Cefuroxime axetil in the treatment of sinusitis. A review

Review

. 1994 Feb;3(2):165-75.

doi: 10.1001/archfami.3.2.165.

G E Pakes 
¹
, J A Graham, A M Rauch, J J Collins

Affiliations

Affiliation

• ¹ Glaxo Inc, Glaxo Inc Research Institute, Research Triangle Park, NC.

• PMID:

  7994439

• DOI:

  10.1001/archfami.3.2.165

Review

G E Pakes et al.

Arch Fam Med.

1994 Feb.

. 1994 Feb;3(2):165-75.

doi: 10. 1001/archfami.3.2.165.

Authors

G E Pakes 
¹
, J A Graham, A M Rauch, J J Collins

Affiliation

• ¹ Glaxo Inc, Glaxo Inc Research Institute, Research Triangle Park, NC.

• PMID:

  7994439

• DOI:

  10.1001/archfami.3.2.165

Abstract

Cefuroxime axetil is a beta-lactamase-stable, second-generation, oral cephalosporin that penetrates sinus tissue in concentrations exceeding the MIC90 values (the minimum concentration of drug needed to inhibit the growth of 90% of an isolate of a particular microorganism) for pathogens most commonly associated with acute sinusitis, including Streptococcus pneumoniae and Haemophilus influenzae. A review of all clinical data published to date demonstrates that cefuroxime axetil has been evaluated in the treatment of acute sinusitis and acute exacerbations of chronic sinusitis (“acute-on-chronic sinusitis”) in 18 clinical trials involving 1516 assessable patients. In 12 randomized, comparative trials, the rates of satisfactory clinical outcomes (cure or improvement, 79% to 100%) and bacteriologic eradication (84% to 100%) reported with the use of 250 mg of cefuroxime axetil twice daily were similar to those observed with the use of amoxicillin, amoxicillin/clavulanate potassium, cefaclor, cefadroxil, cefixime, clarithromycin, and doxycycline. In these comparisons, no antibiotic demonstrated any therapeutic advantages over cefuroxime axetil regarding time to symptom abatement. Cefuroxime axetil was at least as well tolerated as the other antibiotics. Overall, the role of cefuroxime axetil in the treatment of sinusitis appears to be as one of the broad-spectrum antibiotics that can be used for infections due to the most commonly implicated sinus pathogens, especially those due to the increasing number of relatively penicillin-resistant strains of S pneumoniae and beta-lactamase-producing strains of H influenzae and Moraxella catarrhalis.

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MeSH terms

Substances

Penetration of cefuroxime into chronically inflamed sinus mucosa

Clinical Trial

. 1999 Nov;109(11):1841-7.

doi: 10.1097/00005537-199911000-00023.

P B Dinis 
¹
, M C Monteiro, R Lobato, M L Martins, A Gomes

Affiliations

Affiliation

• ¹ Department of Otorhinolaryngology, Hospital de Pulido Valente, Lisbon, Portugal.

• PMID:

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• DOI:

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Clinical Trial

P B Dinis et al.

Laryngoscope.

1999 Nov.

. 1999 Nov;109(11):1841-7.

doi: 10.1097/00005537-199911000-00023.

Authors

P B Dinis 
¹
, M C Monteiro, R Lobato, M L Martins, A Gomes

Affiliation

• ¹ Department of Otorhinolaryngology, Hospital de Pulido Valente, Lisbon, Portugal.

• PMID:

  10569419

• DOI:

  10.1097/00005537-199911000-00023

Abstract

Objectives:

Despite its seeming relevance, limited information exists about antibiotic sinus tissue penetration and how it is affected by inflammation. Thus the reason for the present investigation.

Study design:

A randomized, open, multiple-dose, pharmacological study, employing cefuroxime axetil, an approved oral antimicrobial for the treatment of acute bacterial rhinosinusitis, was developed.

Methods:

Twenty subjects, selected for surgery because of chronic rhinosinusitis, were randomly allocated to receive either a short (3-8 d) or a long (9-14 d) preoperative treatment regime with 500 mg cefuroxime axetil BID, the last dosage being taken 3 to 4 hours before surgery. At the operation, tissue samples were collected at specific sinonasal sites for both pharmacological determination of antibiotic levels and histopathological assessment of the degree of inflammation. The blood levels of the drug were simultaneously assayed.

Results:

Cefuroxime kinetic behavior on chronically inflamed mucosa was shown to be, for the most part, dependent on the blood levels, regardless of the inflammatory state. Distribution was even throughout the different sinus cavities, and the tissue levels were still, 3 to 4 hours after dosing, above the reported minimum inhibitory concentration (MIC) values for some of the most prevalent sinus pathogens. The extended treatment course did not seem to add any extra histopathological or pharmacological benefit.

Conclusions:

Cefuroxime penetrates adequately and uniformly into chronically inflamed sinus mucosa, apparently unaffected by the degree of inflammation, in a way not dissimilar to its pharmacokinetic behavior in the normal state. Persistent MIC levels for common pathogens still warrant antimicrobial efficacy for a significant period of time after dosing.

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Diagnosis and treatment of acute sinusitis | Luchikhin L.

A., Polyakova T.S.

C inusitis is an inflammatory disease of the paranasal sinuses of a bacterial, viral, fungal or allergic nature. This is one of the most common diseases that general practitioners and otorhinolaryngologists deal with.

According to the duration of the course, acute sinusitis is distinguished – with a duration of the disease up to 8 weeks and chronic – with a longer course of the pathological process or with four or more relapses of acute sinusitis per year.

Any of the paranasal sinuses can be involved in the inflammatory process, however, most often in adults and children over 7 years old, the maxillary sinus is affected, then the ethmoid, frontal sinuses, and less often the sphenoid sinus. The process can develop simultaneously in two or more sinuses of one or both sides: maxillary ethmoiditis, hemisinusitis, pansinusitis or polysinusitis.

The term “acute sinusitis” is traditionally used to refer to a bacterial infection of the paranasal sinuses. At the same time, studies using computed tomography (CT) showed that in acute respiratory viral infections, 87% of patients develop rhinosinusitis , which should be regarded as viral, while the sinus disease in most of them resolves without special antibacterial treatment, however, 1-2% of colds viral diseases are complicated by acute bacterial sinusitis.

The main pathogens in acute sinusitis are Streptococcus pneumoniae and Haemophilus influenzae , which are sown in more than 50% of cases. Less common M. catarralis, Str. pyogenes, Staph. aureus , anaerobes, viruses. Sinusitis, which developed against the background of respiratory infections of the upper respiratory tract, is traditionally referred to as community-acquired forms of the disease. In addition, nosocomial (nosocomial) sinusitis has recently been isolated, which occurs after prolonged tamponade of the nasal cavity, nasogastric sounding, or nasotracheal intubation. With this form, the main pathogens are anaerobes, a group of enterobacteria, less often Staphylococcus aureus and fungi.

Acute inflammation of the paranasal sinuses can develop against the background of various infectious diseases, with allergic rhinitis, in violation of the normal drainage of the paranasal sinuses due to hypertrophy of the nasal mucosa, polyposis or curvature of the nasal septum, in diseases of the teeth, due to trauma and intoxication with endo- or exotoxins . When the natural fistulas are closed in the paranasal sinuses, negative pressure develops, hypersecretion and stagnation of the secretion of the mucous glands, the pH changes, and the function of the ciliated epithelium is disturbed. Inhibition or cessation of the beating of cilia contributes to the reproduction of the pathogen on the surface of the mucous membrane, its subsequent penetration through the membranes of the mucous membrane and the development of colonies.

Exudative processes predominate in acute inflammation. Initially, in the early stages of inflammation, the exudate is serous, then mucoserous, and with the addition of a bacterial infection it becomes purulent, containing a large number of leukocytes and detritus. This increases the permeability of capillaries and develops mucosal edema.

The clinical picture of acute sinusitis is determined by general and local signs of inflammation. Manifestations of a general reaction may be, in particular, headache, fever, general malaise, weakness and typical changes in the blood. These symptoms are nonspecific, so local manifestations of the disease are of paramount importance in the diagnosis of sinusitis.

The most common complaints in acute sinusitis are headache, difficulty in nasal breathing, abnormal discharge from the nose and nasopharynx (the secret flows down the back of the pharynx), impaired sense of smell. Headache is often localized in the frontal-temporal regions, often aggravated by tilting the head. With the defeat of the sphenoid sinus, a persistent “night” headache is characteristic with localization in the center of the head and occipital regions. Complaints of headache are sometimes absent, especially if there is a good outflow of exudate through the natural fistula. Difficulty in nasal breathing with sinusitis develops as a result of obstruction of the nasal passages with edema or hyperplasia of the mucous membrane, in the presence of a pathological secret in the nasal passages. With the defeat of the sinuses of one side, the violation of nasal breathing usually corresponds to the side of the lesion.

At rhinoscopy revealed hyperemia and swelling of the nasal mucosa on the affected side. There is also a narrowing of the lumen of the nasal passages, difficulty in nasal breathing, impaired smell. In the middle or upper, as well as common or lower nasal passages, a purulent secret is usually determined. With the defeat of the posterior group of the paranasal sinuses (sphenoid sinus, posterior cells of the ethmoid labyrinth), purulent exudate often flows down the back wall of the pharynx. It should be borne in mind that the absence of pathological discharge in the nasal cavity does not exclude sinus disease. Detachable may not be with a block of the natural anastomosis of the affected sinus, with a high viscosity of the pathological secret.

In the diagnosis of acute sinusitis, special research methods are of great importance: radiography (and in case of an unclear picture – contrast radiography or CT) of the paranasal sinuses and their diagnostic puncture.

A characteristic x-ray sign of acute sinusitis is a decrease in the pneumatization of the paranasal sinuses, sometimes a horizontal level of fluid in the sinus can be seen on the x-ray (if the image was taken in a sitting position). The most common is the study in direct (naso-frontal, naso-chin) projections. CT scan of the paranasal sinuses reveals a limited inflammatory process in one of the sinuses; this study is also necessary if a rhinosinusogenic orbital or intracranial complication is suspected.

Diagnostic and therapeutic puncture of the maxillary sinus is most often performed through the lower nasal passage; access to the sinus cavity is also possible through the middle nasal passage. Trepanopuncture of the frontal sinus is performed through the anterior (according to M. E. Antonyuk) or orbital walls. The pathological discharge from the sinus and nose taken during the puncture is sent for the study of microflora and its sensitivity to antibiotics.

Depending on the severity of the clinical manifestations of acute sinusitis, a mild course of the disease, moderate sinusitis and severe forms of the disease are distinguished.

The course of the disease is defined as mild when, in the presence of local and radiographic signs of sinusitis, there are no or minimally expressed signs of intoxication and such manifestations of the disease as headache, local pain in the area of ​​the affected sinuses. Body temperature in this form of the disease is usually normal or subfebrile.

The disease of moderate severity is characterized by moderate signs of intoxication and a moderate pain syndrome (headache, local pain in the sinuses). There is an increase in temperature to 38°–38.5°C. Minor local reactive phenomena are possible (reactive edema of the eyelid, swelling of soft tissues in the area of ​​the walls of the paranasal sinuses).

Severe sinusitis is accompanied by severe intoxication, intense headache, significant pain in the sinus walls; at the same time, a temperature rise of more than 38.5 ° C is noted. Complications may develop.

treatment for acute sinusitis is based on systemic or local antibiotic therapy. At the same time, measures are being taken to improve the drainage of the sinuses and increase the body’s resistance. With a mild course of the disease and with moderate sinusitis, the patient is treated on an outpatient basis under the supervision and with the participation of an otorhinolaryngologist. In severe sinusitis, and in some cases even with a moderate disease, hospitalization of the patient in the otolaryngological department is indicated. The protocol for the treatment of patients with acute sinusitis includes a set of general and local medication and physiotherapy prescriptions.

The main task of ongoing drug therapy is the eradication of the pathogen and the restoration of the biocenosis of the paranasal sinuses . The most effective is the conduct of etiotropic therapy. However, even with modern equipment of the bacteriological service of a medical institution, accurate identification of the pathogen is possible only by 5-7 days after sending the material for research. Even having an idea about the nature of a possible infectious agent, it is impossible to predict the presence or absence of acquired resistance to a particular antibiotic without special studies. In these conditions, the way out may be the use of drugs, the likelihood of resistance to which is minimal. Therefore, in the initial appointment of antibacterial treatment, the basis is empirical therapy , taking into account the nature of the likely pathogen and the characteristics of the clinical manifestations of the disease. The choice of drug depends on the nature of the most likely pathogen and the characteristics of the clinical manifestations of the disease. According to available data, in Russia, S. pneumoniae and H. influenzae isolated from acute sinusitis remain highly sensitive to penicillin drugs, in particular, to ampicillin, amoxicillin, amoxicillin / clavulanate (Panklav) , and cephalosporins II – III generations. An important problem in Russia is the high resistance of pneumococci and Haemophilus influenzae to co-trimoxazole: a moderate and high level of resistance was found in 40% of S. Pneumoniae and 22% of H. Influenzae .

The choice of antibiotic for the treatment of sinusitis is based on the severity of the patient’s condition. An indispensable requirement for antibacterial agents is also their maximum safety, the absence of ototoxic and other undesirable effects.

For mild cases antibiotics are prescribed orally. The drugs of choice are ampicillin, phenoxymethylpenicillin, roxithromycin, spiramycin, doxycycline, cefuroxime. The course of treatment with these drugs is 7-10 days. Certain possibilities in the treatment of predominantly catarrhal forms of sinusitis are opened by the use of the local antibiotic fusafunzhin. Fusafungin has a wide spectrum of antibacterial activity against the most common pathogens that cause respiratory infections, including pneumococci, Haemophilus influenzae, and staphylococci. Fusafunzhin is effective in infection with fungi of the genus Candida , mycoplasma, some anaerobic pathogens. It has an anti-inflammatory, antioxidant effect, reduces edema and exudative activity of the mucous membrane, indirectly improves mucociliary clearance.

In moderate disease the drugs of choice are oral b-lactam antibiotics from the group of penicillins and cephalosporins II-III generations, fluoroquinolones: amoxicillin/clavulanate, cefuroxime-axetil, cefaclor, levofloxacin, sparfloxacin. Due to their high efficacy and low toxicity, penicillins and cephalosporins occupy one of the first places in terms of frequency of clinical use among all antibiotics.

In particular, amoxicillin / clavulanate (Panklav) , according to numerous studies, demonstrates a high percentage of eradication of the pathogen and good tolerance in both adults and children. Both components of the drug are well absorbed after oral administration, regardless of food intake. The drug is characterized by a good volume of distribution in the fluids and tissues of the body, including the secret of the paranasal sinuses. For adults and children over 12 years of age (or over 40 kg body weight), the usual dose is one 250 mg/125 mg tablet 2 to 3 times daily.

Cefuroxime should be taken with food, all other drugs should be taken with or without food. As a rule, the frequency of taking these drugs is 2 times a day, the duration of the course of treatment is 10–12 days. Among the adverse reactions in penicillins and cephalosporins, the most common are various types of allergic reactions, and in some cases (1-3%) a cross-allergy to penicillins and cephalosporins is possible. In addition, the intake of this group of drugs is accompanied by varying degrees of immunosuppression (which fluoroquinolones are deprived of). In this regard, fluoroquinolones are increasingly used in the treatment of sinusitis.

In case of severe sinusitis and the risk of complications, drugs are prescribed parenterally (intramuscularly or intravenously). Inhibitor-protected penicillins, III-IV generation cephalosporins (cefotaxime or ceftriaxone; cefepime or cefpirome), fluoroquinolones (levofloxacin, ciprofloxacin, sparfloxacin), or carbapenems (imipenem) are recommended. In case of allergy to b-lactam antibiotics, intravenous fluoroquinolones are prescribed, which also have a wide spectrum of bactericidal action against pathogens of upper respiratory tract infections – ciprofloxacin, pefloxacin. Given the possible development of adverse reactions, fluoroquinolones are not recommended for children and gerontological patients, as well as for violations of the liver and kidneys.

Antibiotics of the carbapenem group (imipenem and meropenem) have a higher resistance to the action of bacterial b-lactamases and at the same time a wider spectrum of activity. More often they are used as reserve drugs, but in case of severe inflammation, including nosocomial infection , they can be considered as first-line empirical therapy.

In the presence of clinical signs of anaerobic infection in the sinuses, metronidazole, a synthetic antimicrobial agent from the group of imidazoles, which has a wide spectrum of action, is most pronounced in relation to anaerobes and protozoa, is included in the complex of antibacterial therapy.

In some cases, it is possible to prescribe a stepwise therapy, in which treatment begins with intravenous or intramuscular administration of an antibiotic for 3–4 days, and then they switch to oral administration of the same or a drug similar in spectrum of activity.

In addition to antibacterial agents, in the complex of systemic therapy of sinusitis, drugs with mucolytic and mucoregulatory effects, stimulating mucociliary transport, as well as anti-inflammatory and antihistamines are prescribed. A multilevel effect on the inflammatory process in the sinuses was observed in fenspiride, which belongs to non-steroidal anti-inflammatory drugs, with an effect mainly on the mucous membrane of the respiratory tract. A special place in the treatment of rhinosinusitis is occupied by the phytopreparation sinupret, which has a secretolytic, mucoregulatory, antiviral and anti-inflammatory effect, i.e., in fact, it affects all links in the pathogenesis of the disease. Sinupret can be prescribed already at the initial signs of ARVI according to the initiating scheme, and this is already the prevention of damage to the paranasal sinuses. An important place in the treatment of sinusitis is occupied by complex antihomotoxic and homeopathic preparations, especially in the early stages of serous inflammation, as well as in people who have contraindications to the use of antimicrobial drugs. Among them, it should be noted influenza-hel, traumeel, antigrippin, apis-mercurius, doronR, pneumodoron 1R and 2R, argentum-berberis compositum, oscillococcinum, EDAS Nos. 117, 131, 801, 903, 904, echinacea-compositum, influcid, etc. It should be emphasized that quite often already against the background of initiating therapy, patients experience a decrease in general and local symptoms of the disease.

We consider it necessary to note that it is not advisable to prescribe antihistamines simultaneously with antimicrobial and mucolytic drugs, since in this period, the main task is drainage and cleansing of the mucous membrane. Their use is justified in the presence of allergic inflammation of the mucous membrane, and then the blockade of H ₁ – histamine receptor relieves nasal obstruction.

Simultaneously with systemic therapy in various forms of sinusitis, a local effect on the mucous membrane of the nasal cavity and sinuses is mandatory . In the complex of therapeutic measures, the use of vasoconstrictor drops is important, which allows to reduce swelling of the mucous membrane, improve drainage and at least partially restore aeration of the paranasal sinuses through natural fistulas. Vasoconstrictor drugs are represented by derivatives of xylometazoline, naphazoline, oxymetazoline, etc. However, the introduction of drops into the nasal cavity is not performed correctly by all patients – to achieve the effect, they increase the volume and frequency of administration, and this is always fraught with side effects, often very severe. Most preferred are aerosol forms of vasoconstrictor drugs, and even better dosed. The pump-action form of ximelin meets these requirements. At present, we are widely using nasal aerosol rinofluimucil , which simultaneously provides a vasoconstrictive, mucolytic and anti-inflammatory effect, devoid of an almost irritating effect on the mucous membrane of the nasal cavity. According to the indications, with purulent forms of damage to the paranasal sinuses, a good effect is achieved with the use of combined preparations. In the presence of an allergic process, the use of polydexes (antibacterial components + phenylephrine and corticosteroid) is indicated.

Among local antibacterial drugs, isofra and others are most widely used. Among the drugs injected into the nasal cavity for the purpose of immunocorrection, anti-inflammatory and antiviral therapy, Gepon, Derinat, Euphorbium compositum are increasingly used.

Evacuation of pathological secretion from the paranasal sinuses in case of their exudative inflammation is an important component of pathogenetic therapy. For this purpose, the puncture method is widely used on an outpatient basis and in a hospital. At medical puncture of the sinus after washing the sinus, drugs are introduced into the cavity in order to create a depot of medicinal substances. Typically, antibiotic solutions are used, selected taking into account the characteristics of the pathogen in the same way as for systemic therapy; or other antibacterial agents are introduced (dioxidin, octenisept, ectericide, peloidin, etc.). With viscous, thick purulent contents, proteolytic enzymes such as trypsin, chymotrypsin, and lidase are used for injection into the sinuses. When applied locally, enzymes break down necrotic tissues to polypeptides and amino acids, liquefy viscous secretions, exudates, blood clots, and also have an anti-inflammatory effect. At the same time, the mucolytic, anti-inflammatory and antibacterial effect is achieved by introducing fluimucil with an antibiotic into the sinus. Usually, in the treatment of purulent sinusitis by the puncture method, it is recommended to limit yourself to 5–7 punctures, and if, after such a course of treatment, a purulent secret is still determined in the washing fluid, the patient is shown surgical treatment.

There are non-puncture treatments for inflammatory diseases of the paranasal sinuses. The method of “moving” according to Proetz (the “cuckoo” method) allows you to create a vacuum in the nasal cavity using surgical suction, while pathological contents are removed from the sinuses, and after infusion of medicinal solutions into the nasal passages, the latter rush into the sinuses that have opened and freed from purulent exudate.

Pathological secretion from the paranasal sinuses can be more successfully evacuated using sinus catheter “YAMIK” , developed by G.I. Markov and V.S. Kozlov. The method allows you to aspirate the pathological secret from the sinuses, wash them with disinfectant solutions and inject medicinal substances into the sinuses. The aspiration method using a sinus catheter is preferable for exudative forms of hemisinusitis or simultaneous damage to several sinuses on one side. Both with puncture and non-puncture methods of treatment, when “purity” is achieved, it is desirable to introduce a solution of Gepon into the sinuses, which restores local immunity of the mucous membrane.

In the treatment of acute sinusitis, physiotherapeutic methods are also used: microwaves, UHF and impulse currents, laser therapy, magneto- and magneto-laser therapy. With severe pain syndrome, sinusoidal modulated or diadynamic currents are prescribed. However, if there is exudate in the maxillary sinuses before physiotherapy, they must be freed from the contents by puncture and washing.

Prevention of recurrence of acute sinusitis includes the following requirements:

1. Elimination of various anatomical defects in the nasal cavity that impede normal nasal breathing, leading to disruption of mucociliary transport and drainage of the paranasal sinuses through natural fistulas.

2. Timely sanitation of the oral cavity in order to prevent the development of periodontitis in the area of ​​the roots of the teeth adjacent to the bottom of the maxillary sinus.

3. Systematic implementation of measures to increase the natural local and general resistance of the body.

Of particular importance for the treatment and prevention of acute and chronic sinusitis have acquired means of active immunization using bacterial vaccines.

In recent years, the drug IRS-19 has been successfully used to prevent recurrence of inflammatory diseases of the upper respiratory tract. The drug is available as a spray for intranasal use and contains purified bacterial lysates of 19 of the most significant pathogens of respiratory infections. The drug allows you to stimulate non-specific and specific parts of the immune response, mainly local, from the mucous membrane of the upper respiratory tract. Conducted clinical trials of the drug IRS-19showed its ability to reduce the frequency of recurrences of sinusitis and respiratory diseases in adults and children by 2.5–4 times, provided that repeated immunization is carried out after 4–5 months. As a therapeutic and preventive measure for acute diseases of the nose and paranasal sinuses, it should be recognized as necessary to prescribe probiotics (lactofiltrum, normoflorin B and L, etc. ) during antibiotic therapy, with repetition of courses under microbiological control of the intestinal biocenosis. Aromatherapy occupies a special place in the treatment and prevention of acute diseases of the nose and paranasal sinuses. the use of aromatic oils with anti-inflammatory, antiseptic and virusolytic activity, which have a reflex local vasoconstrictor effect, as well as a central effect through the olfactory nerve and irritation of the nasobulbar centers. Among them, the most commonly used oils are tea tree, eucalyptus, fennel, mint, camphor lavender, etc., as well as aroma mixtures, for example, eca, carmolis, citrosept, etc.

Table 3 – Recommended antibacterial drugs and regimens for the treatment of acute bacterial frontal sinusitis in children \ ConsultantPlus

Table 3 – Recommended antibacterial drugs and regimens for the treatment of acute bacterial frontal sinusitis in children

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<*> Antibacterial resistance risk: regions with a high incidence (> 10%) of the prevalence of invasive strains of penicillin-insensitive pneumococci, children with severe comorbidities, immunodeficiency who have received ABP within the previous 90 days or hospitalized within the previous 5 days, living in “closed” institutions.

– The use of lincomycin and gentamicin preparations in the treatment of acute frontal sinusitis in children is not recommended. [4, 6, 10, 12, 14].

Strength of recommendation – A (level of evidence – I).

Comments: Lincomycin is not recommended for the treatment of acute sinusitis as it has no effect on Haemophilus influenzae, but may be used in cases of suspected osteomyelitis Gentamicin is not active against S. pneumoniae and H. influenzae and also has an ototask effect, therefore it is not indicated for treatment sinusitis

– Recommended topical antibiotic therapy for acute frontal sinusitis.

Strength of recommendation – A (level of evidence – I).

Comments: Antimicrobials for local action on the mucous membranes can be prescribed in combination with systemic antibiotics, and in some cases as an alternative treatment for acute frontal sinusitis [4, 6, 10, 12, 14]

– Elimination-irrigation recommended therapy.

Strength of recommendation – A (level of evidence – I).

Comments: Washing the nasal cavity with isotonic saline solutions to eliminate viruses and bacteria is included in the treatment of acute rhinosinusitis by both domestic and foreign recommendatory documents. Due to the phenomena of osmosis when washing the nasal cavity with hypertonic solutions, partial unloading of fistulas is possible. For these purposes, weak hypertonic solutions of sea water can be used. However, it should be remembered that these drugs should be used only in the acute period, and the maximum duration of treatment according to the instructions for use is 5-7 days [4, 6, 10, 12, 14]

– Relief therapy recommended.

Level of persuasiveness of recommendations – A (level of evidence – I)

Comments: One of the main areas of symptomatic (and, in a sense, pathogenetic) therapy of acute frontal sinusitis is the restoration of patency of the fistulas of the frontal sinuses, the so-called “unloading therapy”. Ensuring normal aeration of the sinuses makes it possible to compensate for the adverse pathogenetic effect of hypoxia and improve the drainage function of the paranasal sinuses through natural fistulas.