1

Introduction

Chronic rhinosinusitis (CRS) represents an inflammatory disorder of at least 3 months’ duration caused by a multitude of etiologies, including microbes (viruses, bacteria, fungi), biofilm, Staphylococcus superantigen, ciliary dysfunction, and derangements in innate and adaptive immunity . The role of infection as a potential pathophysiologic mechanism in CRS has been a source of considerable debate and, at times, controversy in rhinology. Nonetheless, bacterial superinfection is commonly observed during acute exacerbations of CRS contributing to ongoing recalcitrant CRS . Though empiric antimicrobial therapy is often employed in this setting, the emergence of atypical bacterial pathogens and concerns for drug resistance, especially in the setting of post-endoscopic sinus surgery (ESS) refractory CRS, warrant the need for sinus cultures to guide targeted antibiotic therapy . Rigid nasal endoscopy facilitates the capability of concurrent diagnostic visualization and to aspirate or swab purulence to identify the offending microorganism, to guide selection of appropriate antibiotics, and minimize risk of bacterial resistance.

The microbiology of CRS is polymicrobial with assays demonstrating a wide range of bacteria. The predominant organisms reported include Staphylococcus aureus , coagulase-negative Staphylococcus (CNS), and various gram-negative rods, such as Pseudomonas aeruginosa , Escherichia coli , and Stenotrophomonas maltophilia . The accrued literature on microbiology of CRS is quite disparate, reporting culture yield in the clinic and operative setting, various sinonasal subsites, and different assay techniques. With this in mind, the present study reviewed the available evidence base of microbiologic studies in CRS to better understand overall culture yield of the most common aerobic and anaerobic bacteria.

2

Materials and methods

For this systematic review, the clinical indicator was endoscopically-derived bacterial cultures in CRS. The population of interest was adults with CRS without nasal polyps and acute exacerbation on CRS (AECRS). The objective of the review was to ascertain the prevalence of microorganisms yielded by endoscopic cultures based on clinical setting, paranasal sinus subsite, and assay technique.

Criteria for inclusion into the evidence base review were as follows:

• 1.
  

  Index disease of (1) CRS without nasal polyposis or (2) acute exacerbation of CRS

  
  
• 2.
  

  No systemic or topical antibiotics received at least 1 week prior to culture

  
  
• 3.
  

  Cultures, regardless of the assay technique, were performed under endoscopic guidance

2.2

Selection criteria for article inclusion

The PubMed search identified 205 abstracts available for further review. After removing 60 duplicates, a total of 145 citations remained. Both authors screened all abstracts independently. During the title and abstract screening, 77 citations were excluded leaving 68 citations for full-text review. An additional 25 studies did not fulfill the criteria for inclusion and were also excluded. Four studies included both external cultures from maxillary taps and sterile cultures obtained during endoscopic sinus surgery . These were included as the individual reported culture data were in congruence with the more recent endoscopically derived cultures. A total of 43 full-length articles were included for further systematic review and analysis ( Fig. 1 ) .

Flowchart of literature retrieval in systematic review.

2

Materials and methods

For this systematic review, the clinical indicator was endoscopically-derived bacterial cultures in CRS. The population of interest was adults with CRS without nasal polyps and acute exacerbation on CRS (AECRS). The objective of the review was to ascertain the prevalence of microorganisms yielded by endoscopic cultures based on clinical setting, paranasal sinus subsite, and assay technique.

Criteria for inclusion into the evidence base review were as follows:

• 1.
  

  Index disease of (1) CRS without nasal polyposis or (2) acute exacerbation of CRS

  
  
• 2.
  

  No systemic or topical antibiotics received at least 1 week prior to culture

  
  
• 3.
  

  Cultures, regardless of the assay technique, were performed under endoscopic guidance

2.2

Selection criteria for article inclusion

The PubMed search identified 205 abstracts available for further review. After removing 60 duplicates, a total of 145 citations remained. Both authors screened all abstracts independently. During the title and abstract screening, 77 citations were excluded leaving 68 citations for full-text review. An additional 25 studies did not fulfill the criteria for inclusion and were also excluded. Four studies included both external cultures from maxillary taps and sterile cultures obtained during endoscopic sinus surgery . These were included as the individual reported culture data were in congruence with the more recent endoscopically derived cultures. A total of 43 full-length articles were included for further systematic review and analysis ( Fig. 1 ) .

Flowchart of literature retrieval in systematic review.

3

Results

A total of 43 studies were accrued for the data analysis. Patients with CRS without polyps and CRS with/without polyps were reported in 40 (93.2%) and 3 (6.8%) studies, respectively. A total of 36 studies (83.7%) reported cultures in patients without previous surgery. The location of the specimen collection was the ambulatory clinic and operative suite in 10 (23.3%) and 33 (76.7%) studies, respectively. Twenty-three studies (53.5%) reported single site of culture, while 20 studies (46.5%) reported multiple sites. The reported culture technique was as follows: swab in 19 (44.2%), aspirate in 12 (27.9%), and mucosal biopsy in 2 (4.7%) series. Table 1 illustrates the salient characteristics of the 43 studies.

A total of 3528 patients with median age of 36 years (range, 6–50 years) were accrued from the 43 studies. The gender of the patient group was 1932 males (60%) and 1288 females (40%). The total number of specimens collected from each site was 6005, with positive culture specimens being noted in 3826 cases (63.7%). A total of 6152 organisms were isolated in these positive culture specimens. The median number of organisms isolated by swab, aspirate, mucosal biopsy, and not separated by technique was 1.3, 1.3, 1.7, and 3.3, respectively ( Table 2 ).

Table 2

Salient features of the 43 studies.

Label	Number of studies	Total of all studies	Median	Minimum	Maximum
Age (years)	37		36	6.3	50.4
No. of patients	43	3528	52	6	419
Male	39	1932	31	4	268
Female	39	1288	24	2	151
Total culture specimens	43	6005	91	12	609
Positive culture specimens	39	3826	54	12	442
Negative culture specimens	39	1703	16	0	181
No. isolated per positive specimen: swab	25		1.3	0.7	4.2
No. isolated per positive specimen: aspirate	13		1.3	0.7	4
No. isolated per positive specimen: mucosal biopsy	6		1.7	1.2	3.8
No. isolated per positive specimen: not separated by technique	3		3.3	2.1	3.3

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