ANTIBIOTIC THERAPY IN ENT

The choice of an antibacterial compound for a particularPatient and a specific infection is based on several factors:The pharmacokinetic profile of theantibiotic, the adverseEffect profile, the site of infection, the sensitivity profile ofThe infecting organism, the patients immune status,the cost of The regime, and the patients history of allergy to antibiotics.Antibiotics inhibit or abolish the growth ofMicroorganismsAntibacterials areBroadly classified into bactericidals, that kill bacteriaDirectly, and bacteriostatics, which prevent them fromDividing. In the treatment of Most ent infections acquired in the community, the choiceOf either a bacteriostatic or bactericidal antibiotic is ofLimited importance. However, in patients with severeInfection, especially in immunocompromised states, aBactericidal agent must be used.

Parenteral therapy While parenteral administration improves the bioavailabilityOf a drug, it is associated with an increased risk of adverseEffects. Thus, parenteraladministration should be reservedFor patients who are severely ill (e.g. Acute mastoiditis) or inSituations where oral intake is not possible (e.g. Quinsy).Oral treatment can be commenced once the patient showsClinical improvement Frequently used antibiotics in Ent practicebeta lactams These are the most widely used group of antibiotics andInclude penicillins, cephalosporins, monobactams, and Carbapenems. All these drugs fall into this category as theyContain a lactam nucleus in their chemical structure. -Lactams are

bactericidal. They act by binding to penicillinbindingProteins and inhibit the final step in the synthesis of .The peptidoglycan layer of the cell wall.Penicillin is the drug of choice for grampositiveOrganisms, such as group a and b streptococcal infections,Actinomyces, and most bacteria involved in oral andPeriodontal infections. Resistance to penicillin is widespread. In staphylococci and in pneumococci in some geographicAreas. Ampicillin and amoxycillin extend the activity ofPenicillin among gram-negative organisms such as h.Influenzae, but as mentioned below, -lactamase producingVariants exist. The addition of -lactamase inhibitors(clavulanic acid, sulbactam) has extended their spectrum toInclude these resistant gram-negative organisms.Penicillinase-resistant penicillins (e.g. Flucloxacillin) areUsed primarily to treat staphylococcal infections.Carboxypenicillins and ureidopenicillins are especiallyActive against pseudomonas infections.Cephalosporins are categorized into four generationsBased on their activity profile. As a rule of the thumb, theActivity of cephalosporins against gram-negative bacteria isGreater with the newer generations. The fourth generationCephalosporins, however, have true broad spectrum activity.First generation cephalosporins act well against grampositiveBacteria, including penicillinaseproducingStaphylococci. Second and third generation cephalosporinsAre active against the bacterial agents causing sinusitis andOtitis media and against resistant h.Influenzae, thus beingUseful in epiglottitis. Third generation cephalosporins arePrimarily used against multi-drug-resistant gram-negativeAgents such as pseudomonas spp. And when intracranialComplications supervene, as they penetrate the

bloodbrainBarrier well.Carbapenems are primarily used against gramnegativeBacteria resistant to third generationCephalosporins. Aminoglycosides This class of antibiotics is not used as frequently in entInfections. They are bactericidal and prevent proteinSynthesis by binding irreversibly to the 30s subunit of theBacterial ribosome. Their primary indication is in managingGram-negative infections, especially of nosocomial origin,But they are active against staphylococci and pseudomonasSpp. They exhibit poor penetration into abscess cavities andRenal and otic toxicity is one of the major reasons forReduced use. However, topical aminoglycosides are veryEffective incontrolling bacterial otitis media Macrolides Erythromycin, clarithromycin, and azithromycin are veryCommonly used for community acquired entinfections.These are bacteriostatic antibiotics, and act by interferingWith protein biosynthesis and binding to the 50s subunit ofThe ribosome. The spectrum includes gram-positive bacteriaWith limited activity against gram-negative organisms. ItMust be noted that bacteria that are resistant toErythromycin are also resistant to clarithromycin andAzithromycin, owing to a similar mechanism of action. TheLatter two have fewer gastrointestinal side-effects comparedTo erythromycin. These are primarily used in streptococcalPharyngotonsillitis, acute sinusitis, and in patients allergic topenicillin. Unlike penicillin, it must be recognized thatStreptococcus pyogenesresistance to macrolides exists.Clarithromycin and azithromycin are also used in treatingNontuberculous mycobacterial infection.

Lincosamides Clindamycin is the only lincosamide that is widely used.This class of agents is bacteriostatic with a mechanism ofAction similar to the macrolides. It is active against grampositiveAerobes (streptococci and staphylococci) and allStrict anaerobes. Antibiotic associated diarrhoea andPseudomembranous colitis is a welldocumentedComplication that is also associated with most of the otherAntibiotics. Fluoroquinolones This group of antibiotics is bactericidal, acting by inhibitingDna replication and transcription. These antibiotics haveExcellent activity against gram-negative organisms,Including pseudomonas spp. The newer quinolones are alsoActive against gram-positive bacteria. Major indications inEnt practice include second-line therapy for sinusitis (afterTreatment failure) and pseudomonal skull base osteomyelitis(malignant external otitis). Ophthalmic preparations can beUsed topically in chronic otitis media to eradicatePseudomonas spp. Tetracyclines These are bacteriostatic drugs that act by binding reversiblyTo the 30sribosomal subunit and blocking translation. TheyHave a wide spectrum of gram-positive and gram-negativeActivity, but resistance is common of late. Mrsa isSusceptible to tetracylines but treatment should be advisedBased on susceptibility tests. Metronidazole This agent is actively solely against anaerobes, especially theGram-negative species. It disrupts the dna structure afterBeing actively transported into anaerobic bacteria to

beConverted into its active form. It penetrates into abscessCavities very well, but has no activity against aerobicOrganisms. Topical metronidazole is used on malodorousWounds to reduce anaerobic growth. Choice of antibacterial therapy Acute otitis media and acute sinusitis The organisms causing acute otitis media and acute sinusitisHave a similar distribution in children and adults. ApartFrom viruses, streptococcus pneumoniae, haemophilusInfluenzae, moraxellacatarrhalis, and streptococcusPyogenesare implicated. Cultures are difficult to obtain inBoth scenarios without invasive means and therapy isGenerally empirical. Given the above spectrum, amoxicillinIs recommended as the first-line agent and success with thisAgent is well documented. Resistance to penicillin andAmoxicillin is seen in s. Pneumoniae, h. Influenzae, and m.Catarrhalis, with geographic variation. Lack of responseWithin 72 hours may indicate a -lactamase-producing Strain of h. Influenzaeor m. Catarrhalisor a strain ofPenicillinresistant s. Pneumoniae. In these instances, aChange in antibiotic is needed. The choice is best madeTaking into account local sensitivities and directed by cultureResults if appropriate.Therapy is typically administered for 57 days forUncomplicated acute otitis media and 1014 days for acuteSinusitis. Treatment failures can occur with acute sinusitisWith inadequate doses or resistant organisms. In suchInstances, longer courses of culture directed antibiotics for46 weeks may be required to eradicate the infection. Chronic otitis media and topical antibiotics Pseudomonas aeruginosaand staphylococcus aureusareThe common pathogens seen in this setting. Oral andParenteral

antibiotics usually achieve concentrations in theMiddle ear that is slightly above the mic for mostpathogens(46 g/ml). However, a 0.3% topical antibiotic solution(the most common formulation) contains 3000 g/ml, aConcentration that is several hundred times higher than thatAchieved by other routes of administration. Moreover, thisConcentration greatly exceeds the laboratory reported micFor any organism, which are designed for tissueConcentrations achieved by systemic administration. ForThis reason, sensitivity reports have no clinical implication.Thus, topical therapy has very high success rates inControlling the infection and resistance is not an issue.Topical antibiotic preparations include aminoglycosides(gentamicin and framycetin), fluoroquinolones, gramicidin,Andpolymixin, often in combination. Pharyngotonsillitis Gas pharyngitis must be treated with a full 10-day courseOf oral penicillin, with erythromycin being used in penicillinallergicIndividuals. Penicillin resistance has not beenReported so far and newer antibiotics do not offer any Advantage. No treatment is required for pharyngitis causedBy viruses, mycoplasma or chlamydia as these are selfLimiting. Epiglottitis Antibiotic therapy should target h. Influenzaeand shouldBe guided by recent local sensitivity profiles if available.Several studies have shown increasing resistance ofThis organism to -lactam antibiotics and thus therapyWith a -lactam/ lactamase inhibitor combination(amoxicillin/clavulanic acid) or a second- or third generationCephalosporin (cefotaxime, ceftriaxone) is recommended.Clindamycin is reserved for patients allergic to -lactams.Antibiotic therapy should be

continued for 710 days andShould be tailored, if necessary, to the organism recovered inCulture. Unvaccinated children exposed to patients shouldReceive prophylaxis with rifampicin. Neck space abscesses These are life-threatening infections and empirical therapyShould be started soon after a clinical diagnosis is made.This should cover streptococci, oral anaerobes, and s.Aureus. Amoxycillin/clavulanic acid orclindamycin alone isUsually effective. Once cultures are obtained, the antibioticsCan be changed to reflect sensitivity. Drainage of abscess isEssential, as antibiotics do not reach bacteria in the presenceOf pus.