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From: (Steven B. Harris )
Subject: Re: Antibiotics and Chronic Sinusitis
Date: 28 Sep 1995

In <44d2c7$> (WSH) writes:

> (Steven B. Harris ) wrote:
>>In <449nts$> (Chicago)
>>>In <44993i$> (MSpec56301)
>>>>I have chronic sinusitus. I have often been treated with antibiotics,
>>>>which often help. However, often within two weeks or so after stopping
>>>>the antibiotics, I get sick again. I wonder whether the bacteria have
>>>>not been completely killed off, so keep coming back.
>>>>The length of time of the antibiotic treatment has usually been 2-3
>>>>weeks. However, one time I took it for 2 months. The antibiotic I have
>>>>taken the most has been Biaxin.
>>>>What is the longest time one could recommend for antibiotic treatment
>>>>of chronic sinusitis? What antibiotic is considered most effective for
>>>>this disease? I would appreciate responses by E-mail, as I don't check
>>>>these boards often.
>>>>Thank you.
>>>>Michael Spector
>>>Please respond to Michael.
>>   Why should we?  If Michael is too lazy to check the boards, why need
>>we work any harder to inform him?
>>   Sinusitis is not a simple matter-- not a thing to simply be cured or
>>not by the right antibiotic (although it is sometimes that simple).
>>Bacteria grow in sinuses not draining correctly, and the question is
>>why they aren't?  Anatomical problems, allergies, what?  Then there is
>>the problem that chronic sinus infections cause their own damage, and
>>tend to be mixed infections with anaerobes and even fungi.
>>   Finally, there is the problem that there are many things not known
>>about this area.  For instance, I've seen two people on high dose IV
>>mega antibiotics for hospital infections, who were also as a side
>>effect "cured" of nearly life long "seasonal allergies" thereby.
>>Apparently. What was going on there?  I dunno.
>>   If one has to treat chronic sinusitis with antibiotics alone, it's
>>probably best to try a regime with clindamycin in it, to get the
>>anaerobes, and metronidazole so the clinda doesn't cause C. difficile
>>for the 6 weeks you're going to be taking it.  After that, it's a
>>tossup what broad-spectrum antibiotics to try, except that they need to
>>cover H. flu and strep and perhaps staph.  Macrolides are not going to
>>be helpful if you're already using clindamycin, so Biaxin and Zithromax
>>are not great ideas.  Augmentin or a fluoroquinolone can be used.
>>Rifampin is also sometimes very helpful as adjunct in getting at deep
>>seated infections with lots of pus (as in sinuses).
>>  Quite often the main thing, however, is to see the ENT people about
>>drainage, and the allergy people about desensitization.
>>                                Steve Harris, M.D.
>Watch out for the Clindamycin. It can mess up your colon royal,
>because it kills the bowel flora. Supplement it with lots of
>live-culture yogurt, fos, and capsules of friendly bacteria.
>If the friendly bacteria get killed off, the spore producers can run
>wild, and some  very nasty bowel conditions can result.
>--Bill Hopwood

   Yes, but that's what the metronidazole is for-- to keep you from
getting the worst overgrowth.  I never use oral clinda anymore without
it, and it works great.  Of course yogurt never hurt, either.  But add
it on, don't use it instead of the other antibiotic.


From: (Craig Werner)
Subject: Re: Chronic Sinusitis---PLEASE HELP!!
Date: 28 Dec 1996

	If you have chronic sinusitis and you have failed nearly a dozen
antibiotics, may I suggest that what you have is not an antibiotic problem.
Having looked into my share of nasal passages, and loath to give out
antibiotics unless I suspect bacterial infection, I've discovered that
roughly half the non-resolving "sinusitis" is actually allergic rhinitis.
	The treatment is systemic decongestants (I like Pseudofed over the
counter, or Deconsal II, aka Guaphedrine, available by prescription - the
latter being equal to 2 Sudafed times a day plus 4 teaspoons of Robitussin
ever 4 hours, taken as a twice daily drug), maybe an antihistamine, and MOST
IMPORTANTLY, an inhaled steroid.  I like BeconaseAQ because it is the cheapest.
You try it for a month.  If it works, the diagnosis is not only made, but
you'll breath better than you have for years.
Craig Werner, MD/Ph.D  				cwerner@dorsai.ORG
(Yes, THAT Craig Werner!, formerly - very formerly - werner@aecom.YU.EDU)

From: B. Harris)
Subject: Re: sinus infection--best antibiotic
Date: 16 May 1997

In <5lg75v$> (Melvin
Billik) writes:

>Any suggestions on what works best?? I seem to have a miserable one:
>fever, chills, plus the usual vicious sore throat and burning sinus pain.

   The ENT docs generally use Augmentin, and use it for long durations
(3 weeks!).  You can generally get even more bang out of Augmentin for
deep-seated infections by adding the adjunct antibiotic rifampin (which
you must take on an empty stomach).

   For people who've had sinus infections a LONG time, some might
benefit from even better anaerobic coverage, which means clindamycin.
To avoid GI complications (C. difficile overgrowth) from oral
clindamycin, it's often given along with oral metronidazole.

                                     Steve Harris, M.D.

From: B. Harris)
Subject: Re: Attn: Drs. Harris and Mathes (was Re: Beano with Antibiotic?)--
Date: 16 Mar 1999 06:20:25 GMT

In <D7fH2.111$> "     MS"
<> writes:

>Dear Drs. Harris and Mathes,
>Thank you for your responses. If you don't mind, I would be interested
>to hear your responses also to the other post I posted that same day,
>entitled "Residual Effects of Sinus Infection?" (I know, bad title.)
>It describes my antibiotic situation in more detail.

   Alas, it's impossible to give you any sure advice.  As a general
rule, get some marker you and your ENT doc can follow (colored
discharge, pain, even MRI scan results), and treat until it stops
getting better.  My main recommendation is GET an ENT doc.

   A last remark which is a bit off-the-wall: if you have any allergic
component at all, consider long term treatment with one of the new
leukotriene blockers (Zafirlukast, Montelukast).  They seem to do some
of the same things in sinuses that oral steroids do, but can be taken
over the long term, which oral steroids cannot.  This is anecdotal
advice, however-- I can't back it up with much sinus research (these
are asthma drugs, but I find that one part of the allergic respiratory
tract behaves like another).  Nasal steroids are great, but sometimes
don't quite make it to where the problem is.  Remember, the problem in
sinusitis is a vicious cycle of infection, which results in
inflammation, which blocks drainage, which results in continuing
difficult to eradicate infection.  Antibiotics are a key, but so are
drugs that block inflammation.  The leukotriene blockers are two of the
newest, safest, and most interesting of these.  There is another drug,
Zileutin, which has the same effect, but has too many dangerous side
effects to be used in an empirically in a condition in which they have
not been well-studied, such as yours.  You always have to balance risks
vs benefits.  If you use a drug semi-experimentally, make sure it's a
reasonably safe one.  Even the two I mentioned have some
drug-interactions with other drugs, so talk it over with your doctor
and pharmacist carefully first.

                                     Steve Harris, M.D.

From: "Steve Harris" <>
Subject: Re: Sputum sample--discounting for saliva??
Date: Fri, 25 Jan 2002 13:41:37 -0800
Message-ID: <a2sjmm$jb7$>

Steven Litvintchouk wrote in message <>...

>I never smoked in my entire life.
>And right now I'm trying to find out why my bronchitis has gotten so
>much worse since that nasty sinus infection I had back in October.  I
>still think I've got some low-level lingering infection somewhere, even
>though my doctor swears I don't have a sinus infection anymore.

Could be. IMHO, it's a lot easier to find a probable sinus infection (all
you need is an X-ray showing a sinus full of fluid) than it is to rule one
out. It's certainly possible to have continuing sinusitis even though you
don't have any full sinuses on X-ray, so I don't see how your doc can be
certain you don't have one. Sensitive tests don't exist, unless you're going
to have a surgical procedure to INTO a sinus. Infected sinuses can drain
into the throat and be a continuing source of bronchitis. It's particularly
suspicious in cases like yours, where you don't smoke and I gather than the
bronchitis is relatively new, and you've been cleared with an X-ray, right?

Let's face it, if your symptoms continue you're going to have to try a long
empiric course of antibiotics no matter what the cultures show.  I suppose
the only thing a nice positive culture might save you from is having to be
on an expensive sinus-antibiotic (read, one that kills H.flu well), when you
might get away with 4-8 weeks of something cheaper for Strep.  But if the
cheap stuff doesn't work you'll have to try something more expensive
empirically anyway!  So you might as well just get started. The cheapo
routine would be some kind of erythromycin and perhaps also pen VK for those
uncultured sinus anaerobes. The expensive routines are Augmentin, Ceftin,
Suprax, Zithromax.  The very drugs that kill parents paying for ear
infections in kids. ENT docs are still fond of long courses of Augmentin,
and sometimes nothing else will do.


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