Tuesday, April 24, 2012

Treating sinusitis: Politically incorrect drug resistance due to Pneumococcal vaccine

I have treated so many patients with sinusitis in the last several weeks, I decided to review new guidelines that were issued by the Infectious Diseases Society of America (IDSA) recently on sinusitis.  Wow, the changes were BIG and I had missed them.  Seems the drugs I used to use don't work so well any more.

Everyone has heard about drug resistance.  We had to watch a movie about it in medical school in the 1970s.  It was very important that we not use antibiotics with broader, more powerful antimicrobial effects than necessary.  Else plagues of drug-resistant bacteria would rain down upon us, and we would run out of effective antibiotics.

I got it. Use basic, relatively narrow spectrum antibiotics unless there is a very good reason to use the bigger guns -- like your patient was so sick he might not survive if you picked the wrong drug to start.

Plus, there are very few new antibiotics in the pipeline.

I recently learned that 80% of the antibiotics sold in the US don't treat humans.  These antibiotics are used in animal feed, enabling owners of livestock and poultry farms to crowd the animals together, where they frequently live in their own merdeFDA banned this use of fluoroquinolone antibiotics in 2005, but compliance by industry has been poor.  (Industry can still feed animals other classes of antibiotics.) So FDA will now restrict sales of this class of antibiotic to only those with a veterinarian's prescription, and ask farmers for voluntary compliance in reducing use of other antibiotics, 61 years after first approving this practice. 

Yale's Dr. David Katz notes that the use of antibiotics in farm animals is a bigger problem for drug resistance than doctors choosing the wrong antibiotics.

But back to  sinusitis:  too many of my patients needed a change in antibiotic after 4 days on the first antibiotic.  Good drugs for sinusitis used to include penicillins, cephalosporins, macrolides and sulfa drugs:  four different categories of drugs.  Now they are inadequate, caused by too many resistant Strep. pneumoniae and Hemophilus influenzae, the most common bacteria causing sinusitis.

What now?  IDSA's #1 choice is Augmentin, a very broad spectrum combination of amoxicillin and clavulanic acid.  The clavulanic acid prevents most bacterial resistance to amoxicillin.  This treatment may cause more drug resistance down the road.

But what if you are allergic to penicillin?  Doxycycline or a fluoroquinolone can be used.  Doxy can't be used in children, however.  What else should you use?  Clindamycin plus a cephalosporin, say the guidelines.  But Clostridium difficile infections occur in 1-10% of patients treated with clindamycin.  These can be impossible to treat.  This is not looking good, I realize.

Then it gets worse.  What has happened?  IDSA let the cat out of the bag on page e16:
... both the prevalence of H. influenzae (40%– 45%) and proportion of b-lactamase–producing H. influenzae (37%–50%) (extrapolated from middle ear fluid cultures of children with acute otitis media) have markedly increased among other upper respiratory tract infections since the widespread use of conjugated pneumococcal vaccines...
Whereas S. pneumoniae was more common than H. influenzae prior to 2000, the prevalence of H. influenzae has clearly increased while that of S. pneumoniae has decreased in the post–pneumococcal vaccine era, such that currently they are approximately equal...  (* See IDSA citation below)
Now 30% of Strep pneumoniae are resistant to macrolides, while 30-40% are resistant to sulfa drugs (page e3).  What IDSA didn't delve into was the fact that non-vaccine Strep serotype 19A, which is multidrug resistant, spread throughout the world as the result of the niche created by vaccination with the 7-serotype vaccine.  Recently a replacement pneumococcal conjugate vaccine was licensed that includes 13 serotypes in the US, and varied numbers of serotypes in other countries.  Any unintended consequences have yet to be identified.

The strains of Strep pneumoniae circulating among us have changed as a result of the Prevnar 7 vaccine, and the new strains are decidedly more drug resistant.  I'd rate this vaccine's net value a big negative.

WHO and NIAID list the causes of antibiotic resistance:  agricultural use is last on both lists, and vaccines fail to be mentioned. 

Yet the consequences of this change in resistance patterns are profound.   Now routine cases of sinusitis, earaches, strep throats and pneumonias have become significantly harder and more expensive to treat.  I can't tell you the relative contributions that Prevnar 7 vaccine, prescribing errors and antibiotic feeding make to this mess.  But the serious unintended consequence of Prevnar 7 (the 19A proliferation) needs to be fully grasped, and the lesson absorbed, in order to avoid making a similar mess with other vaccines.

* Casey JR, Adlowitz DG, Pichichero ME. New patterns in the otopathogens causing acute otitis media six to eight years after introduction of pneumococcal conjugate vaccine. Pediatr Infect
Dis J 2010; 29:304–9.


Anonymous said...

I concur. My 3 1/2 yr daughter
recently had a sinus infection
that was resistant to amox and
switched to augmentin. Augmentin
is not tolerated well and she
had loose stools from it.

I hope more health care professionals would open their minds to realize that prevnar vaccine is causing more drug resistant bacteria to thrive.
And stop making parents feel guilty
about having concerns over this vaccine.

Anonymous said...

Sinusitis in the most common circumstances can be helped with irrigating the sinuses with homemade saline solution (not the store bought). Use sterile glass droppers (sold at Walmart for around $2) and mix in a sterile cup 1/4 teaspoon of salt per 1 cup of warm water. Make sure the water is not too hot. It also helps to use this same type of solution to rinse out the eyes really well as it will help the sinuses also.

Herbs I have found very helpful I will list here, but do not take without some research to make sure the herb does not pose a risk with a medical condition or a prescribed medicine.

Herb: Goldenseal is excellent for respiratory infections. Effective against both bacteria, some viruses, fungus, and some forms of candida. However, cannot be taken if having anesthesia soon for dental or medical purposes as could result in death as it is a blood thinner. Because it is a blood thinner, it cannot be taken with some blood pressure or heart medications. It can also be a problem for those with diabetes, liver, or kidney disease, or problems of the spleen, or pancreas. Best use is in herbal tea form.

Herb: Pau D'Arco. I love this plant product. It comes from the inner bark of the Pau D'Arco tree from the rainforests of South America. It is pretty mild in terms of any risks. It is effective against some very resistant forms of yeast, other fungal infections, some virus, and some bacteria. (Ladies, I highly recommend. The biggest problem with this product is getting herb tea that is not contaminated. Best use is in Herbal Tea form.

For mild cases of sinus issues you may want to try Cayenne pepper in a capsule or even Feverfew. Not all Feverfew is the same. I recommend the brand "Nature's Way" for consistency and high quality, and no I don't sell it or own stock in it.

Herbs are medicine just like prescription medicine and common sense, some research, and proper use is important. However, given the harrowing effects that can happen from prescription drugs, I would choose the herbs first anyday...unless you have a very high fever, and severe symptoms. Sinus infections like other facial or ear infections can spread to the brain or elsewhere. So use good judgement.

Finally, most doctors are not trained in diseases of the facial glands and often overlook infected glands that could be causing repeated infections of the sinuses. Facial glands will not always be swollen or red. You can have a low level infection, or an infection on the cellular level which does not produce overly obvious symptoms. Or you could have an infection in the deeper glands or in the ducts which is harder to detect..and also very hard to treat. Buried abscess may require some surgery to drain and clean out the infected tissue.

Most Ear, Nose, and Throat doctors are not trained in recognizing these types of infections of the facial glands. It is a sub-specialty and requires a doctor who sub-specializes in this part of the body.