There is published evidence that nasal irrigations and lavage solutions that contain antibiotics or antifungals exhibit a benefit for the user in the eradication of certain bacteria and fungi. These delivery methods have also been observed to help eliminate infections that are in the presence of biofilms in the nasal passages and sinus cavities. I have cited one relatively recent publication on this issue.
ANTIBIOTICS IN SINUS LAVAGE
The antibiotics most commonly added to the irrigation solutions are cindamycin (1mg/ml, in a 1,000ml bottle) and tobramycin (0.2mg/ml, in a 1,000ml bottle). Some have ordered gentamicin, but tobramycin remains the dominant aminoglycoside. These irrigation solutions are compounded in our lab using sterile normal saline.
ANTIFUNGAL IN SINUS LAVAGE
We also make antifungal solutions of amphotericin (100mcg/ml or 200mcg/ml in 1,000ml bottles). It is important to remember that amphotericin looks like a yellow solution. In fact, it is a micro-suspension. Some pharmacists filter the sterile amphotericin before adding it to the sterile irrigation solution. This is wrong. Some of the yellow color may pass through, but the sterilizing filtration actually removes some of the antifungal product. It is important that a prescriber know how the pharmacist makes this preparation. Amphotericin lavage is made in sterile water, NOT saline.
The antibiotics and antifungal preparations have potential serious side effects. However, the lavage and removal of the solution (suspension) shouldn't allow for systemic absorption to the extent where the side effects would be a problem. However, the prescribe and patient must understand that the serious side effects are possible if sufficient amounts of the active are absorbed into the systemic circulation.
We include written warnings about potential side effects with each bottle dispensed.
ADMINISTRATION OF SINUS LAVAGE
Each bottle is dispensed with a NASALINE irrigating syringe. We demonstrate the device and proper handling of the solutions to each customer. We also provide a detailed information sheet that supports the instructions we offered at our pharmacy. Our pharmacists are always available for phone consultation during our normal business hours.
STABILITY & STERILITY
These preparations are chemically stable in water for several weeks. However, we assign a 14-day dating to each bottle because of the risk of contamination once they leave our pharmacy. The user is instructed to keep the solution in the refrigerator and only remove the amount needed for each administration. They are warned to NOT return unused solution to the original bottle of solution.
Nasal Sinus Lavage
Journal of Antimicrobial Chemotherapy, doi:10.1093/jac/dkm087
Evaluation of the in vivo efficacy of topical tobramycin against Pseudomonas sinonasal biofilms
Alexander G. Chiu*, Marcelo B. Antunes, James N. Palmer and Noam A. Cohen
Division of Rhinology, Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, USA
Conclude: This is the first report to examine the effects of topical medications on sinonasal bacterial biofilms. Scanning Electron Microscopy (SEM) has proven to be a valuable tool to identify biofilms, but further research techniques are needed to provide in vivo quantification of biofilm response to therapy.