This month’s Ed’s Choice delightfully reviews the potential cardiovascular consequences of long-term macrolide use in the treatment of chronic rhinosinusitis. This used to be one of my ‘go-to’ topics of conversation at home after a bad day at work, although recently an unnamed source in the Ministry of Rhinology tells me that long-term prescription of antibiotics is falling from favour. Hopefully the effectiveness of antibiotics (or lack of) will be established in the now recruiting MACRO study. With increasing research dedicated to reflux and its role in chronic sinusitis there appears to be a new medical treatment option in the management of sinonasal symptoms.
Charles Giddings FRCS(ORL-HNS), FRACS Consultant ENT, Head and Neck Surgeon, Monash Health, Melbourne, Australia.
This interesting cohort study from the UK aims to evaluate the risk of cardiovascular risk with taking macrolide antibiotics for chronic rhinosinusitis (CRS), using primary care electronic health records. This group of antibiotics has anti-inflammatory and immunomodulatory properties in CRS patients. Macrolides are known to prolong the QT interval and potentially increase the short-term risk of arrhythmia. A recent US FDA communication noted the possibility of long-term cardiovascular risk associated with clarithromycin after the CLARICOR trial in Denmark. Patients were identified who had CRS and were prescribed one or more courses of macrolide and/or penicillin-based antibiotic and were aged between 16 and 80 years. Outcomes studied were time to all-cause death, cardiac death, fatal and non-fatal myocardial infarction, stroke, diagnosis of peripheral vascular disease, and cardiac arrhythmia. Anonymised patient records from the CALIBER system which enables utilisation of longitudinal structured records from the Clinical Practice Research Datalink, Hospital Episode Statistics and Office for National Statistics, were analysed. A total of 88,000 cases of CRS were identified; 70,000 of these had been prescribed macrolide and/or penicillin-based antibiotics. These were divided into groups for analysis; 58,000 in the penicillin group and 23,500 in the macrolide group. The analysis included 321,000 prescriptions, most commonly a one-week course; 68% for penicillin, 68% for macrolides and 76% for clarithromycin. Median follow-up was 4.24 years, and during the entire follow-up time, there were 3251 deaths due to any cause, 815 of which were cardiovascular. There were 925 myocardial infarctions, 859 strokes, 637 diagnoses of peripheral vascular disease and 1436 recorded arrhythmias. After adjusting for confounders, no statistically significant difference at the 5% level was found for either short or long-term risk of cardiovascular disease after the prescription of macrolides. There was a trend towards an increase in the short-term risk of myocardial infarction in the 30 days following prescription of macrolides that did not reach statistical significance, especially with reference to clarithromycin. Specifically, the best estimates suggest macrolide prescription being associated with a 60% increase in hazard of myocardial infarction. In summary, there appears to be an increased short-term risk of myocardial infarction in the 30 days post macrolide prescription for CRS but this is less so for clarithromycin.