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International Journal of Health, Nursing & Medicine ISSN: 2193-3715, Volume 6, Issue 2, page 25 - 37
Zambrut
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Ayu, A. P. M. S. 2020. Analysis of the Effectiveness of Antibiotic Therapy in Acute Bacterial
Rhinosinusitis (Studied of Pediatric and ................
25
Analysis of the Effectiveness of
Antibiotic Therapy in Acute
Bacterial Rhinosinusitis (Studied of Pediatric and Adult Outpatients in the ENT Hajj Hospital, Surabaya)
Ayu Angger Putri M. Soleh
Ayu Angger Putri M. Soleh
Harapan Bangsa Health College Jember (STIKES)
Jember, East Java, Indonesia
Abstract: Antibiotics are indicated in the case of Acute Bacterial Rhinosimusitis, the
administration of antibiotics should be guided by appropriate culture whenever possible,
especially in patients who have failed in initial first-line antimicrobial therapy. This research
will provide data on the effectiveness of antibiotics in the treatment process of Acute Bacterial
Rhinosinusitis and patterns of microbial sensitivity to anibiotics in Acute Bacterial
Rhinosinusitis. The affordable population in this study were all outpatients with Acute
Bacterial Rhinosinusitis who received empirical and definitive antibiotic therapy at Haji
Hospital Surabaya. The sampling technique in this study uses total sampling technique, which
is one of the non-probability sampling techniques. The effectiveness of empirical and
definitive antibiotics is assessed based on improvement of clinical conditions. The
effectiveness data will be categorized into 2, namely "effective" and "ineffective". If the patient
experiences an improvement in the clinical condition and the results of the physical
examination reveal that there is an improvement, then the use of antibiotics is considered
effective, but if the opposite occurs, the antibiotics are considered ineffective. Sensitivity test
results obtained include sensitive bacteria (S), intermediates (I) and resistant (R) to
antibiotics. Pseudomonas aeruginosa bacteria analyzed in this study were still sensitive to
Piperacilintazobactam. Antibiotics that are intermediate to Pseudomonas aeruginosa are
meropenen and Piperacilin. The most common bacteria that cause infections are
Pseudomonas aeruginoa, Enterobacter cloacae and Staphylococcus aureus. Infectious
Disease Society of America (IDSA), states the prevalence of dominant pathogens in Maxillary
Acute Rhinosinusitis for pediatric and adult patients (average percentage of specimen). Acute
Bacterial Rhinosinusitis patients with bacteria that cause Staphylococcus aureus,
Streptococcus haemolyticus and Enterobacter cloacae against administration of empiric
antibiotics of clavulanate amoxicillin show effective. After conducting research for 3 months
at Surabaya Haji Hospital, it can be concluded that the administration of antibiotic
Amoxicillin Clavulanate is effective for use as a therapeutic treatment for Acute Bacterial
Rhinosinusitis.
Keywords: Antibiotics, Acute Bacterial Rhinosimusitis, Patients, Therapy, Treatment,
Effectiveness, Test Results for Using Antibiotics, and Bacteria.
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Ayu, A. P. M. S. 2020. Analysis of the Effectiveness of Antibiotic Therapy in Acute Bacterial
Rhinosinusitis (Studied of Pediatric and ................
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1. INTRODUCTION
Rhinosinusitis is defined as inflammation of the paranasal sinuses and nasal cavity. Acute
Rhinosinusitis starts when the virus infects the upper respiratory tract, then extends into the paranasal
sinuses, which can be followed by bacterial infections. Simus puncture, which is performed for
bacterial examination, is considered the gold standard for bacterial diagnosis. The most common
bacteria of pediatric and adult patients on Acute Bacterial Rhinosimusitis are Streptococcus
pneumoniae, Haemophilus influenzae, Morarella catarrhalis, and Streptococcus pyogenes.1
Goal of treatment in Acute Bacterial Rhinosinusitis is sinus drainage
and eradication of pathogenic bacteria. Antibiotics are indicated in the case of Acute Bacterial
Rhinosimusitis, the administration of antibiotics should be guided by appropriate culture whenever
possible, especially in patients who have failed in initial first-line antimicrobial therapy. The
development of germ resistance to antibiotics is strongly influenced by the intensity of antibiotic
exposure in an area, uncontrolled use of antibiotics tends to increase the resistance of germs that were
initially sensitive. The discovery of MDR, the selection of appropriate antibiotics will be a problem,
including cost constraints. Most use of antibiotics occurs in hospitals, so in its management should
have a program to control infection, control of resistant germs, create a new guideline for the
continuous use of antibiotics and monitor antibiotic use in hospitals.1,8
Based on these reasons, we want to do a research that aims to find out the effectiveness of
antibiotics in the treatment of Acute Bacterial Rhinosinusitis in Haji Hospital Surabaya. It is hoped that
the results of this study will be able to be used as one of the recommendations for formulating an
appropriate antibiotic use policy, to prevent and control resistance and infection associated with Acute
Bacterial Rhinosinusitis. What is the effectiveness of antibiotic therapy for the treatment process of
Acute Bacterial Rhinosinusitis? The general objectives of the study are: Effectiveness of the
administration of antibiotic therapy to the treatment process of Acute Bacterial Rhinosinusitis The
specific objectives of the study are:
a. Knowing the bacteria that causes Acute Bacterial Rhinosinusitis.
b. Knowing the pattern of germs and bacterial sensitivity to antibiotics in Acute Bacterial
Rhinosinusitis.
c. Knowing alternative antibiotics that can be used in Acute Bacterial Rhinosinusitis.
This research will provide data on the effectiveness of antibiotics in the treatment process of
Acute Bacterial Rhinosinusitis and patterns of microbial sensitivity to anibiotics in Acute Bacterial
Rhinosinusitis.
2. LITERATURE REVIEW
2.1 ACUTE BACTERIAI RHINOSINUSITIS
Acute Bacterial Rhinosinusitis (ABRS) is a condition characterized by inflammation of the
paranasal cynical membrane that occurs due to 5 to 7 days after infection with vurus, bacteria, fungi or
allergens in the upper respiratory tract.8
2.2 CLASSIFICATION OF RHINOSINUSITIS BACTERIAL ACUTE
Acute Bacterial Rhinosinusitis can be classified based on the size of the largest paranasal sinus,
namely the maxillary sinus (located on the cheek), frontalis sinus (located on the forehead), ethmoid
sinus (between the two eyes) and sphenoidalis; pathogens (viruses, bacteria, fungi); complications
(orbital, intranial), and other factors (nasal polyposis, immunosuspension, anatomical variants).
2.3 PARANASAL SINUS ANATOMY
The paranasal sinuses (maxillary, ethmoid, frontal, and sphenoid) consist of four air-filled
spaces coated by pseudostratified, columnar epithelium and ciliated. Mucus formed in the paranasal
sinuses is born into the nasal meatus
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Ayu, A. P. M. S. 2020. Analysis of the Effectiveness of Antibiotic Therapy in Acute Bacterial
Rhinosinusitis (Studied of Pediatric and ................
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Figure 2.1 Anatomy of the Paranasa Sinus
The flow starts from the frontal sinus, etmoid arterior cells, and the maxillary sinus then enters
the meatus-medius. Clinically, the important part is the ostiomeatal complex. The Ostiomeatal complex
is a gap in the lateral wall of the nose that is bounded by the media concha and lamina papyrase. This
area is important because almost all the channel holes of the paranasal sinuses are there. Ostiomeatal
Complex (OMC) as a place for ventilation and as a drainage path for the frontal sinus, ethmoidalis, and
maxillary.
2.4 PATHOPHYSIOLOGY ACUTE BACTERIAI RHINOSINUSITIS
The pathophysiology of rhinosinusitis involves 3 important elements:
1. Sinus ostia obstruction
Sinus ostia obstruction prevents mucous drainage. Ostia can be blocked by the mucosa of the brain
or local causes (for example, trauma and rhinitis), as well as by certain systemic inflammatory
related disorders and immune disorders. Mechanical obstruction due to nasal polyps, salty objects,
septal deviation, or tumors can also cause ostial blockage. Specifically, anatomic variations that
narrow the ostiomeatal complex, including the division of the septum, the paradoxical concha
media, and Haller cells make this area more sensitive to obstruction due to mucosal inflammation.
2. Interruption of the Ciliary Function
Metacronus coordination of the columnar columnar epithelial cells pushes sinus contents toward the
sinus ostia. Any dysfunction of the cilia causes fluid accumulation in the sinuses. Poor ciliary
function can result from loss of ciliated epithelial cells; high air flow; viral, bacterial, or siliotoxin
environment; inflammatory mediators; relationship between two mucosal surfaces; scar; and
Kartagener's syndrome.
3. Changes in mucous quantity and quality
If the composition of the mucus changes and the mucus produced is thicker (for example, as in
cystic fibrosis), transport to the ostia is much slower, and the gel layer proves to be thicker. This
results in a collection of thick mucus that is still retained in the sinuses for various periods. Faced
with a lack of secretion or loss of moisture on the surface which cannot be compensated by mucous
glands or goblet cells, the mucus becomes thicker and the sol phase can be very thin so that it allows
the gel phase to have intense contact with the cilia and inhibit their movement. Excess mucus can
flood the mucociliary cleaning system.2,4
2.5 SINUS PUNCTURE
Sinus puncture is the most accurate way to determine which organisms cause sinusitis and to
define pathogenic organisms when standard therapy fails or in high-risk immunocompromised patients.
Sinus puncture is an invasive procedure, so it is not done routinely
2.6 MICROBIOLOGY ACUTE BACTERIAI RHINOSINUSITIS
Patients with viral sinusitis develop into acute bacterial infections, this is generally caused by
facultative aerobic bacteria (ie, S. pneumoniae, H. influenzae, and M. catarrhalis).
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Ayu, A. P. M. S. 2020. Analysis of the Effectiveness of Antibiotic Therapy in Acute Bacterial
Rhinosinusitis (Studied of Pediatric and ................
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2.7 ANTIMICROBIAL AGENTS
Initial therapy in patients with infections is often given empirically and guided by clinical
presentations. Antimicrobial agents used are broad spectrum (sometimes in combination with
antimicrobial agents). Empirical therapy is carried out, because microbiological results are not
available in 24 to 72 hours.
2.8 ANTIMICROBIAL RESISTANCE
The mechanism of bacterial resistance to antibiotics:
Genetic of antibiotic resistance:
a. Mutation. Mutations occur due to errors of replication or repair errors from damaged DNA
b. Hypermutators. Some bacterial cells can increase mutations from 10-50 times to 10,000 times.
c. Horizontal gene transfer
d. Transfer of resistant genes from one bacterium to another is called horizontal gene transfer. The
main mechanism of this transfer process is plasmid transfer, transfer with viral media, and transfer
by free DNA.
e. Adaptive mutagenesis. Most mutations occur during the process of cell division, but can also occur
when cells do not divide or divide slowly. Mutations that occur only during the nonlethal selection
phase, are called adaptive mutations.
3. RESEARCH METHODS
3.1 RESEARCH DESIGN
This research is an observational descriptive study and the data will be taken prospectively
(prospective descriptive study). Descriptive research is research that aims to report numbers without
looking for cause-effect relationships.13 This study aims to describe the effectiveness of antibiotic
therapy related to the process of treatment of Acute Bacterial Rhinosinusitis and find out other
alternative antibiotics that can be recommended.
3.2 CHANGE PARAMETERS OF CLINICAL CONDITIONS
3.2.1 Effectiveness of Empirical and Definitive Antibiotic Therapy
The effectiveness of antibiotic therapy in this study was assessed based on parameters
indicating an improvement in clinical condition and no other complications.
Assessment of improvement of clinical conditions based on the decision of the ENT specialist
doctor performed on the 4th day or when the first control patient was in the ENT Poly and on the 7th
day from the start of antibiotic therapy.
3.2.1.1 Empirical Antibiotic Therapy
Empirical antibiotic therapy referred to in this study is the administration of antibiotics to treat
acute bacterial rhinosinusitis before the causative organism is identified and sensitive antibiotics are
determined. The selection of types, dosages and frequency of antibiotics is adjusted to the Clinical
Practice Guidance (PPK) of ENT Poly Haji Hospital Surabaya.
3.2.1.2 Definitive antibiotic therapy
The definitive antibiotic therapy referred to in this study is the administration of antibiotics for
specific microorganisms that cause Acute Bacterial Rhinosinusitis and the sensitivity of known
antibiotics in each patient during the study period.
3.3 POPULATION & SAMPLE
The target population in this study were all patients with Acute Bacterial Rhinosinusitis. The
affordable population in this study were all outpatients with Acute Bacterial Rhinosinusitis who
received empirical and definitive antibiotic therapy at Haji Hospital Surabaya during November 2016 -
January 2017.
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Ayu, A. P. M. S. 2020. Analysis of the Effectiveness of Antibiotic Therapy in Acute Bacterial
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The sampling technique in this study uses total sampling technique, which is one of the non-
probability sampling techniques. Total sampling is a sampling technique where the number of samples
is equal to the population. The recruitment process is carried out until the sampling deadline is over.
3.4 ETHICAL CONSIDERATIONS
The research proposal that has been compiled by researchers has been submitted to Surabaya
Haji Hospital for a review by the Surabaya Haji Hospital Ethics Committee. After going through the
research proposal examination process and obtaining a permit that was signed by the chairman of the
Surabaya Haji Hospital ethics committee, this research could be carried out. Before conducting data
collection, researchers need to provide an explanation to the research subjects regarding the flow of
research, the risks that might occur if participating in the research, the benefits of the study, the
confidentiality of the data taken and explain who can be contacted if there are questions about this
research, then if the subjects are willing In this study, the subjects were asked to sign an informed
consent. There are 2 sheets of informed consent that must be signed by the patient, i.e. the patient
consent information sheet can be seen in appendix 2 and the consent statement sheet. The statement of
consent form can be seen in appendix 3. The statement of consent form form will be signed by the
researcher and the patient's family. Informed consent was made in the form of 2 copies, where 1 sheet
to be submitted to the patient and 1 sheet to the researcher.
3.8 DATA ANALYSIS TECHNIQUE
1. Data Collection
a. Collecting patient database (including medical record number, patient name (with initials), patient
age, gender, date of visit to hospital, history of allergies, diagnosis) and data on the patient's clinical
condition from medical records.
b. Collecting data on empirical antibiotic therapy from medical records or drug use records.
c. Collecting data on the results of bacterial culture and testing its sensitivity to antibiotics from the
Microbiology Laboratory of Surabaya Haji Hospital.
d. Collecting data on definitive antibiotic therapy from medical records or records of drug use that
includes the type, dose and frequency of administration.
e. Collecting research data on effectiveness on day 4 after administration of empirical antibiotics and
day 7 from the start of antibiotic therapy. Recording the effectiveness of antibiotics is done through
observations on improving the clinical condition of patients obtained from medical records.
2. Analysis of the effectiveness of Empirical and Definitive Antibiotics
The effectiveness of empirical and definitive antibiotics can only be analyzed descriptively and
cannot be analyzed statistically because there is only a small amount of available data, if a statistical
test is performed it can be ascertained that the results are biased.
The effectiveness of empirical and definitive antibiotics is assessed based on improvement of
clinical conditions. The effectiveness data will be categorized into 2, namely "effective" and
"ineffective". If the patient experiences an improvement in the clinical condition and the results of the
physical examination reveal that there is an improvement, then the use of antibiotics is considered
effective, but if the opposite occurs, the antibiotics are considered ineffective.
4. RESEARCH RESULT
4.1 Bacterial Sensitivity Pattern Causes Acute Bacterial Rhinosinusitis AgainstAntibiotics
Sensitivity test results obtained include sensitive bacteria (S), intermediates (I) and resistant (R)
to antibiotics. Pseudomonas aeruginosa bacteria analyzed in this study were still sensitive to
Piperacilintazobactam. Antibiotics that are intermediate to Pseudomonas aeruginosa are meropenen and
Piperacilin.
Based on table 4.3, Pseudomonas aeruginosa shows resistance to 14 types of antibiotics.
Resistance is also found in isolates of Enterobacter cloacae, bacteria resistant to penicillin antibiotics
(ampicillin, amoxicillin kalvulanate), cephalosporins (cephazolin) and macrolides (erythromycin,
clindamycin). Enterobacter cloacae is sensitive to 19 types of antibiotics, Staphylococcus aureus is
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Ayu, A. P. M. S. 2020. Analysis of the Effectiveness of Antibiotic Therapy in Acute Bacterial
Rhinosinusitis (Studied of Pediatric and ................
30
resistant to amoxicillin and cefixim antibiotics. whereas Streptococcus haemolyticus is resistant to
oxacillin and colistin.
Table 4.1 Table Percentage of Frequency of Sensitivity of Bacteria in the Result of Maxillary Sinus
Culture on Provision of Antibiotic Therapy
Antibiotik
Pseuomonas
aeruginosa
Staphylococcus
aureus
Streptococcus
haemolyticus
Enterobacter
cloaceae
Susceptible
Amikacin
Gentamycin
Amoxicillin
Ampicillin
Piperacillin
Cephazolin
Cefuroxime
Ceftazidime
Cefotaxime
Ceftriaxone
Cefoperazone
Cefixime
Cefpodoxime
Cefepime
Amoxicilin-
clavulanat
Piperacillin-
tazobactam
Cefoperazone-
sulbactam
Meropenem
Cefoxitin
Astreonam
Cotrimoksasol
Tetrasiklin
chloramphenicol
Erythromycin
Clindamycin
Ciprofloxacin
Ofloxacin
levofloxacin
Vancomycin
Linezolid
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Ayu, A. P. M. S. 2020. Analysis of the Effectiveness of Antibiotic Therapy in Acute Bacterial
Rhinosinusitis (Studied of Pediatric and ................
31
Antibiotik
Pseuomonas
aeruginosa
Staphylococcus
aureus
Streptococcus
haemolyticus
Enterobacter
cloaceae
Intermediate
Amikacin
Gentamycin
Amoxicillin
Ampicillin
Piperacillin
Cephazolin
Cefuroxime
Ceftazidime
Cefotaxime
Ceftriaxone
Cefoperazone
Cefixime
Amoxicilin-
clavulanat
Piperacillin-
tazobactam
Cefoperazone-
sulbactam
Meropenem
Cefoxitin
Astreonam
Cotrimoksasol
Tetrasiklin
chloramphenicol
Erythromycin
Clindamycin
Ciprofloxacin
Ofloxacin
levofloxacin
Vancomycin
Linezolid
Antibiotik
Pseuomonas
aeruginosa
Staphylococcus
aureus
Streptococcus
haemolyticus
Enterobacter
cloaceae
Susceptible
Amikacin
Gentamycin
Amoxicillin
Ampicillin
Piperacillin
Cephazolin
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Ayu, A. P. M. S. 2020. Analysis of the Effectiveness of Antibiotic Therapy in Acute Bacterial
Rhinosinusitis (Studied of Pediatric and ................
32
Cefuroxime
Ceftazidime
Cefotaxime
Ceftriaxone
Cefoperazone
Cefixime
Cefpodoxime
Cefepime
Amoxicilin-
clavulanat
Piperacillin-
tazobactam
Cefoperazone-
sulbactam
Meropenem
Cefoxitin
Astreonam
Cotrimoksasol
Tetrasiklin
chloramphenicol
Erythromycin
Clindamycin
Ciprofloxacin
Ofloxacin
levofloxacin
Vancomycin
Linezolid
Information:
S (Susceptible): A category that shows that bacterial isolates can be inhibited at minimum mineral
concentrations of certain antibiotics
I (Intermediate): A category that shows that bacterial isolates can be inhibited at the minimum
inhibitory concentration of certain antibiotics but with a lower response than sensitive categories
R (Resistant): A category that indicates that bacterial isolates cannot be inhibited at the minimum
inhibitory concentration of certain antibiotics.
4.2. Effectiveness of Empirical and Definitive Antibiotics Prescribed in Patients with Acute Bacterial
Rhinosinusitis
Data on antibiotic effectiveness was obtained from patient medical record data. Data are
presented separately for each empirical antibiotic and definitive antibiotic. Based on the discovery of
germs or not, antibiotic therapy can be divided into two, namely empirical therapy and definitive
therapy.
4.2.1 Effectiveness of Empirical Antibiotics
The selection of empirical antibiotic therapy given to patients with Acute Bacterial
Rhinosinusitis in Haji Hospital Surabaya is based on the Permanent Procedure of Haji Hospital
Surabaya or Clinical Practice Guidelines (PPK) on Procedure for ENT-KL Case 2014-2016. The
effectiveness of empirical antibiotics is assessed at day-to-day visits 4 post-treatment until bacterial
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Ayu, A. P. M. S. 2020. Analysis of the Effectiveness of Antibiotic Therapy in Acute Bacterial
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culture results and sensitivity tests were obtained from the Clinical Microbiology Laboratory of
Surabaya Haji Hospital. The effectiveness data will be categorized into 2, namely "effective" and
"ineffective". If the patient experiences an improvement in clinical condition (inflammation of the sinus
mucosa, secretions and water's radiograph) and the results of the physical examination indicate an
improvement, then the use of definitive antibiotics is considered effective, but if the opposite happens,
then definitive antibiotics are considered ineffective. Clinical success is defined as the resolution or
improvement of signs and symptoms of Acute Bacterial Rhinosinusitis so that no further antimicrobial
therapy is needed; Clinical failure is defined as a lack of improvement or worsening of symptoms of
Aeute Bacterial Rhinosinusitis that requires further antimicrobial therapy.
4.2.2 Effectiveness of Definitive Antibiotics
The selection of definitive antibiotic therapy is based on the results of bacterial culture and
sensitivity tests from the Clinical Microbiology Laboratory of Surabaya Haji Hospital. The examination
of culture in the Microbiology Laboratory of Surabaya Haji Hospital, only included identification of
gram-positive and gram-negative aerobic bacteria, while identification of anaerobic bacteria could not
be done, due to the unavailability of conditions that support the growth of anaerobic bacteria. The
sensitivity test in this study was carried out by the disk diffusion method. Data obtained from the
Microbiology Laboratory of Surabaya Haji Hospital, where the data will include the nature of bacterial
sensitivity, namely: susceptible, intermediate or resistant. This assessment is based on the measurement
of antibiotic inhibition zones on the growth of bacterial culture.
The effectiveness of definitive antibiotics was assessed at the 7th post-treatment visit. If the
patient experiences an improvement in clinical condition (inflammation of the sinus mucosa, secretions
and water's radiograph) and the results of the physical examination indicate an improvement, then the
use of definitive antibiotics is considered effective, but if the opposite happens, then definitive
antibiotics are considered ineffective. Data on the evaluation of definitive antibiotic effectiveness.
5. DISCUSSION
The diagnosis of Acute Bacterial Rhinosinusitis in this case is based on history, physical
examination, transillumination examination and examination of benefits such as radiology with water’s.
Radiology with water shows mucosal thickening or air fluid level in the diseased sinuses. Water's sinus
X-ray projection is useful for evaluating the maxillary sinus.
5.1 PATIENT CHARACTERISTICS
Based on Table 4.1, Acute Bacterial Rhinosinusitis patients were male with 1 patient and 3
female patients. Patients aged <11 years were 2 patients and 2 patients> 50 years. Based on European
Position Paper data on Rhinosinusitis and Nasal Polyps in 2017, age <50 years is the most suffering
from rhinosinusitis. Research by Yoshiurs et al. in Japan 68 sinusitis patients studied, the average age
of most patients at the age of 46 years.11,12
From some of the research data it can be seen that rhinosinusitis is more common in young
adults. This is presumably because paa young adults or productive ages are more likely to be often
exposed to allergens and have been exposed to pollutants for longer periods so that moreover can occur
Acute Bacterial Rhinosinusitis at that age can interfere with its production. The results of this research
have not been able to show the highest proportion of age that can be affected by Acute Bacterial
Rhinosinusitis in RSU Haji Surabaya.
Based on the work in Table 4.1, 2 patients were students, 1 patient worked as a driver and 1
patient was an entrepreneur. In this study found students, because students most often move outside the
home so often exposed to pollutants such as smoke or dust or irritants that can cause mucosal changes
and damage the cilia that can ultimately increase the occurrence of Acute Bacterial Rhinosinusitis.
5.2 BACTERIAL PATTERNS ON SUSTAINARY SPECIMEN SPECIMENS
Based on Table 4.2, examining 10 specimens taken from maxillary sinus, only 4 specimens
showed positive bacterial growth and 6 specimens showed no bacterial growth. The bacteria found are
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gram-negative bacteria (Pseudomonas aeruginoa, Enterobacter cloacae) and gram-positive bacteria
(Staphylococcus aureus, Streptcccus haemlyticus).
Based on data on bacterial patterns and sensitivity at the Surabaya Haji General Hospital for the
period of 2015, the most common bacteria that cause infections are Pseudomonas aeruginoa,
Enterobacter cloacae and Staphylococcus aureus. Infectious Disease Society of America (IDSA), states
the prevalence of dominant pathogens in Maxillary Acute Rhinosinusitis for pediatric and adult patients
(average percentage of specimen) reported before 2000 and in 2010. Indicates that the most frequent
pathogenic bacteria are Streptococcus pneumoniae and Haemophilus influenza, Staphylococcus aureus,
Steptrococcus pyogenes, Enterobacteriacae spp are relatively rare pathogens in acute axillary sinusitis.
The prevalence of negative specimens (absence of bacterial growth) is also relatively frequent in acute
maxiary sinusitis.
5.3 BACTERIAL SENSIVITY
5.3.1 Pattern of Gram Negative Bacteria Sensitivity to Acute Bacterial Rhinosinusitis Against
Antibiotics
In the sensitivity test results of table 4.3, gram-negative bacteria Pseudomonas aeruginosa
showed resistance to more than 6 classes of antibiotics. Pseudomonas aeruginsoa isolate in this study
still shows its sensitivity to Piperacilin tazobactam. Tazobactam complements the work of Piperacilin
by binding to the β-lactamase enzyme so that it permanently causes the β-lactamase enzyme to no
longer be active and cannot interfere with Piperacilin's action. Meropenem and Piperacilin show
intemediate to Pseudomonas aeruginosa. Meropenem is broad spectrum, this class of antibiotics are 3rd
line antibiotics where the first line and second line antibiotics are no longer effective. 16,17,18
One gram-negative bacterial isolate Enterobacter cloacae is sensitive to 19 antibiotics and there is
resistance to 5 anatibiotics including antibiotics Cephazolin, Ampicillin, Amoxicilin Kavulanat,
Erithromycin and Clindamycin. Based on data on bacterial patterns and sensitivity at the Surabaya Haji
General Hospital for the period of 2015, Enterobacter cloacae showed 60% sensitive to Gentamicin,
Amikacin, Nitrofurantoin, Meropenen, Phosphomycin, Piperazilin Tazobactam and Cefoxitin.
5.3.1 Pattern of Gram Positive Bacteria Sensitivity to Acute Bacterial Rhinosinusitis Against
Antibiotics
GRM positive bacterial isolates Staphylococcus aureus showed resistance to amoxicillin and
cefixime antibiotics, resistance that occurs is closely related to the potential occurrence of MRSA
epidemics (Meticillin resistant Staphylococcus aureus). resistant to Oxacillin and Colistin. Resistance
that occurs due to Oxacillin is called anti-Staphylococcus penicillin which has a narrow spectrum
antimicrobial activity.
5.4 ANTIBIOTIC EFFECTIVENESS
5.4.1 Effectiveness of Empirical Antibiotics
All patients in this study received empirical antibiotics of clavulanate moxicillin. The choice of
empirical antibiotics for treating Acute Racterial Rhinosinusitis is outlined in appendix 2, most
guidelines recommend amoxicillin as first-line therapy because of its safety, effectiveness, low cost,
and narrow microbiological spectrum. The results of the effectiveness of using empirical antibiotics are
in Table 4.4. Acute Bacterial Rhinosinusitis patients with bacteria that cause Staphylococcus aureus,
Streptococcus haemolyticus and Enterobacter cloacae against administration of empiric antibiotics of
clavulanate amoxicillin show effective. Patients with bacteria that cause Pseudomonas aeruginosa have
received empirical antibiotic Amoxicillin Clavulanate syr at a dose of 3 x 2 cth. Infectious empirical
antibiotic Disease Society of America (IIDSA) recommends amoxicillin clavulanate better than single
Amoxicillin in children with Acute Bacterial Rhinosinusitis. The recommended high dose of
clavulanate amoxicillin in children is 90 mg / kg / day orally twice a day. Sedian circulating in
Indonesia, namely, Amoxicillin Clavulanate in the form of a syrup, with each 5 ml of syrup containing:
Amoxicillin Trihydrate is equivalent to Amoxicillin 125 mg and Clavulanic Potassium is equivalent to
31.25 mg Clavulanic Acid. Doses can be given 10 ml, 3 x 1. Based on table 4.4 Pseudomonas
aeruginosa against empirical antibiotics Amoxicillin Clavulanate shows treatment failure based on
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Rhinosinusitis (Studied of Pediatric and ................
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clinical conditions and clinical examination. Therefore, the antibiotic Amoxicillin Clavulanate against
Pseudomonas aeruginosa is ineffective.
5.4.2 Effectiveness of Definitive Antibiotics
Based on the results of bacterial sensitivity tests to antibiotics from the Microbiology
Laboratory of Surabaya Hajj Hospital (table 4.3). Sensitive antibiotics are definitive antibiotics that can
be recommended in patients with Acute Bacterial Rhinosinusitis. All patients in this study received the
definitive antibiotic Amoxicillin Clavulanate. The definitive antibiotic given to patients with Acute
Bacterial Rhinosinusitis with the bacteria that causes Staphylococcus aureus is to continue the
empirical antibiotic therapy of amoxicillin clavulanate 3 x 2 cth. Provision of definitive antibiotic
Amoxicillin Clavulanate is combined with physiotherapy therapy. The duration of clavulanate
amoxicillin antibiotic therapy is 14 days. In this case after the management of definitive antibiotic
Amoxicillin Clavulanate with physiotherapy showed improvement in clinical conditions. In this case
the definitive antibiotic Amoxicillin Clavulanate is effective. Research conducted by Eli Hosoien et all.
find out whether there is a difference between the effects of ultrasonographic exposure and antibiotic
therapy (amoxicillin) on pain and short-term Acute Bacterial Rhinosinusitis congestion. The
experimental group received 4 days consecutive ultrasonographic therapy and the control group
received 10 days consecutive antibiotic therapy. Once entered day 4, pain around the nose decreased by
1.5 in from 10 (95% CI 0.6-2.5) more in the experimental group than in the control group. There were
no other differences in pain reduction and congestion between groups on day 4 or day 21. The results of
this study indicate that ultrasonographic therapy is an alternative to antibiotic therapy in the
management of Acute Bacterial Rhinosinusitis. Ultrasound intensity increases the antibiotic
bactericidal action of bacteria in vitro and in vivo, including Planktonic bacteria, Biofilm bacteria,
Chlamydia, and bacteria in the implant. This literature shows that low intensity ultrasound alone is not
effective in killing bacteria, whereas the combination of low intensity ultrasound and antibiotics is
promising.
Acute Bacterial Rhinosimusitis patients with bacteria that cause Streptococcus haemolyticus
have improved clinical conditions. The results of sensitivity culture test, obtained Amoxicillin
Clavulanate is sensitive to Streptococcus haemolyticus, therefore, the definitive antibiotic Amoxicillin
Clavulanate in this case is effective. The patient received the definitive antibiotic Amoxicillin
Clavulanat which was not in accordance with the results of the bacterial sensitivity test to the antibiotic.
The incompatibility of this definitive antibiotic was deciphered because the culture results and the
sensitivity test from the Microbiology Laboratory of Surabaya Haji Hospital were only obtained on the
fifth day or after the patient had done control. Laboratory results show that Amoxicillin Clavulanate is
resistant to Enterobacter cloacae. Evaluate the patient's clinical condition for 6 days after receiving the
Amoxicillin Clavulanate antibiotic, which is an improvement in the clinical condition. Improvement of
clinical conditions is not in accordance with the results of the microbiology laboratory. Antibiotics are
anti-prosthetic substances produced by various species of microorganisms that can suppress growth and
or kill other microorganisms. However, this case shows that Amoxicillin Clavulanate has been resistant
to Enterobacter cloacae. Evaluation of clinical conditions was assessed based on history, physical
examination, transillumination examination and supporting examinations such as radiology with
Water's X-ray sinus projection Waters in this case performed Acduakalinya useful for evaluating the
maxillary sinus. Photographs show a normal sign on the sinus that is, there is no limit of air fluid (water
una level) in the sinus. Comparison of the Pehlama Waters projection sinus X-rays and the two covered
a significant difference.
Definitive antibiotics that can be recommended in the case of Pseudomonas, namely sensitive
antibiotics (Piperacilin-Tazobaktam) and intermediate antibiotics (Piperacilin and Meropenem).
However, Piperacilin Tazobaktam and Piperacilin Antibiotics cannot be used in this case. Antibiotics
Piperacilin and Piperacilin Tazobaktam are the same class of antibiotics. If Piperacillin is intermediate,
there is a risk of resistance to Piperacillin Tazobaktam in this case. Meropenem is an intermediate
antibiotic, it also worries clinicians to give antibiotics the last choice that can be given to patients.
Therefore, clinicians take action that can be done in improving the clinical condition of the patient that
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Ayu, A. P. M. S. 2020. Analysis of the Effectiveness of Antibiotic Therapy in Acute Bacterial
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is planned to be carried out Functional Endoscopic Minus Surgery (BSEF) while still considering
giving
Amoxicillin Clavulanate antibiotics. Therefore, the definitive antibiotic Amoxicillin
Clavulanate in this case does not match the results of the sensitivity test and is not effective.
5.5 ALTERNATIVE ANTIBIOTIC THERAPY
From the results of this research we can see that the most widespread spread and has a fairly
high sensitivity test result is levofloxacin. Based on the IDSA Guideline, levofloxacin is an antibiotic
recommended in patients with Acute Bacterial Rhinosinusitis. Concerned for antibiotic resistance or
failure of initial therapy or the occurrence of severe infections that do not require hospitalization and no
beta-lactam allergy, then recommendations that can be given are other antibiotics with a better
sensitivity percentage than Amoxicillin-Klavulanate namely Levofloxacin.
5.6 LIMITATIONS OF RESEARCH
Researchers have tried to carry out this research well, but of course there are still limitations in
this study, namely:
a. The number of research samples is small, if more samples are obtained then the results of this study
will better be able to describe the real condition of the patient population of Acute Bacterial
Rhinosinusitis.
b. The limited number of isolates used to make antibiograms, so the sensitivity pattern of bacterial
culture results to antibiotics in this study can only be used as an illustration only.
6. CONCLUSION
After conducting research for 3 months at Surabaya Haji Hospital, it can be concluded that the
administration of antibiotic Amoxicillin Clavulanate is effective for use as a therapeutic treatment for
Acute Bacterial Rhinosinusitis.
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