Topical antimicrobials in the management of chronic rhinosinusitis: a systematic review.

Background: Chronic rhinosinusitis (CRS) is a common disease that can significantly impact health. The mainstay of medical treatment is topical steroids and oral antibiotics, but little is known about the efficacy of topical antibiotics. The purpose of this study was to identify evidence for the use of topical antibiotics in the treatment of CRS and exacerbations of CRS.

Methods: Systematic review of literature with a search of the MEDLINE, EMBASE, and CINAHL databases; Cochrane Central Register of Controlled Trials (Third Quarter 2007); and Cochrane Database of Systemic Reviews (3rd Quarter 2007) databases were performed. The dates of search were from December 1, 1949 to September 30, 2007.

Results: Fourteen studies that fulfilled the inclusion criteria were identified: seven were controlled trials and of these, five were double blinded and randomized. Only one of the randomized studies showed a positive outcome. Overall, there was low-level corroborative evidence for the use of antibacterials. No definite conclusions could be made regarding the use of antifungals. Currently, there is evidence for the use of nasal irrigation or nebulization rather than delivery by nasal spray. For the antibacterial studies, the highest level of evidence currently exists for studies that have used postsurgical patients and culture-directed therapy. Both stable and acute exacerbations of CRS appear to benefit from topical antimicrobials.

Conclusion: Topical antibiotics appear effective in the management of CRS. Given the combination of low-level evidence (level III, with inherent potential confounders of natural progression of disease and placebo effect) and the level IIb evidence being limited to the cystic fibrosis group of patients, topical antibiotics should not be first-line management but may be attempted in patients refractory to the traditional topical steroids and oral antibiotics. Larger and better-designed randomized double-blind placebo-controlled trials are required to more fully evaluate this emerging modality of treatment.