title: Azithromycin add-on therapy in high-risk postendoscopic sinus surgery patients failing corticosteroid irrigations: A clinical practice audit.
abstract: BACKGROUND
  Chronic rhinosinusitis (CRS) has a high potential for recurrence after endoscopic sinus surgery (ESS), despite a postoperative therapy of topical corticosteroid irrigations. Azithromycin (AZI) is a macrolide antibiotic with anti-inflammatory properties that may be of benefit in such steroid-unresponsive patients. Follow-up study was performed to (1) review the effectiveness of the management strategy of adding AZI in high-risk post-ESS patients failing standard management and (2) identify predictive factors for steroid nonresponsiveness.
  
  
  METHODS
  A retrospective audit of the postoperative evolution of all patients undergoing ESS for CRS in 2010 by a single surgeon was undertaken. Patients deemed at high risk of recurrence based on preoperative history and/or perioperative findings received nasal irrigation with 0.5 mg of budesonide (BUD) in 240 mL of saline twice daily after ESS. Patients showing signs of endoscopic recurrence at 4 months, despite BUD, had AZI at 250 mg three times a week added to their treatment regimen.
  
  
  RESULTS
  A total of 57 high-risk patients underwent ESS during this period. At 4 months, 63.2% (36/57) had a favorable outcome solely with BUD. Twelve of the 21 nonresponders received AZI, with an additional 66.7% (8/12) subsequently showing a favorable response. Failure of BUD was associated with female gender (p = 0.048), having elevated alpha-1-antitrypsin levels (p = 0.037) and lower recovery rates of Staphylococcus aureus (p = 0.063). Although the AZI subgroup was too small for statistical analysis, female gender was more frequently associated with failure of both BUD and AZI, while IgE was not useful.
  
  
  CONCLUSIONS
  A significant subgroup of high-risk patients showing disease recurrence after ESS despite topical corticosteroid therapy may respond to the addition of AZI as part of their therapy. These findings suggest that topical steroid-unresponsive CRS may represent a distinct entity and that alternate anti-inflammatory agents may be required for optimal management.
authors.affiliation: Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, PQ, Canada.
authors.forename: Anastasios
authors.initials: A
authors.lastname: Maniakas
authors.forename: Martin
authors.initials: M
authors.lastname: Desrosiers
mesh_terms: D000305:Adrenal Cortex Hormones / Q000008:administration & dosage; D017963:Azithromycin / Q000008:administration & dosage* / Q000009:adverse effects; D054316:Biomarkers, Pharmacological / Q000378:metabolism; D019819:Budesonide / Q000008:administration & dosage; D017024:Chemotherapy, Adjuvant; D002908:Chronic Disease; D054869:Clinical Audit; D004724:Endoscopy; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D010256:Paranasal Sinuses / Q000187:drug effects* / Q000601:surgery; D011182:Postoperative Care; D058996:Quality Improvement; D012008:Recurrence; D012189:Retrospective Studies; D012220:Rhinitis / Q000188:drug therapy* / Q000601:surgery; D012307:Risk Factors; D012737:Sex Factors; D012852:Sinusitis / Q000188:drug therapy* / Q000601:surgery; D007507:Therapeutic Irrigation; D017211:Treatment Failure
chemical_list: D000305:Adrenal Cortex Hormones; D054316:Biomarkers, Pharmacological; D019819:Budesonide; D017963:Azithromycin