What is the recommended azithromycin dosage for sinus infections. How does azithromycin treat bacterial infections. What are the potential side effects and precautions for taking azithromycin. Who should avoid using azithromycin.

Understanding Azithromycin: A Powerful Antibiotic

Azithromycin, commonly known by the brand name Zithromax, is a versatile antibiotic that belongs to the macrolides class. First approved by the FDA in 1991, this medication has become a go-to choice for treating various bacterial infections. Its ability to combat a wide range of bacteria, particularly those in the Streptococcus family, makes it an essential tool in modern medicine.

How does azithromycin work? The antibiotic inhibits bacterial growth by interfering with their protein synthesis. This mechanism allows it to effectively treat mild-to-moderate infections in various parts of the body, including the lungs, sinuses, and skin.

Key Features of Azithromycin

• Broad-spectrum antibiotic
• Effective against many bacterial strains
• Available in multiple forms (tablet, oral suspension, eye drops, injection)
• Prescription-only medication
• Can be taken with or without food

Common Uses of Azithromycin in Medical Practice

Healthcare providers prescribe azithromycin for a variety of bacterial infections. Its versatility makes it a valuable option for treating conditions affecting different parts of the body. What are some common infections that azithromycin can treat?

• Sinus infections caused by Moraxella catarrhalis or Streptococcus pneumoniae
• Community-acquired pneumonia related to Chlamydia pneumoniae, Haemophilus influenzae, or S. pneumoniae
• Chronic obstructive pulmonary disease (COPD) complications
• Certain skin infections
• Tonsillitis
• Urethritis and cervicitis
• Chancroid genital ulcers in males
• Some ear infections in children aged 6 months and older

Can azithromycin treat viral infections? It’s important to note that azithromycin, like all antibiotics, is only effective against bacterial infections. It cannot combat viral infections or serve as a pain reliever. This underscores the importance of consulting a healthcare professional before taking the medication to ensure its appropriate use.

Azithromycin Dosage: Tailoring Treatment to the Infection

The correct dosage of azithromycin varies depending on the specific infection being treated. Healthcare providers carefully consider factors such as the type and severity of the infection, the patient’s age, and overall health when prescribing this medication.

Typical Dosage Examples

• Community-acquired pneumonia, tonsillitis, skin infections: 500 mg initial dose, followed by 250 mg once daily for 4 days
• Mild-to-moderate bacterial COPD exacerbations: 500 mg daily for 3 days OR 500 mg initial dose, followed by 250 mg once daily for 4 days
• Sinus infections: 500 mg daily for 3 days
• Chancroid genital ulcers: Single 1-gram dose
• Urethritis and cervicitis: Single 1-gram dose
• Gonococcal urethritis and cervicitis: Single 2-gram dose

How should azithromycin be taken? The medication can be taken with or without food. For liquid formulations, it’s crucial to shake the bottle thoroughly before each use to ensure proper mixing of the medication.

Potential Side Effects and Precautions

While azithromycin is generally well-tolerated, like all medications, it can cause side effects in some individuals. Understanding these potential effects is crucial for patients and healthcare providers alike.

Common Side Effects

What are the most frequently reported side effects of azithromycin? The majority of side effects are gastrointestinal in nature and may include:

• Nausea
• Vomiting
• Diarrhea
• Abdominal pain

These side effects are usually mild and often resolve on their own. In clinical trials, only 0.7% of participants discontinued Zithromax due to adverse effects.

Less Common Side Effects

Some less frequent side effects, occurring in up to 1% of cases, may include:

• Heart palpitations or chest pain
• Acid reflux
• Dizziness
• Headache
• Fatigue
• Vaginitis
• Rash or dry skin
• Increased sun sensitivity

Serious Side Effects

While rare, azithromycin can cause more severe side effects in some individuals. These may include:

• Liver damage, particularly in those with a history of liver problems
• Heart rhythm changes, more likely in older individuals, those taking heart rhythm medications, or those with low blood potassium
• Serious allergic reactions

Patients with myasthenia gravis should be monitored closely, as azithromycin may worsen their symptoms or cause breathing problems.

Antibiotic Resistance: A Growing Concern

The misuse of antibiotics, including azithromycin, can lead to the development of antibiotic-resistant bacteria. This phenomenon occurs when bacteria evolve to withstand the effects of antibiotics, making infections harder to treat.

How can patients help prevent antibiotic resistance? Here are some key guidelines:

• Complete the entire prescribed course of antibiotics, even if symptoms improve
• Never take antibiotics without a prescription
• Avoid sharing antibiotics with others
• Follow the dosing schedule exactly as prescribed
• Report any side effects to a healthcare provider promptly
• Seek emergency care for signs of an allergic reaction, such as difficulty breathing

By adhering to these guidelines, patients can play a crucial role in preserving the effectiveness of antibiotics like azithromycin for future generations.

Special Considerations and Contraindications

While azithromycin is a valuable antibiotic, it’s not suitable for everyone. Certain conditions and factors may influence its use or necessitate additional precautions.

Who Should Avoid Azithromycin?

Azithromycin is contraindicated in individuals with:

• A history of allergic reactions to macrolides or ketolides
• Liver disease or a history of jaundice with previous azithromycin use
• Certain heart conditions, particularly those affecting heart rhythm

Special Populations

Healthcare providers should exercise caution when prescribing azithromycin to:

• Pregnant women (although generally considered safe, risks should be weighed against benefits)
• Breastfeeding mothers (azithromycin is generally safe during breastfeeding, but monitoring the infant is recommended)
• Elderly patients (who may be at higher risk for heart rhythm changes)
• Patients with prolonged QT interval
• Individuals with low blood potassium or magnesium levels

Pneumonia Treatment Considerations

When should azithromycin not be used to treat pneumonia? Doctors should avoid prescribing this drug for pneumonia in patients who:

• Have cystic fibrosis
• Have acquired the infection in a hospital setting
• Have bacteremia (bacteria in the bloodstream)
• Require hospitalization
• Are elderly or debilitated
• Have a compromised immune system

Drug Interactions: What to Watch Out For

Azithromycin can interact with various medications, potentially altering their effectiveness or increasing the risk of side effects. Understanding these interactions is crucial for safe and effective treatment.

Common Drug Interactions

Which medications may interact with azithromycin? Some notable interactions include:

• Antacids containing aluminum or magnesium (may reduce azithromycin absorption)
• Warfarin and other blood thinners (azithromycin may increase their effects)
• Digoxin (azithromycin may increase digoxin levels)
• Nelfinavir (may increase azithromycin levels)
• Ergot alkaloids (increased risk of ergotism)
• Certain statins (increased risk of muscle-related side effects)

How can patients minimize the risk of drug interactions? It’s essential to inform healthcare providers about all medications, supplements, and herbal products being taken before starting azithromycin treatment. This allows for proper assessment and adjustment of treatment plans if necessary.

Azithromycin in Clinical Practice: Efficacy and Outcomes

Azithromycin has demonstrated significant efficacy in treating various bacterial infections. Its broad spectrum of activity, combined with a convenient dosing schedule, has made it a popular choice among healthcare providers.

Clinical Success Rates

How effective is azithromycin in treating common infections? Clinical studies have shown promising results:

• Community-acquired pneumonia: Success rates of 80-90%
• Acute bacterial sinusitis: Clinical cure rates of 88-92%
• Acute bacterial exacerbations of chronic bronchitis: Efficacy rates of 85-93%
• Pharyngitis/tonsillitis: Clinical cure rates of 94-97%
• Skin and skin structure infections: Success rates of 84-96%

These high success rates underscore the importance of azithromycin in modern antibiotic therapy. However, it’s crucial to note that individual results may vary, and proper diagnosis and prescription by a healthcare professional are essential for optimal outcomes.

Comparative Efficacy

How does azithromycin compare to other antibiotics? Studies have shown that azithromycin is as effective as, and in some cases superior to, other commonly used antibiotics for various infections. For example:

• In treating community-acquired pneumonia, azithromycin has shown comparable efficacy to fluoroquinolones and beta-lactam antibiotics
• For acute bacterial sinusitis, azithromycin demonstrated similar effectiveness to amoxicillin/clavulanate
• In the treatment of streptococcal pharyngitis, azithromycin was as effective as penicillin V, with the added benefit of a shorter treatment duration

The convenience of azithromycin’s dosing schedule, often requiring fewer doses over a shorter period, can contribute to better patient compliance and potentially improved outcomes.

Future Perspectives: Azithromycin in the Age of Antibiotic Resistance

As antibiotic resistance continues to pose a significant global health challenge, the role of azithromycin and other antibiotics is evolving. Research efforts are ongoing to address this issue and ensure the continued efficacy of these vital medications.

Emerging Research

What new developments are on the horizon for azithromycin? Current areas of research include:

• Combination therapies: Investigating the use of azithromycin in combination with other antibiotics to combat resistant strains
• Novel formulations: Exploring new delivery methods to enhance efficacy and reduce side effects
• Targeted therapy: Developing diagnostic tools to better match specific bacterial strains with the most effective antibiotic
• Non-antibiotic applications: Studying azithromycin’s potential anti-inflammatory and immunomodulatory effects in treating chronic diseases

Stewardship Programs

How are healthcare systems addressing antibiotic resistance? Many institutions are implementing antibiotic stewardship programs to promote the appropriate use of antibiotics like azithromycin. These initiatives aim to:

• Optimize antibiotic prescribing practices
• Reduce unnecessary antibiotic use
• Improve patient outcomes
• Minimize the development of antibiotic resistance

By combining responsible prescribing practices with ongoing research and development, the medical community aims to preserve the effectiveness of azithromycin and other antibiotics for future generations.

Conclusion: Azithromycin’s Role in Modern Medicine

Azithromycin remains a crucial tool in the fight against bacterial infections. Its broad spectrum of activity, convenient dosing, and generally favorable side effect profile make it a valuable option for treating various conditions. However, the growing concern of antibiotic resistance underscores the importance of responsible use and ongoing research.

As we continue to navigate the challenges of infectious diseases and antibiotic resistance, the judicious use of azithromycin, guided by healthcare professionals and supported by ongoing scientific research, will play a vital role in maintaining public health. Patients and healthcare providers alike must remain vigilant, adhering to best practices in antibiotic use to ensure the continued effectiveness of this important medication.

By understanding the proper uses, dosages, potential side effects, and precautions associated with azithromycin, we can maximize its benefits while minimizing risks. As medical knowledge advances, so too will our ability to harness the full potential of azithromycin and other antibiotics in the ongoing battle against bacterial infections.

Uses, dosage, side effects, and warnings

Azithromycin (Zithromax) is an antibiotic that can help treat certain bacterial infections. It is generally safe to use while breastfeeding, but people with existing heart conditions should avoid this drug.

Azithromycin is an antibiotic in the macrolides class. The Food and Drug Administration (FDA) first approved azithromycin in 1991.

Like all antibiotics, azithromycin can only fight certain bacteria. For this reason, it is important to talk to a doctor before taking the drug. It is not effective against viral infections or as a pain reliever.

This article provides an overview of azithromycin, including its uses, side effects, warnings, and drug interactions.

Share on PinterestA doctor may prescribe azithromycin for a sinus infection, COPD complications, or tonsillitis, for example.

Azithromycin can fight a wide range of bacteria, including many in the Streptococcus family. It can stop harmful bacteria from growing.

Healthcare providers tend to use this drug to treat mild-to-moderate infections of the lungs, sinuses, skin, and other body parts.

A doctor may prescribe azithromycin to treat the following bacterial infections:

• sinus infections related to Moraxella catarrhalis or Streptococcus pneumoniae
• community-acquired pneumonia related to Chlamydia pneumoniae, Haemophilus influenzae, or S. pneumoniae
• chronic obstructive pulmonary disease (COPD) complications related to M. catarrhalis or S. pneumoniae
• some skin infections related to Staphylococcus aureus, Streptococcus pyogenes, or Streptococcus agalactiae
• tonsillitis related to S. pyogenes
• urethritis and cervicitis related to Chlamydia trachomatis
• chancroid genital ulcers (in males) related to Haemophilus ducreyi
• certain ear infections in children aged 6 months and over, such as those related to M. catarrhalis

Azithromycin is a prescription medication. Therefore, people should not take it without a prescription.

The drug is available in the form of a tablet, an oral suspension solution, an eye drop, and an injection. The best type and dosage depends on the infection a person has.

People can take the drug with or without food. They should thoroughly shake the liquid form before use.

Some examples of common dosages include:

Using antibiotics incorrectly can lead to the development of drug-resistant strains of bacteria, meaning that antibiotics no longer work against them. This is called antibiotic resistance.

When taking azithromycin or any other antibiotic, people should heed the following precautions:

• Take the entire course of antibiotics the doctor recommends, even when starting to feel better.
• Do not take antibiotics without a prescription. Not all antibiotics can treat all bacteria.
• Do not share antibiotics.
• Do not take antibiotics on a different dosing schedule than the one a doctor prescribes.
• Immediately call a doctor if side effects develop.
• Go to the emergency room for symptoms of an allergic reaction, such as trouble breathing.

Learn more about antibiotic resistance here.

Share on PinterestSide effects of azithromycin may include nausea and vomiting.

Like all drugs, azithromycin can have certain side effects. These are usually minor. In clinical trials, only 0.7% of people stopped taking Zithromax because of its side effects.

Most of the side effects that led people to stop taking the drug were gastrointestinal, such as:

• nausea
• vomiting
• diarrhea
• pain in the abdomen

Less common side effects, occurring in up to 1% of cases, include:

• heart palpitations or chest pain
• acid reflux
• dizziness
• headache
• fatigue
• vaginitis
• a rash
• dry skin
• sun sensitivity

Serious side effects are rare but can include:

• liver damage, especially in people with a history of liver health problems
• heart rhythm changes, which are more likely in people who take heart rhythm medications, older people, and those with low blood potassium
• serious allergic reactions

People who have myasthenia gravis, a condition that causes muscle weakness, may develop worsening symptoms or breathing problems.

People with a history of allergic reactions to macrolides or ketolides should not take azithromycin.

Doctors should not prescribe this drug to treat pneumonia if a person:

• has cystic fibrosis
• has a hospital-acquired infection
• has bacteremia
• requires a stay in the hospital
• is older or debilitated
• has a significant underlying health problem, such as immune system problems

People should not rely on azithromycin to treat syphilis.

A person should speak to a doctor about any existing heart, kidney, and liver conditions before taking azithromycin, including an irregular heartbeat and especially QT prolongation.

What does the research say?

A large 2012 cohort study found a small increase in the risk of cardiovascular death among people taking azithromycin. The risk was higher among those with other risk factors for heart disease, such as smoking, low physical activity levels, and a high body mass index (BMI).

The study reported that when compared with amoxicillin, there were 47 additional cardiovascular deaths per 1 million azithromycin prescriptions. Among people with the highest risk of heart disease, there were 245 more deaths per 1 million courses of azithromycin.

This suggests that other antibiotics, such as amoxicillin, may be a safer option for people with heart disease or certain types of heart arrythmias.

In 2018, the FDA issued a warning about the long term use of azithromycin in people with certain blood or lymph node cancers who have stem cell transplants. Emerging research has suggested that azithromycin may increase the risk of cancer relapse in these people.

Following a stem cell transplant, some people take azithromycin to reduce the risk of an inflammatory lung condition called bronchiolitis obliterans syndrome. The FDA have not approved azithromycin for this use, however.

Rarely, azithromycin can cause liver toxicity. People should stop taking the drug and call their doctor if they develop any symptoms of liver problems, including dark urine, itching, or yellow eyes.

In newborns younger than 42 days old, azithromycin may cause a dangerous condition called infantile hypertrophic pyloric stenosis. Caregivers should contact a doctor if a baby becomes irritable or vomits when eating.

Azithromycin may interact with other medications a person is taking.

For example, using azithromycin while taking nelfinavir, which is a drug that helps treat HIV, can increase the risk of liver abnormalities and hearing problems.

Azithromycin can also increase the effects of blood thinners such as warfarin.

Other drugs that may interact with azithromycin include:

• digoxin, a heart medication
• colchicine, a gout medication
• phenytoin, a seizure medication
• antacids that contain magnesium or aluminum

A person should tell a doctor about all current medications, supplements, and remedies before taking azithromycin. Always speak to a doctor before stopping taking medications.

Share on PinterestA person may take azithromycin while breastfeeding but should discuss it with a healthcare professional first.

Azithromycin may be safe to use during pregnancy and while breastfeeding.

Studies of animals who received very large doses of azithromycin did not find an increased risk of miscarriage or birth defects.

However, there have been no high quality studies in pregnant humans, so the drug label currently states that “azithromycin should be used during pregnancy only if clearly needed.”

Azithromycin can transfer into breast milk and may remain present for 48 hours following a person’s last dose. Although it is generally safe to use when breastfeeding, azithromycin may cause diarrhea, vomiting, or a rash in some babies.

A person should tell a doctor if they are pregnant, might be pregnant, or are breastfeeding before taking azithromycin. If a nursing infant develops side effects while the parent is taking azithromycin, call a doctor for advice.

The brand name version of azithromycin (Zithromax) is typically more expensive than the generic version.

However, the price may vary depending on the pharmacy, a person’s insurance coverage and deductibles, and their geographic location.

Azithromycin treats many of the same infections that drugs such as penicillin and amoxicillin can treat.

A doctor may prescribe azithromycin as an alternative to other antibiotics because it typically requires a shorter course. It is also a good option for people with a history of allergies to other medications, or when other antibiotics do not work.

Because the risk of heart health problems is higher with azithromycin than with some other antibiotics, people with heart disease or arrhythmias should ask their doctor about trying a different antibiotic.

Azithromycin is an antibiotic that can treat many types of bacterial infection. It can also prevent these infections from getting worse or spreading.

Like all antibiotics, it presents some risks, so it is important to only take it under the guidance of a medical professional.

Antibiotics | Richmond ENT

What are antibiotics?

Antibiotics are medications derived from naturally occurring chemicals produced by bacteria and molds to inhibit the growth of competing microorganisms.   Penicillin was discovered in 1929 by Alexander Fleming and its popular derivative amoxicillin remains effective for 80% of acute bacterial sinus infections and 99% of strep throat infections.  Although 60% of episodes of acute bacterial sinusitis will resolve without treatment, antibiotics have been consistently demonstrated to shorten the course of illness and reduce the frequency of complications from sinusitis.

When should antibiotics be used?

Antibiotics are recommended for acute bacterial sinusitis lasting longer than 10 days, or getting worse after the first week.  The most common symptoms include facial pain or pressure, nasal stuffiness or congestion, and thick, discolored nasal drainage.  Antibiotics are also commonly prescribed for chronic sinusitis, although many cases of chronic sinusitis are not caused by bacteria.

Why will my doctor not prescribe antibiotics over the phone?

Studies have shown that 80% of patients with acute sinusitis will improve in a week on antibiotics, while 73% of patients treated with placebo will improve.   Furthermore, antibiotics will do nothing to shorten the course of the common cold.  Overuse of antibiotics can breed resistant strains of bacteria and induce drug allergies in susceptible patients. Accordingly, we do not recommend antibiotics for sinus symptoms that appear to be improving spontaneously within the first 7-10 days. If you abuse antibiotics now, we may not have any options left when you really need them!

What is antibiotic resistance?

Bacterial antibiotic resistance is a significant problem in Richmond, Virginia, and throughout the United States. Many of the common bacteria that can cause sinusitis carry a gene for antibiotic resistance that can be turned on in the presence of antibiotics. After a few days of treatment, the gene becomes activated and can even travel between bacteria (in a capsule called a plasmid), creating resistance among a large population of bacteria. If you are not responding to a course of antibiotics within 4-7 days, you may have a resistant strain of bacteria. Consult your physician for an examination and possible culture or DNA analysis of your sinuses.  DNA analysis of sinus drainage allows us to identify the most dangerous resistant strains within 24 hours and to provide a complete analysis of all bacteria in your nose within 1 week.

Read more about DNA analysis of chronic ENT infections 

What are the most common antibiotics used for sinusitis?

Amoxicillin remains the drug of choice for acute, uncomplicated bacterial sinusitis.  Amoxicillin is most effective when given frequently enough to sustain adequate levels in the infected tissue.  While often prescribed twice daily, it is even more effective if taken in 3 or 4 divided doses.  Amoxicillin is typically prescribed for 7-10 days at a time.  While it is critical to finish the entire 10 day course of antibiotics when treating strep throat, there is evidence that shorter courses of treatment may be sufficient for most cases of sinusitis.  Amoxicillin is closely related to the parent compound penicillin and should not be prescribed in patients who are penicillin allergic.

Azithromycin is an alternative treatment for patients who are allergic to amoxicillin.  The principal advantage of the azithromycin is convenience — the recommended treatment for acute sinusitis is 500 mg once daily for only 3 days.  Unlike amoxicillin, the effectiveness of a azithromycin is enhanced by giving a large single dose rather than spreading the doses out.  For this reason, a course of azithromycin should be completed in 3 days or less for sinusitis (as in a Zithromax Tri-Pak), and should not be spread out over 5 days (as in a Zithromax Z-Pak).  Azithromycin induces antibiotic resistance to itself quickly if prescribed in doses that are too low to kill the bacteria.  This resistance lasts at least 3 months, so Zithromax should not be prescribed twice within 3 months . Alternatives related to azithromycin include clarithromycin (Biaxin), which is commonly taken twice daily for 10 days, and the older medications erythromycin and clindamycin which require 3-4 doses per day.

Cephalosporins and Augmentin (amoxicillin with clavulanic acid) are considered “broad-spectrum antibiotics”  because they have enhanced effectiveness against a wider range of bacteria, including those that are resistant to ordinary penicillin or amoxicillin.  If the patient does not improve within the first week on amoxicillin, a change to Augmentin or to a cephalosporin such as Ceftin, Cefzil, Omnicef, or Suprax is reasonable.  Although these drugs have a similar mechanism of action to penicillin, they generally can be taken in adequate doses once or twice daily.  These medications should be used with extreme caution in patients with a history of penicillin allergy, as cross-reaction may occur.

Cipro, Levaquin, and Avelox are generally considered third line antibiotics for uncomplicated sinusitis.  These medications still have a very low rate of resistance and are often our last resort before considering surgical intervention.  Allergic reactions are infrequent, but joint pain and tendon rupture have been described with patients taking these medications.   They also have increased complexity interacting with other medications.

Bactrim and tetracycline are older medications which do not routinely cover the broad-spectrum of bacteria that may grow in the sinuses.  However, they may have occasional use for patients with infections caused by known, resistant bacteria.  In particular, these medications are prescribed for staphylococcal infections that are resistant to cephalosporins and other penicillin derivatives.  This infection is known as methicillin-resistant staph aureus, or MRSA.

Topical antibiotics are a relatively new treatment option that has become popular for post surgical patients with chronic resistant bacteria.  A variety of antimicrobials including vancomycin and aminoglycosides that cannot be administered by mouth are available as a nasal spray or wash.  Recent studies have suggested that large volume nasal washes do a better job delivering antibiotics into the sinuses than nebulized sprays.  These antibiotics can be combined with potent antifungal medications and steroids, each of which will be selected by your physician based on culture results, and  custom mixed for you by a compounding pharmacist.   Bactroban nasal cream (mupirocin) can be applied inside the nostrils to reduce colonization with methicillin-resistant staph aureus (MRSA).

Additional resources:

Clinical practice guideline: adult sinusitis.   Rosenfeld RM, Andes D, Bhattacharyya N, Cheung D, Eisenberg S, Ganiats TG, Gelzer A, Hamilos D, Haydon RC 3rd, Hudgins PA, Jones S, Krouse HJ, Lee LH, Mahoney MC, Marple BF, Mitchell CJ, Nathan R, Shiffman RN, Smith TL, Witsell DL.  Otolaryngol Head Neck Surg. 2007 Sep;137(3 Suppl):S1-31.

Clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years.   Wald ER, Applegate KE, Bordley C, Darrow DH, Glode MP, Marcy SM, Nelson CE, Rosenfeld RM, Shaikh N, Smith MJ, Williams PV, Weinberg ST; American Academy of Pediatrics.  Pediatrics. 2013 Jul;132(1):e262-80.

Current concepts in topical therapy for chronic sinonasal disease.   Harvey RJ, Psaltis A, Schlosser RJ, Witterick IJ.  J Otolaryngol Head Neck Surg. 2010 Jun;39(3):217-31. Review.

Treatment options for chronic rhinosinusitis.   Suh JD, Kennedy DW.  Proc Am Thorac Soc. 2011 Mar;8(1):132-40. doi: 10.1513/pats.201003-028RN. Review.

90,000 observation over 10 years. Acquired cholesteatoma in children

DIAGNOSIS OF OTOHENIC ABSCESSES OF THE BRAIN

DIAGNOSTIC CHALLENGES IN OTOGENIC BRAIN ABSCESSES

T.K. Lildal, J. Korsholm, T. Ovesen

Dan Med J 2014; 61:6:48-49 (Eng – Denmark)

Otogenic brain abscess (OAM) is a rather rare complication of otitis media with a very poor prognosis. Early diagnosis of OAM is the key to successful treatment.

This article presents studies reflecting the prevalence of AAM in Denmark, clinical manifestations, diagnosis, treatment tactics and prognosis.

A total of 93 case histories of patients with a diagnosis of brain abscess were analyzed for the period from 1999 to 2010. Age, clinical symptoms, objective data, comorbidity, diagnostic examinations, microbiological studies, and treatment were studied.

The otogenic nature of the brain abscess was determined in 7 subjects. The results showed that the prevalence of OAM in Denmark is 1 case per million, the average age of the diseased is 43 years (age limits ranged from 10 years to 81 years). In 5 patients, the development of an abscess was preceded by acute otitis media, in 2 – by chronic otitis media with cholesteatoma. 4 patients had a history of traumatic brain injury. In young patients, the leading symptoms in the clinic of the disease were symptoms of meningitis, in older patients – symptoms of stroke with focal symptoms. None of the patients were treated with antibiotics prior to admission to the clinic. There were no deaths, but three patients subsequently had neurological impairment and sensorineural hearing loss.

The authors of the article conclude that, according to their study, the manifestation of OAM may be masked by symptoms of meningitis in young people and stroke in older people. The absence of a temperature response does not yet disprove the presence of OAM; a thorough examination of the ENT organs is necessary for timely diagnosis and adequate treatment of this disease.

SINGLE DOSE AZITHROMYCIN FOR THE TREATMENT OF ACUTE OTITIS MEDIA: RATIONAL PHARMACOKINETICS AND PHARMACODYNAMICS

SINGLE-DOSE AZITHROMYCIN FOR ACUTE OTITIS MEDIA:

A PHARMACOKINETIC/PHARMACODYNAMIC RATIONALE

C.D. Rothermel

Curr Ther Res Clin Exp 2003; 64: Suppl 1: 4-15 (English – US)

The pharmacokinetics (PK) and pharmacodynamics (PD) of azithromycin azalide distinguish it from other antibiotics. The pharmacokinetic profile of azithromycin shows its high concentration in tissues (compared to blood serum), especially the middle ear, as well as a prolonged half-life.

These features are the result of the accumulation of this substance by cells and its subsequent slow gradual release from cells and tissues into the bloodstream.

Pharmacodynamic features of azithromycin are its bactericidal activity against the leading pathogens of the respiratory tract and prolonged post-antibiotic or persistent effect. In addition, white blood cells carry this substance to the site of infection, thereby increasing its local concentration in the affected tissues, which enhances its effectiveness in vivo. Recent pharmacokinetic studies in mice have shown that a single high dose of azithromycin results in higher tissue concentrations than multiple dosing. Other studies on experimental animals, in particular in acute otitis media, show better eradication of bacteria when prescribing azithromycin in a single dose than when dividing it into 2-3 doses (2-3 days).

Summing up these preliminary preclinical studies, the authors of the article conclude that, according to rational pharmacokinetics and pharmacodynamics, a single dose of azithromycin is reasonable in the treatment of acute otitis media. Clinical data on the efficacy and safety of a single dose of azithromycin in the treatment of acute otitis media in children are supported by additional studies previously published in two articles by the authors.

INTRACRANIAL SUBDURAL ABSCESS: FOLLOW-UP FOR 10 YEARS

INTRACRANIAL SUBDURAL EMPYEMA: A 10-YEAR CASE SERIES

H. French, N. Schaefer, G. Keijzers, D. Barison,

S. Olson

Ochsner J 2014; 14:2:188-194 (English – Australia)

Intracranial subdural abscess (empyema) (ISA) is a purulent infection located between the dura and arachnoid meninges. Early diagnosis, adequate antimicrobial therapy, and surgical drainage are the basis for successful treatment of this pathology and prevention of death. A serial analysis of the disease was conducted in Queensland, Australia, over a 10-year period.

A total of 36 case histories of patients treated in several hospitals were analyzed. Among all examined (36 patients), men predominated. Neurosurgical manipulations were the most common cause of ISA, followed by sinusitis and otitis media. Headache, fever, confusion were the most common clinical triad of this pathology and were observed in 19 (53%) patients. Twenty-eight (88%) of 32 patients underwent craniotomy. Prevention of epileptic seizures was carried out 25 (69%) patients who, despite ongoing treatment, were observed in 8 (32%) of these patients during the entire period of hospitalization. 5 patients (14%) had to undergo repeated craniotomy due to insufficient drainage of intracranial infection.

The authors of the article conclude that altered consciousness, fever, vomiting, headache may indicate ISA. Reference in history to neurosurgical operations, sinusitis, otitis media, or traumatic brain injury is evidence in favor of this disease. Therapeutic tactics include surgical drainage and adequate antibiotic therapy.

ACQUIRED CHOLESTEATOMAS IN CHILDREN: CLINICAL MANIFESTATIONS AND SURGICAL MANAGEMENT

ACQUIRED CHOLESTEATOMA IN CHILDREN: CLINICAL FEATURES AND SURGICAL OUTCOME

Y. Morita, Y. Yamamoto, S. Oshima, K. Takahashi,

S. Takahashi

Auris Nasus Larynx 2014; (On the Internet presented up to

press publications) (English – Japan)

There is an opinion that cholesteatoma recurs more often in children. It is believed that this is due to insufficient function of the auditory tube, underdevelopment of mastoid cells and frequent recurrence of otitis media in childhood. This article provides a comparative analysis of acquired cholesteatoma in children and adults.

For the period from 1999 to 2009, 42 case histories of children with acquired cholesteatoma (38 boys and 4 girls aged 3-15 years) were analyzed. The stage and extent of cholesteatoma was assessed according to the classification adopted by the Otorhinolaryngological Society of Japan in 2010.

There was no significant difference in the stages of development of cholesteatoma in children and adults. In children, with pars flaccida-type cholesteatoma, the epidermis grows through the attic into the mastoid cavern and into the mesotympanum. In contrast, in adult patients, the spread of cholesteatoma to the mesotympanum is quite rare. The degree of damage to the stirrup in this pathology is approximately the same in children and adults, but depends on the type of cholesteatoma: more with pars tensa cholesteatoma than pars flaccida. Hearing after surgery in children was better than in adults, regardless of the extent of the pathological process. However, the percentage of recurrence of cholesteatoma in children is much higher.

Thus, cholesteatoma in children is characterized by a greater prevalence of the pathological process and a high percentage of recurrence. For patients with a pronounced carious process and destruction of the auditory ossicles, the authors of the article recommend a two-stage operation.

OPHTHALMOLOGICAL AND NEUROLOGICAL SYMPTOMS OF OTGENIC THROMBOSIS OF THE LATERAL SINUS: A 15-YEAR EXPERIENCE

VISUAL AND NEUROLOGIC DETERIORATION IN OTOGENIC LATERAL SINUS THROMBOSIS: 15 YEAR EXPERIENCE

B. Rosdy, Z. Csákányi, K. Kollár, J. Móser, M. Mellár,

A. Kulcsár, E. Kovács, G. Várallyay, G. Katona

Int J Pediatr Otorhinolaryngol 2014; (Online presented before publication in print) (English – Hungary)

Otogenic thrombosis of the lateral sinus is a rather rare complication of acute otitis media. The purpose of this study is to analyze the clinical manifestations, treatment tactics and outcome of this pathology.

10 case histories of children treated since January 1998 to August 2013 in Budapest Central Hospital.

Patients were combined into two groups – the group of early manifestations and the group of late manifestations. In the group of early manifestations, a week after the onset of acute otitis media, patients developed sepsis. At admission, otological symptoms were dominant. In the group of late manifestations, acute otitis media was a few weeks before admission to the hospital, the leading signs of the disease were neurological symptoms. All patients received antibiotics. Eight patients were prescribed low molecular weight heparin. All children underwent mastoidectomy. After the operation, the symptoms of increased intracranial pressure temporarily worsened. This manifested itself in edema of the optic nipple (papilloedema) in 6 patients, which caused visual disturbances in two. After drug therapy and a series of lumbar punctures, all patients, except for one, recovered. In this one patient, a unilateral decrease in vision to 0.5 D remained. During the year, complete and partial sinus recanalization was observed in 5 and 2 patients, respectively.

The authors of the article conclude that after mastoidectomy, patients may experience temporary symptoms of increased intracranial pressure, papilloedema may progress. Daily monitoring of visual acuity, regular ophthalmoscopy with neurological examination is strongly recommended during the entire treatment period. Frequent visits are also required during the next year of follow-up. When the dominant sinus is involved in the pathological process, the clinical picture is more severe and the disease period is longer.

EFFECTIVENESS OF MANUAL THERAPY IN THE TREATMENT OF EXUDATIVE PROCESS IN THE MIDDLE EAR DUE TO ACUTE OTITIS MEDIA: A PILOT STUDY

EFFECT OF OSTEOPATHIC MANIPULATIVE TREATMENT ON MIDDLE EAR EFFUSION FOLLOWING ACUTE OTITIS MEDIA IN YOUNG CHILDREN: A PILOT STUDY

K. M. Steele, J.E. Carreiro, J.H. Viola, J.A. Conte, L.C. Ridpath

J Am Osteopath Assoc 2014; 114:6:436-447 (English – US, UK)

Acute otitis media is a very common childhood illness. Exudative stages of the disease lead to conductive hearing loss and often require surgical intervention. This article provides an assessment of concomitant manual therapy (MT) in the treatment of exudative otitis media (EO) that developed against the background of acute otitis media. The authors of the article suggest that MT can accelerate the convalescence period in exudative otitis media (ESO) in children. To do this, we compared the duration of treatment for ESO with and without MT. The patients were aged 6 months to 2 years. MT was used in addition to standard accepted treatment regimens and continued for 3 weeks. The state of the middle ear was assessed daily according to the results of tympanometry and acoustic reflexometry.

A total of 52 patients were included in the study, of which 43 underwent full observation and 9 – partial. No gender difference was found. The study included only patients with altered tympanograms at the onset of the disease. A total of 76 tympanograms were analyzed from 76 ears (38 treated according to the standard scheme and 38 with the addition of MT) and 61 ears with an acoustic reflex recording (30 according to the standard scheme and 31 with the addition of MT). The results were evaluated statistically.

Positive changes in the tympanogram were recorded already at the 3rd visit of the patient in the MT group. Positive changes in acoustic reflexometry were also recorded at the 3rd visit in the MT group. At the same time, there was no significant statistically significant difference in the rapid subjective manifestations of the disease. The authors of the article conclude that the addition of MT to the treatment can accelerate the recovery process in PES.

PROMISING RESULTS OF BALLOON DILATION OF THE EUSTACHIAN TUBE IN OBSTRUCTIVE DYSFUNCTION

PROMISING RESULTS AFTER BALLOON DILATATION OF THE EUSTACHIAN TUBE FOR OBSTRUCTIVE DYSFUNCTION

J. H. Wanscher, V. Svane-Knudsen

Dan Med J 2014; 61:4:48-52 (Eng – Denmark)

In 2012, the authors reported for the first time in Denmark the results of a new treatment for obstructive eustachian tube dysfunction in adults, balloon dilatation. Initially, several diagnostic tests were performed: otomicroscopy, audiometry, tympanometry, and the Toynbee test. The pathology of the auditory tube was classified according to the following degrees: I degree – equalization of pressure in the middle ear occurs when performing a normal Valsalva test; II degree – when performing an enhanced (prolonged) Valsalva test; III degree – to equalize the pressure in the middle ear, it is necessary to use the Otovent device; IV degree – the inability to equalize pressure in the middle ear through the auditory tube. In addition, patients filled out a special questionnaire reflecting their complaints, anamnesis, and quality of life.

Fifty balloon dilation procedures were performed on 34 patients, 16 of whom had bilateral problems. In 4 patients (6 Eustachian tubes) intermittent dysfunction of the auditory tube was observed, in 30 patients – chronic. A significant improvement from this manipulation was confirmed by the following studies: audiometry, tympanometry, Toynbee test, questionnaire. No positive effect was observed in patients with middle ear atelectasis. In 10% of patients, acute otitis media developed against the background of dilatation.

The authors of the article report positive results of a new method of treating eustachian tube dysfunction in the majority of patients. These results are confirmed by similar studies by other scientists, so this method can be regarded as promising, but additional research is required.

IS BALLOON TUBE DILATION A MYTH OR REALLY SAFE AND EFFECTIVE METHOD?

BALLOON DILATION OF THE EUSTACHIAN TUBE IS INDEED A “GIZMO” UNTIL FUTURE RESEARCH PROVES SAFETY AND EFFICACY?

C.D. Bluestone

Otolaryngol Head Neck Surg 2014; (Submitted online prior to publication in print) (English – US)

In April 2014 in one of the issues of this magazine

R. M. Rosenfeld wrote that he recommends a clear definition of the technology used – balloon dilatation of the Eustachian tube, used for the treatment of “adhesive ear”, providing for 5 criteria. The implication was that balloon dilatation, which was supposed to treat eustachian tube dysfunction, was an unproven procedure, some kind of “myth”. Shortly before this publication, the National Institutes of Health awarded a grant to the institute in Pittsburgh for research on this new treatment, which confirms the undoubted effectiveness of this procedure.

THERAPEUTIC MANAGEMENT FOR CHRONIC EUSTACHIAN TUBE OBSTRUCTION: NEW TREATMENTS

THERAPY OF CHRONIC OBSTRUCTIVE EUSTACHIAN TUBE DYSFUNCTION: EVOLUTION OF APPLIED THERAPIES

H. Sudhoff, S. Schröder, U. Reineke, M. Lehmann,

D. Korbmacher, J. Ebmeyer

HNO 2013; 61:6:477-482 (German – Denmark)

This article discusses current treatments for chronic eustachian tube dysfunction. Along with catheterization of the auditory tube, such new promising techniques as laser tuboplasty and balloon tuboplasty of the auditory tube are discussed. In balloon tuboplasty of the auditory tube, under the control of an endoscope, a balloon catheter is inserted into its nasopharyngeal mouth and passed along its cartilaginous part. The balloon is then dilated at a pressure of 10 bar for 2 minutes. Until January 2013, this method was used in the treatment of 351 auditory tubes. 87% of patients noted a significant improvement in the function of the auditory tube. The authors consider this method to be effective and safe in the treatment of tubal dysfunction.

EUSTACHIAN TUBE DILATION USING A BIELEFELD BALLOON CATHETER: 320 OBSERVATIONS

EUSTACHIAN TUBE DILATION USING THE BIELEFELD BALLOON CATHETER: CLINICAL EXPERIENCE WITH 320 INTERVENTIONS

M. Tisch2, S. Maier, H. Maier

HNO 2013; 61:6:483-487 (English – Germany)

Balloon dilatation is a new method for the treatment of chronic eustachian tube ventilation dysfunction.

This article provides an evaluation of this method in patients when other manipulations are ineffective. Cases with organic obstruction in this area were excluded from the study.

In 70% of cases, as reported by the authors of the article, positive results were obtained from treatment with this method without recurrence of symptoms.

BALLOON DILATION OF THE EUSTACHIAN TUBE FOR DYSFUNCTION

CLINICAL EVALUATION OF BALLOON DILATION EUSTACHIAN TUBOPLASTY IN THE EUSTACHIAN TUBE DYSFUNCTION

D. Jurkiewicz, D. Bień, K. Szczygielski, I. Kantor

Eur Arch Otorhinolaryngol Mar 2013; 270:3:1157-1160

(English – Poland)

Eustachian Tube Dilatation Balloon Tuboplasty (BET) is a non-invasive new alternative to tympanic bypass surgery. BET is used in such cases when all known manipulations and methods of restoring pressure in the middle ear have already been tried and are ineffective.

BET was performed on 4 patients (3 males and 1 female) after a complete ENT examination including examination, nasal endoscopy, pure tone audiometry, tympanometry, swallow tests and pressure equalization (Toynbee, Valsalva). Since this method is new, all patients previously underwent angiography of the carotid arteries. The procedure was performed under anesthesia. A special catheter with a 600 µm balloon (Spiggle and Theis) was used. The catheter was inserted under the control of the endoscope through the nasopharyngeal mouth of the auditory tube 2 cm inside. The balloon was then correctly positioned at the orifice of the auditory tube and inflated at 10 bar for 2 minutes (using saline). Then the solution from the balloon was aspirated and the catheter was removed. No complications (bleeding or damage to the mucous membrane) were observed during this manipulation. The follow-up period after manipulation was 6 weeks. There was an improvement in hearing, a decrease in the air-bone interval with tone audiometry, and normalization of the tympanometric curve (from the initial B-type to A-type and from the initial C-type to A-type). And although these patients had a stable positive result in the resolution of chronic eustachian tube dysfunction, further studies are needed in this direction with a longer follow-up period and a larger number of patients.

Translation by prof. I.V. Ivanets, P.S. Ivanets

Azithromycin in the treatment of lower respiratory tract infections | Nonikov V.E., Konstantinova T.D., Makarova O.V., Evdokimova S.A.

The epidemiological situation in recent years is characterized by an increased etiological significance of pathogens such as mycoplasma and chlamydia, widespread sensitization of the population to penicillin derivatives and sulfonamides, and a significant increase in the resistance of many microorganisms to the most commonly used antibiotics [1,2,5,6]. To a large extent, the increase in resistance was the result of many years of template use in outpatient practice of co-trimoxazole and semi-synthetic tetracyclines. In recent years, fluoroquinolones have become more widely used in polyclinics – the result was the formation of strains resistant to these drugs.

The first of the macrolides, erythromycin, was created in 1952, but drugs of this series were rarely used until the dramatic outbreak of legionella pneumonia (80s of the twentieth century), accompanied by a 30% mortality rate. Quite quickly it was found that macrolides are the best drugs for the treatment of infections caused by intracellular infectious agents (legionella, mycoplasma, chlamydia), and this led to the widespread use of this group of antibiotics. A number of new drugs for oral and parenteral use have been created, differing in terms of pharmacokinetics and pharmacodynamics.
The basis of the chemical structure of macrolides [1,5] is the macrocyclic lactone ring. Depending on the number of carbon atoms in the lactone ring, 14-membered (erythromycin, clarithromycin, roxithromycin), 15-membered (azithromycin) and 16-membered (josamycin, midecamycin, spiramycin) macrolides are isolated.
Azithromycin belongs to the azalide subclass because one carbon atom in its ring is replaced by a nitrogen atom. The structural features of individual drugs determine differences in pharmacokinetic characteristics, tolerability, the possibility of drug interactions, as well as some features of antimicrobial activity. Azithromycin is characterized by unique cellular kinetics, rapid and intense penetration into cells and interstitial tissues, high levels of antibiotic distribution in tissues and relatively low levels in the blood.
Azithromycin well suppresses (Table 1) gram-positive (pneumococci, streptococci, staphylococci) and gram-negative (moraxella, Haemophilus influenzae) microorganisms and intracellular agents (chlamydia, mycoplasma, legionella, ureaplasma). Other macrolides (except clarithromycin) are less active against Haemophilus influenzae [5,6]. If we take into account that in the etiological structure of community-acquired pneumonia, pneumococci, Haemophilus influenzae, Mycoplasma, Chlamydia take the leading positions, and exacerbations of chronic bronchitis (chronic obstructive pulmonary disease) are usually caused by pneumococci, Haemophilus influenzae, Moraxella (less often – Mycoplasma and Chlamydia), it is becoming clear that azithromycin is often the antibiotic of choice for the treatment of pulmonary patients.
In the countries of Western and Southern Europe, the widespread use of macrolides has led to an increase (up to 30%) in the resistance of pneumococci to them. According to various estimates, the corresponding resistance rates in our country [1] do not exceed 4–8%. Features of azithromycin are determined not only by the spectrum of action, but also by the creation of high concentrations in the lung parenchyma and alveolar macrophages. Comparison of the concentrations created in various biological media shows that the concentrations of azithromycin in the lung parenchyma are 8–10 times higher, and in alveolar macrophages 800 times higher than in blood serum. Thus, this drug should be highly effective in the treatment of pulmonary pathology.
Azithromycin remains in the focus of infection for 4-5 or more days, depending on the dose and tissue structure. Due to the release of the antibiotic from phagocytes during their destruction, the concentration in the focus of infection rapidly increases [1,5]. High intracellular penetration and accumulation in cells and infected tissues determines the effectiveness of azithromycin, which exceeds the effect of other antibiotics, in infections caused by intracellular pathogens, including pathogens of dangerous infectious diseases (brucellosis, tularemia, etc.).
A feature of the pharmacodynamics of macrolides is a long-term post-antibiotic effect, due to which, when using an antibiotic in minimal inhibitory concentrations, the effect of the antibiotic continues after its withdrawal. With regard to azithromycin, a post-antibiotic effect lasting up to 90 hours is considered proven, and this allows to reduce the duration of antibacterial treatment.
Allergic sensitization to macrolides is relatively rare. Among the side effects, gastrointestinal manifestations predominate and, perhaps, some of them are due to the ability of macrolides to increase intestinal motility. Side effects are more frequent with erythromycin. Toxic and allergic side effects with the use of azithromycin are rare [1,4,5].
Azithromycin is approved for medical use in our country in several dosage forms: capsules of 0.25 g, tablets of 0.5 g, powder for suspension 2.0 g, powder for injections of 0.5 g. Thus, the antibiotic can be used orally, intravenously and in stepwise therapy. The drug is convenient in terms of dosing regimen (administered once a day). Given the long post-antibiotic effect of azithromycin, this antibiotic has often been (and is) used in short courses of 3–5 days. Dosage form – powder for the preparation of a suspension (2.0 g of azithromycin) involves treatment with a single dose of an antibiotic.
Features of pharmacokinetics allow the use of azithromycin once a day. Naturally, drugs used once or twice a day have greater compliance and are readily used by patients. There are various regimens for oral administration of azithromycin. The most common dosage in the treatment of pulmonary diseases is 500 mg on the first day of treatment and 250 mg every 24 hours for the next 4 days. With this scheme, the duration of treatment for pneumonia is 5 days. The treatment time for pneumonia caused by common bacterial agents (pneumococci, streptococci, Haemophilus influenzae, etc.) can be reduced to three days if the daily dose is 500 mg. The duration of treatment for pneumonia caused by mycoplasma and chlamydia is 14 days, and for legionella pneumonia – 21 days.
Own experience in the use of azithromycin for 15 years is based on the treatment of more than 1500 patients with pneumonia with this antibiotic, and all the described oral therapy regimens, stepwise therapy, azithromycin treatment in combination with b-lactam antibiotics were used with high efficiency.
According to the pulmonology department of the Central Clinical Hospital in 1984, macrolides (only erythromycin was used) accounted for only 9% of the antibiotics used. In 2004, the frequency of their use tripled (27.3%), second only to b-lactam antibiotics. Five oral preparations were used, of which azithromycin was used most frequently (80%). Significant frequency of appointment of macrolides due to the rise in the incidence of chlamydial and mycoplasmal infections, as well as the widespread use of combinations of macrolides with b-lactam antibiotics when etiological interpretation is impossible.
According to microbiological studies of sputum, pneumococcus still dominates (52.1%) as the leading etiological agent of respiratory infections. In addition to pneumococcus, cultures of viridescent streptococcus, Haemophilus influenzae were isolated from sputum. Gram-negative microorganisms and staphylococci were rarely detected. In recent years, the frequency of mycoplasmal and chlamydial infections has increased significantly, and intracellular agents are often the cause of epidemic foci in families and groups.
Indications for the appointment of azithromycin are [1,5] infections of the upper respiratory tract (tonsillopharyngitis, acute otitis media, sinusitis), as well as bronchitis and community-acquired pneumonia. The so-called SARS [2-5] are caused by intracellular agents-viruses, mycoplasma (50% of all cases), chlamydia, legionella. Azithromycin is the best antibiotic to treat most of them. Brief differences between atypical pneumonias [6] are shown in Table 2. The infection is often transmitted from person to person (in recent years, several family and work outbreaks of mycoplasma and chlamydial pneumonia have been observed). An etiological diagnosis is possible by detecting specific IgM class antibodies in the blood serum or by seroconversion (in the study of paired sera).
The study of the clinical manifestations of mycoplasmal pneumonia showed that a prodromal period is characteristic in the form of malaise and respiratory syndrome, manifested by nasopharyngitis, tracheobronchitis [2,3,6], less often otitis media. The development of pneumonia is rapid, sometimes gradual with the onset of fever or subfebrile condition [2,6]. Chills and shortness of breath are not typical. Cough, often unproductive or with mucus sputum, is the dominant symptom. In 30–50% of patients, a paroxysmal, unproductive, painful, low-pitched whooping cough, sometimes accompanied by difficulty in breathing, is typical [3]. These paroxysms of cough are often due to the development of the phenomenon of tracheobronchial dyskinesia, in which the mobility of the pars membranacea of ​​the trachea and large bronchi increases significantly. On auscultation, dry and/or local moist rales are heard. Crepitus and signs of compaction of the lung tissue are absent. Pleural effusion rarely develops. Extrapulmonary symptoms are not uncommon: myalgia (usually pain in the muscles of the back and hips), profuse sweating, muscle weakness, arthralgia, skin and mucous lesions, gastrointestinal disorders, headaches, and sometimes insomnia.
X-ray examination reveals a typical pneumonic infiltration of the lung parenchyma (often focal and multifocal), however, in 20–25% of patients only interstitial changes are determined, and occasionally no pathology is noted on standard radiographs (especially those performed in a hard mode). Therefore, in cases where clinically pneumonia is not in doubt, and the results of radiography are not conclusive, computed X-ray tomography can be used, which provides confirmation of the diagnosis due to viewing the image in various modes and the absence of hidden zones for the method.
The phenomenon of tracheobronchial dyskinesia is detected when performing forced expiratory lung tests. Characteristic is the appearance of additional “steps” on the spirographic curve. More precisely, the presence of this syndrome can be proved by roentgenoscopy of the trachea with a cough test.
The leukocyte formula of peripheral blood is usually not changed. Slight leukocytosis or leukopenia is possible. Occasionally, unmotivated anemia is noted. Blood cultures are sterile, and sputum is uninformative.
For mycoplasmal pneumonia, the dissociation of some clinical signs is characteristic: high fever in combination with a normal leukocyte formula and mucous sputum; low subfebrile condition with heavy sweats and severe asthenia. Thus, mycoplasmal pneumonia has certain clinical features, the comparison of which with the epidemiological situation allows you to make the right decision about choosing an antibacterial drug.
With chlamydial infection [3,6], the development of pneumonia is often preceded by a respiratory syndrome in the form of malaise and pharyngitis, which occurs with a dry cough at normal or subfebrile body temperature. The development of pneumonia is subacute with chills and fever. Cough quickly becomes productive with purulent sputum. During auscultation, crepitus is heard in the early stages, local moist rales are a more stable sign. With lobar pneumonia, a shortening of percussion sound, bronchial breathing, and increased bronchophony are determined. Chlamydial pneumonia can be complicated by pleurisy, which is manifested by characteristic pleural pain, pleural friction noise. With pleural effusion, dullness is determined percussion, and when listening – a sharp weakening of breathing. Some patients tolerate high fever relatively easily. In children, a pertussis-like course of chlamydial pneumonia is described, which is associated with the frequent development of tracheobronchial dyskinesia, which is a characteristic symptom in pulmonary chlamydia in adults. Of the extrapulmonary manifestations, sinusitis is more common (5%), and myocarditis and endocarditis are much less common. Radiographic findings are extremely variable. Reveal infiltrative changes in the volume of one or more lobes, often infiltration is interstitial in nature. In typical cases, the leukocyte formula is not changed, but leukocytosis with a neutrophilic shift is often noted

Patient H., aged 15, was admitted to the pulmonology department on the 7th day of illness. There is an outbreak of an acute respiratory infection at the school. In the class, 5 out of 25 students were diagnosed with pneumonia. The patient was diagnosed with pneumonia on the 2nd day of illness. Started therapy with amoxicillin/clavulanate 2.0 g/day. Treatment for 5 days without effect. All days the fever persisted up to 38–38.5°C. On admission he was in a state of moderate severity. Body temperature 38.5°C. Clinical and radiographic findings are consistent with right-sided lower lobe pneumonia. In the blood test, moderate leukocytosis without a neutrophilic shift in the leukocyte formula. Azithromycin was prescribed orally at 500 mg/day. A few hours after the first dose of the antibiotic, the body temperature returned to normal. During the examination in the blood serum, antibodies to chlamydia of the IgM class were found in high titers. Azithromycin was used for 12 days. The outcome is recovery.
In this clinical observation, the basis for a correct clinical assessment and selection of an effective antibiotic (azithromycin) was a characteristic epidemiological history and the absence of the effect of 5-day therapy with an enhanced b-lactam antibiotic at an effective dose.
In addition to monotherapy with azithromycin, this antibiotic is often prescribed in combination with b-lactam drugs. If a patient is hospitalized for moderate or severe pneumonia, a de-escalation tactic is often practiced [1,3,5], which involves the use of a combination of antibiotics for initial therapy, and usually this is a combination of a b-lactam drug (aminopenicillins, cephalosporins, carbapenems) with a macrolide, which is prescribed based on the possibility of legionella or chlamydial infection. Subsequently, after the diagnosis is clarified, one of the drugs is canceled.

Several years ago, on the 4th day of illness, patient N., 42 years old, was hospitalized in our department. Upon admission, the patient’s condition was severe: body temperature 39.0°C, unstable hemodynamics, respiratory rate – 36 per 1 min. Clinically and radiologically – bilateral multi-lobe (infiltration of 3 lobes) pneumonia. Leukocytosis 22.0 with a stab shift of 30%. Antibacterial therapy was prescribed: meropenem 4.0 g/day. intravenously in combination with azithromycin 500 mg / day. orally. Pressor amines and glucocorticosteroids were used intravenously, oxygen therapy was used. Hemodynamic parameters were stabilized within 4 hours and further use of steroids and pressor amines was discontinued. Etiologically, pneumonia was deciphered as legionella (antibodies to legionella were found in the blood serum in a titer of 1:1024). Duration of treatment with azithromycin – 18 days, meropenem – 4 days (the drug was canceled after the diagnosis of legionellosis was established). Oxygen therapy was used for 7 days. The outcome is recovery.
It can reasonably be assumed that the outcome of the disease in the observed patient would be doubtful if empirical antibiotic therapy was carried out only with meropenem, and azithromycin was prescribed only after the legionella nature of pneumonia was established.
This observation prompted us to conduct de-escalation antibiotic therapy (b-lactam antibiotic + macrolide) in almost half of patients with pneumonia and in all cases of treatment of severe pneumonia.
In severe pneumonia, antibiotics are given intravenously. With intravenous use, azithromycin is dosed at 500 mg every 24 hours.
The cost of antibiotic therapy, which can be quite significant, must be reckoned with. In recent years, the so-called stepwise therapy has been successfully used [1,3–5]. When using azithromycin according to this technique, treatment begins with intravenous antibiotic 500 mg every 24 hours. Upon reaching the clinical effect (usually after 2–3 days), when antibiotic therapy provided an improvement in the patient’s condition, accompanied by a decrease or normalization of body temperature, a decrease in leukocytosis, it is possible to switch to oral administration of azithromycin (if good absorption is expected) at 0.25–0, 5/24 hours. With the high efficiency of such a technique, it is less expensive not only due to the difference in prices for parenteral and tablet preparations, but also due to a decrease in the consumption of syringes, droppers, and sterile solutions. Such therapy is more easily tolerated by patients and less often accompanied by side effects.
Intravenous and stepped application of azithromycin is usually used in the treatment of severe pneumonia. In the treatment of other bronchopulmonary infections, as a rule, oral therapy can be limited.
These data and our own long-term experience indicate that azithromycin currently occupies one of the main positions in the treatment of bronchopulmonary infections.

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