Staphylococcus aureus on Sinus Culture Is Associated With Recurrence of Chronic Rhinosinusitis After Endoscopic Sinus Surgery

Abstract

<b>Objectives:</b> Identify whether identification of <i>S. aureus</i> on conventional culture is a predictor of success or failure after ESS followed by budesonide nasal irrigations (BUD) in chronic rhinosinusitis (CRS) patients at high risk of recurrence. <b>Methodology:</b> Prospective clinical trial including 116 patients from a tertiary care center at high-risk of disease recurrence following ESS+BUD. Blood samples, microbial swabs, and SNSS/SNOT-22 were taken on the day of surgery (Visit-1) and 4 months postoperatively (Visit-2). Outcomes were evaluated using symptoms and mucosal status as assessed by the Lund-Kennedy endoscopic score. <b>Results:</b> Seventy-five patients (69.4%) attained SNOT-22 MCID or higher. (Mean = 33.4, range 9-75). Objective documentation of recurrence of disease, as defined by combined endoscopic/symptomatic criteria, was noted in 58/116 patients (50%). Revision surgery was associated with a significantly higher rate of disease recurrence (60.0 vs. 28.0%; <i>p</i> < 0.001). Culture for <i>Staphylococcus aureus</i> was associated with disease recurrence, preoperatively and at 4 months post-surgery (<i>p</i> = 0.020; <i>p</i> < 0.001). This was restricted to post-operative cultures in the revision group (10.0 vs. 48.8%; <i>p</i> < 0.001). Other factors associated with poor outcome included intolerance to non-steroidal anti-inflammatory drugs (NSAID) (<i>p</i> = 0.036). Significantly higher Lund-Kennedy scores in the recurrence groups despite similar symptom intensity, emphasizing the importance of considering objective outcome in addition to patient-reported ones. <b>Conclusion:</b> Patients undergoing revision ESS are at high risk of disease recurrence, even when budesonide irrigations are used post operatively. Presence of <i>S. aureus</i> on culture pre-operatively or at 4 months post-ESS is associated with a negative outcome. This suggests that <i>S. aureus</i> negatively influences outcome, possibly via a number of mechanisms, including interactions with the (i) immune system, (ii) regeneration and repair of the sinus epithelium, or (iii) via interference with the sinus microbiome. This suggests that <i>S. aureus</i> may be a simple and inexpensive biomarker for disease severity and indicates a clear need to better appreciate <i>S. aureus</i> on how it contributes mechanistically to disease development and persistence in order to develop targeted therapeutic strategies.