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Objective: Assessment of the microbiology and management of patients who suffered from chronic maxillary sinusitis was studied retrospectively. Design: Retrospective analysis of microbiology and antimicrobial therapy of 68 patients who underwent the Caldwell-Luc procedure for chronic sinusitis had not received antimicrobials before surgery and whose cultures showed bacterial growth. Setting: This study was performed at the Naval Hospital in Bethesda, Md. Intervention: Amoxicillin-clavulanic acid was given to 18 patients, amoxicillin or ampicillin to 25, cefaclor to 17, and erythromycin to eight. Results: A total of 183 isolates (123 anaerobic and 60 aerobic) were recovered. Anaerobic organisms only were recovered from 35 (51%), specimens, and aerobic or facultative bacteria only in 12 (18%), and mixed aerobic and anaerobic flora in 21(31%). Thirty-four aerobic and anaerobic [beta]-lactamase-producing bacteria were isolated from 28 patients. The 18 patients who received amoxicillin-clavulanic acid had the most rapid and complete response to therapy, none required a change in therapy, and surgical drainage was required in one case. Of 25 patients who received amoxicillin or ampicillin, eight required a change of therapy due to clinical failure (32%), including three who also had surgical drainage. Of 17 that received cefaclor, five had an antibiotic change (29%), one with surgical drainage. Of the eight who were treated with erythromycin, three needed antibiotic change (38%), two with surgical drainage. Resistant organisms were recovered from most of the patients that required therapeutic change. Conclusions: These findings indicate the major role of aerobic and anaerobic [beta]-lactamase-producing bacteria organisms in the polymicrobial etiology of chronic maxillary sinusitis and illustrate the superiority of therapy effective against these bacteria. (1994;120:1317-1320) Itzhak Brook et al, PO Box 70412, Chevy Chase, MD 20813-0412.

Objective: To assess the bacteriology of nosocomial sinusitis in mechanically ventilated children. Method: Retrospective review of sinus aspirate specimens obtained from 20 children with nosocomial sinusitis. The specimens were processed for aerobic and anaerobic bacteria. Results: A total of 58 isolates (2.9 per specimen), 30 aerobic or facultative (1.5 per specimen) and 28 anaerobic (1.4 per specimen), were recovered. Aerobes only were present in 8 patients (40%), anaerobes only in 5 (25%), and mixed aerobic and anaerobic flora in 7 (35%). The predominant aerobes were Pseudomonas aeruginosa (6 isolates), Staphylococcus aureus (5 isolates), Escherichia coli (3 isolates), and Klebsiella pneumoniae (3 isolates). The predominant anaerobes were Peptostreptococcus species (8 isolates), Prevotella species (6 isolates), and Fusobacterium species (4 isolates). Forty-one β-lactamase bacteria were recovered from 14 specimens (70%). Thirty isolates similar to the sinus isolates were also recovered from the trachea, 6 from blood culture specimens, and 6 from other sites. Anaerobes were more commonly isolated from sinus aspirate samples obtained after 18 days of mechanical ventilation (21 vs 7, P<.05 by χ[sup 2]). Conclusion: This study demonstrates the polymicrobial aerobic-anaerobic flora of nosocomial sinusitis in mechanically ventilated children. [ABSTRACT FROM AUTHOR]

Objective: To compare the frequency of recovery of aerobic and anaerobic bacteria with interfering capability of group A β-hemolytic streptococci (GABHS) in the tonsils of children with and without a history of recurrent GABHS pharyngotonsillitis. Patients and Methods: Tonsillar cultures were taken from a group of 20 children with and 20 without history of recurrent GABHS pharyngotonsillitis. Results: Eleven aerobic and anaerobic isolates with interfering capability with GABHS were recovered from 6 (30%) of the 20 children with recurrent GABHS, and 40 such organisms were isolated from 17 (85%) of the 20 without recurrences (P<.01). The interfering organisms included aerobic (α-hemolytic and nonhemolytic streptococci) and anaerobic organisms (Prevotella and Peptostreptococcus species). Conclusions: The tonsils of children with a history of recurrent GABHS infection contain fewer aerobic and anaerobic bacteria with interfering capability of GABHS than those without the history of recurrent GABHS infection. The presence of these interfering bacteria may play a role in preventing GABHS infection. [ABSTRACT FROM AUTHOR]

Objective: To identify the pathogens isolated from children with acute otitis media who did not respond to antimicrobial drug therapy. Methods: Retrospective analysis of cultures obtained by tympanocentesis from 46 children. Results: Organisms were recovered from 34 children (74%), and 43 isolates were recovered from these individuals. The organisms were Streptococcus pneumoniae (16 isolates), Haemophilus influenzae non–type b (12 isolates), Moraxella catarrhalis (5 isolates), Streptococcus pyogenes (5 isolates), Staphylococcus aureus (3 isolates), and Peptostreptococcus species (2 isolates). Resistance to the antimicrobial agent used was found in 27 (63%) of 43 isolates found in 22 patients (48%). Of patients who did not respond to amoxicillin therapy, H influenzae predominated. Streptococcus pneumoniae was recovered from 5 (56%) of 9 of those who did not respond to trimethoprim and sulfamethoxazole therapy, 4 (44%) of 9 patients after azithromycin therapy, 3 (25%) of 12 patients after amoxicillin therapy, and 2 (40%) of 5 patients after cefixime therapy. Streptococcus pyogenes was recovered from 2 (40%) of 5 patients after trimethoprim and sulfamethoxazole therapy and from 2 (40%) of 5 patients after cefixime therapy. Conclusions: The data illustrate the relation between resistance to antimicrobial drug therapy and failure of patients with otitis media to improve. They also highlight the importance of diagnostic tympanocentesis in establishing the presence of resistant microorganisms. [ABSTRACT FROM AUTHOR]

Objective: To investigate the persistence of group A β-hemolytic streptococci (GABHS) in toothbrushes and removable orthodontic appliances (ROAs) in children who suffer from acute GABHS pharyngotonsillitis and the association with penicillin treatment failure. Setting: Private practice setting. Patients and Methods: Pharyngotonsillar and toothbrush cultures were obtained from 104 children with acute GABHS pharyngotonsillitis before and after 10 days of penicillin V potassium therapy. Cultures of ROAs were also obtained from 21 children. The persistence of GABHS in 10 daily rinsed and 10 nonrinsed toothbrushes was studied in vitro. Results: Group A β-hemolytic streptococci were isolated from 11 (11%) of the toothbrushes and 18 (17%) of the patients after the completion of penicillin therapy. Toothbrushes of 5 (28%) of the 18 children who harbored GABHS were colonized with the organism. Group A β-hemolytic streptococci were also isolated from 4 (19%) of 21 ROAs after therapy. In vitro studies illustrated the persistence of GABHS in nonrinsed toothbrushes for up to 15 days. In contrast, the organism was not isolated from rinsed toothbrushes beyond day 3. Conclusion: Toothbrushes and ROAs that harbor GABHS may contribute to the persistence of GABHS in the oropharynx and may account for the failure of penicillin therapy in some cases of pharyngotonsillitis. [ABSTRACT FROM AUTHOR]

Presents a reply to a comment on a study on the microbiology of acute and chronic frontal sinusitis.

The author reflects on how his speech disability offered some benefits. He claimed that as an infectious disease physician, he loves teaching. However, when he was diagnosed with hypopharyngeal squamous cell carcinoma, the clinical management he received led him to have an impaired speech and caused him frustrations. The author recalled how a lecture he gave about his throat cancer changed his views on his disease and how it inspired patients with the same condition.

Objective: To compare the effects on the nasopharyngeal flora of therapy of acute otitis media in children with either a low dose or a high dose of amoxicillin., Design: Retrospective study., Patients: Of 50 children diagnosed as having acute otitis media, 25 received a low dose of amoxicillin (45 mg/kg/d) (group 1) and 25 received a high dose of amoxicillin (90 mg/kg/d) (group 2) for 10 days, and both groups were evaluated., Intervention: Antimicrobial treatment., Results: Before therapy, potential pathogens (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and Staphylococcus aureus) were isolated from the nasopharynx of 15 children in group 1 (60%) and 13 in group 2 (52%). The number of penicillin-susceptible isolates was equally reduced after both therapies. However, an increase was noted in the recovery of S aureus only in group 2 (from 2 to 6 organisms). A greater eradication rate of interfering organisms following therapy was noted in group 2 (from 86 to 36) than in group 1 (from 92 to 60) (P < .001). These organisms include alpha-hemolytic streptococci, and Peptostreptococcus and Prevotella species., Conclusions: The oral flora at the end of therapy with a high dose of amoxicillin is more depleted of organisms with interfering capability than following treatment with a low dose of amoxicillin. These changes may contribute to the greater recovery rate of patients infected with S aureus who received a high dose of amoxicillin.

Objective: To determine the effect of smoking cessation on the frequency of recovery of potential pathogens and aerobic and anaerobic interfering bacteria in the nasopharynges of smokers., Design: Nasopharyngeal cultures were taken from 20 smokers before and 12 to 15 months after cessation of smoking. Potential pathogens and aerobic and anaerobic bacteria with interfering capabilities against these organisms were identified., Results: Eleven potential pathogens (0.92 pathogens per subject) were isolated from nasopharyngeal cultures obtained from 9 individuals before smoking cessation, and 2 (0.17 per subject) were recovered from 2 individuals after smoking cessation (P < .05). Bacterial interference between 2 aerobic (alpha and nonhemolytic streptococci) and 2 anaerobic species (Prevotella and Peptostreptococcus species) and 4 potential pathogens (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and Streptococcus pyogenes) was observed. Bacterial interference was noted in 35 instances against the 4 potential pathogens by 14 normal flora isolates that were recovered from the smokers before cessation and in 116 instances by 42 isolates after cessation (P < .01)., Conclusion: To our knowledge, these findings illustrate for the first time that the high number of pathogens and low number of interfering organisms found in the nasopharynx of smokers revert to normal levels after complete cessation of smoking.

Objective: To establish the microbiological characteristics of acute exacerbation of chronic sinusitis (AECS)., Setting: Academic medical center., Patients: Thirty-two patients with chronic sinusitis and 30 patients with AECS., Main Outcome Measure: The aerobic and anaerobic microbiology of maxillary AECS and chronic maxillary sinusitis., Results: A total of 81 isolates (33 aerobic and 48 anaerobic) were recovered from the 32 cases (2.5 per specimen) with chronic sinusitis. Aerobes alone were recovered in 8 specimens (25%), anaerobes only were isolated in 11 (34%), and mixed aerobes and anaerobes were recovered in 13 (41%). The predominant aerobic and facultative bacteria were Enterobacteriaceae and Staphylococcus aureus. The predominant anaerobic bacteria were Peptostreptococcus subspecies, Fusobacterium subspecies, anaerobic gram-negative bacilli, and Propionibacterium acnes. Twenty-one beta-lactamase-producing bacteria were recovered from 17 specimens (53%). A total of 89 isolates (40 aerobic and facultatives, and 49 anaerobic) were recovered from the 30 patients (3.0 per specimen) with AECS. Aerobes were recovered in 8 instances (27%), anaerobes only in 11 (37%), and mixed aerobes and anaerobes were recovered in 11 (37%). The predominant aerobes were Streptococcus pneumoniae, Enterobacteriaceae, and S aureus. The predominant anaerobes were Peptostreptococcus subspecies, Fusobacterium subspecies, anaerobic gram-negative bacilli, and P acnes. Thirty-six beta-lactamase-producing bacteria were recovered from 28 specimens (53%)., Conclusions: This study demonstrates that the organisms isolated from patients with AECS were predominantly anaerobic and were similar to those generally recovered in patients with chronic sinusitis. However, aerobic bacteria that are usually found in acute infections (eg, S pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis) can also emerge in some of the episodes of AECS.

Objective: To explore the efficacy of the ketolide telithromycin compared with azithromycin in eradicating S pneumoniae from the nasopharynx of adults with acute maxillary sinusitis. The growing resistance of Streptococcus pneumoniae to penicillin and macrolides brought about the development of a new class of antibiotics-the ketolides-that are effective against resistant pneumococci., Setting: Otolaryngology clinic., Patients: One-hundred five patients with acute maxillary sinusitis., Interventions: Nasopharyngeal cultures were obtained before therapy and 10 to 12 days after initiation of treatment. Fifty-nine patients were treated with 500 mg of azithromycin daily for 3 days and 46 were treated with 800 mg of telithromycin daily for 5 days., Results: Sixty-seven potential pathogens were recovered prior to initiation of therapy in 57 patients, 32 treated with telithromycin and 25 treated with azithromycin: S pneumoniae (31 isolates), Haemophilus influenzae (non-type b) (13), Staphylococcus aureus (8), Streptococcus pyogenes (8), and Moraxella catarrhalis (7). The distribution of the pathogens was similar in both groups. The number of S pneumoniae isolates in the azithromycin group was reduced following treatment from 14 to 8 (43% reduction), and 5 of these 8 isolates were resistant to azithromycin. In contrast, the number of S pneumoniae isolates in the telithromycin group was reduced following treatment from 17 to 1 (94% reduction) (P < .01). This isolate was susceptible to azithromycin and telithromycin. No differences were noted in the eradication rate of all of the other potential pathogens, which were all susceptible to both azithromycin and telithromycin. Development of resistance to the antimicrobial agents used (defined as increase in the minimal inhibitory concentration by at least 2 tubes) was found only in 5 isolates (4 S pneumoniae and 1 H influenzae) recovered only from patients who received azithromycin (P < .05)., Conclusion: These data illustrate the superiority of telithromycin to azithromycin in the eradication of S pneumoniae from the nasopharynx.

Objective: To evaluate the organisms recovered from infected sinuses and associated intracranial abscesses (IAs)., Design: Retrospective review of findings from aspirate of pus from 10 infected sinuses and their corresponding IAs., Setting: Academic medical center., Patients: Ten patients diagnosed as having sinusitis (age range, 7-58 years)., Main Outcome Measure: Aerobic and anaerobic bacteria findings from infected sinuses and IAs., Results: Polymicrobial flora was found in 9 sinuses and 8 IAs. Anaerobes were isolated from all sinuses and 9 IAs. A total of 26 isolates (2.6 isolates per specimen) were recovered from the sinuses: 19 anaerobic, 6 aerobic or facultative, and 1 microaerophilic; 17 isolates were found in the IAs (1.7 isolates per site): 13 anaerobic, 2 aerobic or facultative, and 2 microaerophilic. The predominant anaerobes were Fusobacterium species (in 5 corresponding sinuses and abscesses, 1 in a sinus only, and 1 in an IA only), Prevotella species (in 3 corresponding sinuses and abscesses), Peptostreptococcus species (in 2 corresponding sinuses and abscesses, and 4 in a sinus only), Staphylococcus aureus, Haemophilus influenzae type b, microaerophilic streptococci, and Bacteroides ureolyticus (in 1 corresponding sinus and abscess each). Streptococcus pneumoniae was recovered 2 times, only from a sinus. Alpha-hemolytic streptococci and beta-hemolytic streptococci group F were each isolated once from the sinus. Concordance in the microbiological findings between the sinus and the IA was found in all instances. However, certain organisms were present at only one or the other site., Conclusion: These data illustrate the concordance in the recovery of organisms from infected sinuses and their associated IA and confirm the importance of anaerobic bacteria in sinusitis and IA.

Objective: To compare the effects of cefdinir (14 mg/kg per day) and amoxicillin (90 mg/kg per day) antimicrobial therapy on the nasopharyngeal flora of children with acute otitis media., Design: Nasopharyngeal cultures for aerobic and facultative bacteria were obtained before therapy and 2 to 4 days after completion of therapy., Setting: Outpatient clinic., Patients: Fifty children, aged 7 months to 5 years 4 months., Main Outcome Measures: After completion of therapy, 22 (88%) of the 25 patients treated with cefdinir and 16 (64%) of the 25 patients treated with amoxicillin were considered clinically cured (P<.05). A significant reduction in the number of all isolates occurred following therapy in those treated with cefdinir (36 vs 71, P<.01) or with amoxicillin (56 vs 73, P<.05). However, the total number of isolates recovered after therapy was significantly lower in those treated with cefdinir (36) compared with those treated with amoxicillin (56) (P<.01)., Results: The recovery of potential pathogenic organisms (eg, Streptococcus pneumoniae, Staphylococcus aureus, beta-hemolytic streptococci, Haemophilus species, and Moraxella catarrhalis), as well as penicillin-resistant bacteria, was lower following completion of therapy in the cefdinir group (6 pathogens, including 5 that were penicillin resistant), compared with the amoxicillin group (27 pathogens, including 16 that were penicillin resistant) (P<.01)., Conclusion: This study illustrates the greater ability of cefdinir compared with amoxicillin to reduce the number of potential nasopharyngeal pathogens as well as penicillin-resistant bacteria in children with acute otitis media.

Objective: To study the frequency of isolation of potential pathogens and interfering bacteria in the posterior nasopharynx of otitis media-prone (OMP) children and their smoking and nonsmoking parents to possibly explain why active and passive exposure to smoking is associated with carriage of potentially pathogenic bacteria and an increased risk of respiratory tract infection in both adults and children., Setting: Outpatient clinic., Participants: Twenty OMP children and their smoking parents (smoking group) and 20 OMP children and their nonsmoking parents (nonsmoking group)., Interventions: Posterior nasopharynx cultures were taken from 20 OMP children and their smoking parents and 20 OMP children and their nonsmoking parents., Main Outcome Measure: Potential pathogens and aerobic and anaerobic bacteria with interfering capabilities against these organisms were identified., Results: Fourteen potential pathogens were isolated from smoking parents, and 17 were recovered from their children. Concordance in isolation of a pathogen between a parent and child was noted in 11 instances. Three potential pathogens were isolated from nonsmoking parents (P<.001 compared with the parents and children in the smoking group and children in the nonsmoking group), and 16 were recovered from their children. Bacterial interference by normal flora isolates against potential pathogens was noted in 58 instances in smoking parents and in 55 instances in their children (P<.05). Bacterial interference was noted in 129 instances in nonsmoking parents (P<.05 compared with the parents and children in the smoking group and children in the nonsmoking group) and in 55 instances in their children., Conclusions: A high recovery rate of potential pathogens and a low number of interfering organisms were observed in OMP children. This was not related to their parents' smoking habits. The posterior nasopharynx flora of smoking parents contained more potential pathogens similar to the ones recovered from OMP children and fewer interfering organisms than nonsmoking parents.

Aspirates of 15 acutely and 13 chronically infected frontal sinuses were processed for aerobic and anaerobic bacteria. A total of 20 isolates (1.3 per specimen) were recovered from the 15 cases of acute frontal sinusitis, 16 aerobic and facultative isolates (1.1 per specimen) and 4 anaerobic isolates (0.3 per specimen). Aerobic and facultative organisms alone were recovered in 13 specimens (87%), and mixed aerobic and anaerobic bacteria were recovered in 2 (13%). The predominant aerobic and facultative organisms were Haemophilus influenzae (6), Streptococcus pneumoniae (5), and Moraxella catarrhalis (3). A total of 32 isolates were recovered from the 13 cases (2.5 per patient) of chronic frontal sinusitis, 12 aerobic and facultative isolates (0.9 per specimen) and 20 anaerobic isolates (1.5 per specimen). Aerobic and facultative organisms only were recovered in 3 instances (23%), anaerobes only in 7 instances (54%), and mixed aerobic and anaerobic bacteria in 3 instances (23%). The predominant aerobic bacteria were gram-negative bacilli (H influenzae, Klebsiella pneumoniae, and Pseudomonas aeruginosa). The predominant anaerobes included Prevotella species (8), Peptostreptococcus species (6), and Fusobacterium species (4). These findings illustrate the microbiologic features of acute and chronic frontal sinusitis.