Nebulized Antibiotics for the Treatment of Refractory Bacterial Chronic Rhinosinusitis

OBJECTIVE: To review the safety and efficacy of nebulized antibiotics for refractory bacterial chronic rhinosinusitis (CRS) in adults. DATA SOURCES: PubMed (up to February 2011) and The Cochrane Library (up to February 2011) were searched using the terms nebulizer, nebulized, antibiotics, and chronic sinusitis. STUDY SELECTION AND DATA EXTRACTION: All English-language articles reporting clinical trials in adults were evaluated; 4 relevant studies were identified. DATA SYNTHESIS: Conventional therapy for CRS, including pharmacologic treatments (eg, oral antibiotics, corticosteroids, antihistamines) and surgery, are not effective for all patients, which has led to experimentation with nebulized antibiotics. The 4 trials analyzing the effectiveness of nebulized antibiotics for refractory CRS in adults identified in our literature search were diverse in their methods, and different antibiotics were used in each trial. Furthermore, all of the trials had small sample sizes, with the largest comprising 42 patients. Two of the studies compared nebulized antibiotics to nebulized saline, and even though rhinosinusitis symptoms improved, nebulized antibiotics were found to offer no additional benefit over saline. The 2 other trials had no control groups and found that nebulized antibiotics led to an improvement in symptoms. In 1 trial, antibiotics were selected based on the results of sinus cultures, which led to infection resolution in 38 of 50 (76%) treatment courses. Nebulized antibiotics were well tolerated, with only minor adverse effects noted. CONCLUSIONS: Based on current studies, use of nebulized antibiotics for refractory CRS cannot be recommended at this time. Although supportive evidence is limited, nebulized antibiotics appear to improve rhinosinusitis symptoms in some patients with minimal adverse effects. With further studies, culture-directed nebulized antibiotic therapy may be a treatment option in patients with CRS refractory to conventional treatments.