Treating sinusitis: Politically incorrect drug resistance due to Pneumococcal vaccine
Posted Apr 24 2012 8:47pm
I have treated so many patients with sinusitis in the last several weeks, I decided to review new guidelines that were issued by the Infectious Diseases Society of America (IDSA) recently on sinusitis. Wow, the changes were BIG and I had missed them. Seems the drugs I used to use don't work so well any more.
Everyone has heard about drug resistance. We had to watch a movie about it in medical school in the 1970s. It was very important that we not use antibiotics with broader, more powerful antimicrobial effects than necessary. Else plagues of drug-resistant bacteria would rain down upon us, and we would run out of effective antibiotics.
I got it. Use basic, relatively narrow spectrum antibiotics unless there is a very good reason to use the bigger guns -- like your patient was so sick he might not survive if you picked the wrong drug to start.
Plus, there are very few new antibiotics in the pipeline.
What now? IDSA's #1 choice is Augmentin, a very broad spectrum combination of amoxicillin and clavulanic acid. The clavulanic acid prevents most bacterial resistance to amoxicillin. This treatment may cause more drug resistance down the road.
... both the prevalence of H. influenzae (40%– 45%) and proportion of b-lactamase–producing H. influenzae (37%–50%) (extrapolated from middle ear fluid cultures of children with acute otitis media) have markedly increased among other upper respiratory tract infections since the widespread use of conjugated pneumococcal vaccines...
Whereas S. pneumoniae was more common than H. influenzae prior to 2000, the prevalence of H. influenzae has clearly increased while that of S. pneumoniae has decreased in the post–pneumococcal vaccine era, such that currently they are approximately equal... (* See IDSA citation below)
The strains of Strep pneumoniae circulating among us have changed as a result of the Prevnar 7 vaccine, and the new strains are decidedly more drug resistant. I'd rate this vaccine's net value a big negative.
WHO and NIAID list the causes of antibiotic resistance: agricultural use is last on both lists, and vaccines fail to be mentioned.
Yet the consequences of this change in resistance patterns are profound. Now routine cases of sinusitis, earaches, strep throats and pneumonias have become significantly harder and more expensive to treat. I can't tell you the relative contributions that Prevnar 7 vaccine, prescribing errors and antibiotic feeding make to this mess. But the serious unintended consequence of Prevnar 7 (the 19A proliferation) needs to be fully grasped, and the lesson absorbed, in order to avoid making a similar mess with other vaccines.
* Casey JR, Adlowitz DG, Pichichero ME. New patterns in the otopathogens causing acute otitis media six to eight years after introduction of pneumococcal conjugate vaccine. Pediatr Infect Dis J 2010; 29:304–9.