Anti-inflammatory effects of macrolide antibiotics in the treatment of chronic rhinosinusitis.

Apart from their obvious antibiotic effects, the macrolides have some potentially useful immunomodulatory properties. Which pathway dominates the clinical effect is debatable. Favoring the anti-inflammatory effects are the substantial in vitro data and serum concentrations well below minimal inhibitory concentrations for several pathogens. Furthermore, tissue reparative effects are seen in diffuse panbronchiolitis regardless of the presence of P. aeruginosa, a pathogen not sensitive to macrolide antibiotics. Clinical studies support the view that prolonged treatment is likely to be beneficial in most patients who have CRS. The evidence concerning CRS is still weak because placebo-controlled trials are missing. One should remember, however, the general lack of placebo-controlled trials even in the "more established" medical management of CRS. The concern for an increasing incidence of macrolide-resistant bacterial strains must be taken seriously. Therefore the authors advocate repeated nasal cultures during macrolide therapy. It is hoped that the future will bring larger, prospective, randomized, controlled trials that will investigate the efficacy and safety of macrolides in CRS.