases exhibiting aggravated of symptoms of CRS.
From the 230 examined children, real pathogens were cultivated in 100 cases from material taken from one or both sinuses. Bacterial aetiology of chronic rhinosinusitis was confirmed in 43.5% of the children examined.
In material taken from the maxillary sinuses there was no growth of pathogens in 66% from the left side and 63.5% from the right side. Among pathogens most frequently observed, Staphylococcus aureus, Haemophilus influenza, Moraxella catarrhalis, Streptococcus pneumoniae, Klebsiella pneumonia were cultured. On the left side in the group under ‘others’ the following were detected: Acinetobacterlwoffii (1), Escherichia coli (1), Pseudomonas aeruginosa (1), Enterobacter cloacae ESBL (-) (1), Pantoea spp. (1), C. guillermondi (1), Staphylococcus mitis (1), Staphylococcus agalactiae (1). Mixed bacterial cultures were seen in 12 cases (fig. 1).
Fig. 1. Results of bacterial cultures from the left maxillary sinus.
On the right side in the group under ‘others’ the following were detected: Acinetobacterlwoffii (1), Escherichia coli (1), Pseudomonas aeruginosa (1), Klebsiella planticolha (1), Staphylococcus mitis (1), Staphylococcus agalactiae (1), Propionibacterium acnes (1), Haemophilus parainfluenzae (1), Proteus mirabilis (1), E. faecalis (1), Candida albicans (1), Actinomyces naeslundii (1). Mixed bacterial cultures were seen in 9 cases (fig. 2).
Fig. 2. Results of bacterial cultures from the right maxillary sinus.
In the material from under the middle nasal turbinates there was no growth of pathogens in 74% on the left side and in 74.3% on the right side. Among pathogens most frequently observed Staphylococcus aureus, Haemophilus influenza, Moraxella catarrhalis, were cultured. On the left side in the group under ‘others’ the following were detected: Pseudomonas aeruginosa (1), Escherichia coli (1), Staphylococcus mitis (1). Mixed bacterial cultures were seen in 6 cases (fig. 3).
Fig. 3. Results of bacterial cultures from under the left middle nasal turbinate.
On the right side in the group under ‘others’ the following were detected: Streptococcus pyogenes (1), Escherichia coli (1), Staphylococcus mitis (1), Alcaligenes spp. (1), Klebsiellaoxytoca (1) were stated. Mixed bacterial cultures were stated in 8 cases (fig. 4).
Fig. 4. Results of bacterial cultures from under the right middle nasal turbinate.
A more detailed analysis of the infection was performed for separate and mixed pathogens for the following: Staphylococcus aureus, Haemophilusinfluenzae, Streptococcus pneumoniae and Moraxella catarrhalis.
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