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Bacteriology of Acute and Chronic Frontal Sinusitis

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Bacteriology of Acute and Chronic Frontal Sinusitis ORIGINAL ARTICLE Bacteriology of Acute and Chronic Frontal Sinusitis Itzhak Brook, MD, MSc spirates 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 recov- ered 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 faculta- Ative organisms alone were recovered in 13 specimens (87%), and mixed aerobic and anaerobic bac- teria were recovered in 2 (13%). The predominant aerobic and facultative organisms were Hae- mophilus 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 Fu- sobacterium species (4). These findings illustrate the microbiologic features of acute and chronic frontal sinusitis. Arch Otolaryngol Head Neck Surg. 2002;128:583-585 Frontal sinusitis is a potentially devastat- ACUTE FRONTAL SINUSITIS ing infection with a high frequency of in- tracranial complication. In contrast to max- A total of 20 isolates were recovered from illary sinusitis, the microbiologic features the 15 cases (1.3 per specimen), 16 aero- of frontal sinusitis are not well estab- bic and facultative isolates (1.1 per speci- lished, and only a few reports1-3 document men) and 4 anaerobic isolates (0.3 per the organisms isolated. The role of anaero- specimen). The number of isolates per speci- bic bacteria in this infection was also not men varied from 1 to 3. Aerobic and facul- well studied, although their recovery was tative organisms alone were recovered in 13 recorded in a few cases.4-6 This report de- specimens (87%), and mixed aerobic and scribes my experience during a 25-year anaerobic bacteria were recovered in 2 period of studying the aerobic and anaero- (13%). The predominant aerobic and fac- bic microbiologic characteristics of fron- ultative isolates were Haemophilus influen- tal sinusitis. zae (6), Streptococcus pneumoniae (5), and Moraxella catarrhalis (3) (Table). Seven ␤-lactamase–producing bacteria (BLPB) RESULTS were recovered from 5 specimens (33%). No differences were noted in the micro- CHRONIC FRONTAL SINUSITIS biologic findings between children and adults, the year of the infection, the ad- A total of 32 isolates were recovered from ministration of previous antimicrobial the 13 cases (2.5 per patient), 12 aerobic therapy, or the surgical approach (osteo- and facultative isolates (0.9 per speci- plastic vs endoscopic). men) and 20 anaerobic isolates (1.5 per specimen). The number of isolates var- From the Department of Pediatrics, Georgetown University School of Medicine, ied from 2 to 4. Aerobic and facultative Washington, DC. organisms only were recovered in 3 in- (REPRINTED) ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 128, MAY 2002 WWW.ARCHOTO.COM 583 ©2002 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/28/2021 PATIENTS AND METHODS persisted for more than 1 month. Frontal surgery was per- formed by the osteoplastic flap approach in 13 patients and by an intranasal endoscopic approach in 15. Other si- The 28 patients included in the report were studied be- nuses were involved at the time of surgery in 6 patients (4 tween June 1975 and June 2001. Excluded are 9 addi- ethmoid and 2 maxillary). tional patients whose frontal sinusitis showed no bacterial The specimens were obtained during surgery, using growth. The patients were seen in the following hospitals: strict asepsis to avoid any contamination, and were trans- University of California Medical Center and County Medi- ported to the laboratory in a syringe sealed with a rubber cal Center in Los Angeles (1974-1977), Children’s Hospi- stopper after evacuation of the air or in an anaerobic trans- tal National Medical Center in Washington, DC (1977- port tube (Port-A-Cul; Baltimore Biological Laboratories, 1980), and Naval Hospital in Bethesda, Md (1977-1998). Cockeysville, Md). The time between the collection of ma- Similar microbiologic methods for collection and trans- terials and inoculation of the specimen was generally less portation of specimens were used in these institutions. than 60 minutes for syringes and less than 3 hours for the Patients’ ages ranged from 11 to 72 years (mean age, anaerobic transport tube. 38 years 8 months), and 18 were male. Five patients Specimens were inoculated onto 5% sheep’s blood, were children (younger than 18 years). Included in the chocolate agar, and MacConkey agar plates for aerobic and study were 15 patients with acute and 13 with chronic facultative organisms. The plates were incubated at 37°C sinusitis. Antimicrobial therapy was administered to 15 aerobically (MacConkey) or under 5% carbon dioxide (5% patients (54%) in the month before sample collection. sheep’s blood and chocolate agar) and examined at 24 and These patients included 10 with acute and 5 with chronic 48 hours. For anaerobes, the material was plated onto pre- sinusitis. reduced vitamin K1–enriched Brucella blood agar, an an- Only patients who fulfilled the following criteria were aerobic blood agar plate containing kanamycin sulfate and included in the study: typical clinical symptoms of sinus- vancomycin hydrochloride, an anaerobic blood plate con- itis (headache, fever, nasal drainage); positive radio- taining colistin sulfate and nalidixic acid, and an enriched 7 graphic findings; bacterial growth on cultures; biopsy speci- thioglycolate broth (containing hemin and vitamin K1). mens demonstrating acute or chronic inflammation of the The anaerobic plates were incubated in anaerobic jars (Gas- sinus mucosal lining; or clinical and radiologic findings com- Pak jars; Baltimore Biological Laboratories) and examined patible with frontal sinusitis followed by clinical and ra- at 48 and 96 hours. diologic improvement following surgery and treatment with Anaerobes were identified by techniques described pre- antibiotics. viously.7 Aerobic bacteria were identified by conventional Sinusitis was considered acute if the duration of symp- methods.8 ␤-Lactamase activity was determined by use of toms was less than 1 month and chronic if symptoms the chromogenic cephalosporin analog 87/312 method.9 stances (23%), anaerobes only in 7 instances (54%), and chronic maxillary sinusitis, where anaerobic bacteria are mixed aerobic and anaerobic bacteria in 3 instances (23%). the main isolates.6,10-12 These were mainly Peptostrepto- The predominant aerobic bacteria were gram-negative ba- coccus species, Fusobacterium species, and pigmented Pre- cilli (H influenzae, Klebsiella pneumoniae, and Pseudomo- votella and Porphyromonas species, all members of the nas aeruginosa) (Table). None of the patients who had oropharyngeal flora. P aeruginosa were diagnosed with cystic fibrosis. The pre- The frequent involvement of anaerobes in chronic dominant anaerobes included Prevotella species (8), Pep- frontal sinusitis may be related to the poor drainage and tostreptococcus species (6), and Fusobacterium species (4). increased intranasal pressure that develops during in- Twelve BLPB were recovered from 8 patients (62%). These flammation.13 This can reduce the oxygen tension in the included all Staphylococcus aureus isolates, 3 (75%) of 4 inflamed sinus14 by decreasing the mucosal blood flow15 of Fusobacterium species, and 4 (50%) of 8 of Prevotella and depressing the ciliary action.16 The lowering of the species. oxygen content and pH of the sinus cavity supports the growth of anaerobic organisms by providing them with 16 COMMENT an optimal oxidation-reduction potential. ␤-Lactamase–producing bacteria were isolated in 13 This study demonstrates the microbiologic features of (46%) of 28 patients. The recovery of BLPB is not surpris- acute and chronic frontal sinusitis. Since the number of ing, since more than half of our patients received antimi- patients included in this report was small and was col- crobial agents, including the ␤-lactams within the past 3 lected during a period of more than 25 years, prospec- months, which might have selected for these organisms. tive studies are required. The small number of patients Surgical drainage is essential in most cases, and an may also account for the lack of correlations between clini- initial, empiric, broad spectrum antimicrobial coverage cal (eg, age and previous antibiotic therapy) and micro- is required. However, the unique microbiologic features biologic findings. Similar to the study by Ruoppi et al,2 of acute and chronic frontal sinusitis and the recovery the present study also recovered S pneumoniae, H influ- of BLPB in approximately half of the specimens require enzae, and S aureus from patients with acute frontal si- adjusting an initial empiric therapy to a specific one when- nusitis. These findings are similar to the microbiologic ever possible. features of acute maxillary sinusitis, where S pneumo- The antimicrobial agents most commonly used to treat niae, H influenzae,
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