Chronic Rhinosinusitis with Nasal Polyps in Pregnancy: Management of Antibiotic-Resistant Bacterial Colonization

Case at a Glance

A 35-year-old pregnant woman at 28 weeks gestation with a history of aspirin-exacerbated respiratory disease (AERD) and chronic rhinosinusitis with nasal polyps presents with persistent sinus symptoms despite multiple antibiotic courses. Sinus culture revealed Staphylococcus capitis with multidrug resistance, raising questions about treatment necessity and safety during pregnancy.

Patient's Story

The patient, a 35-year-old woman with known AERD and history of multiple sinus surgeries for recurrent nasal polyps, presented with a year-long history of sinus infection symptoms. She was currently 28 weeks pregnant and taking levothyroxine, prenatal vitamins, and Dupixent for chronic rhinosinusitis with nasal polyps. She had documented allergies to sulfa medications and aspirin/NSAIDs. Over the past year, she had received four courses of antibiotics (augmentin twice, doxycycline, and cefdinir) without symptom improvement. The patient reported that her symptoms had worsened after a period of insurance-related interruption in her Dupixent therapy the previous year, which led to return of nasal polyps and development of the current infection. She described copious green drainage specifically from the right maxillary sinus, while the left side remained clear.

Initial Assessment

Physical examination by the ENT specialist revealed no visible nasal polyps, consistent with effective Dupixent therapy. The patient's left nasal cavity appeared clear, while the right side showed evidence of ongoing infection with purulent drainage. Given the persistent symptoms despite multiple antibiotic courses and the patient's complex medical history including pregnancy, the ENT decided to obtain a culture to guide targeted therapy.

The Diagnostic Journey

Sinus culture was performed, which grew Staphylococcus capitis with resistance to multiple antibiotics. The culture results prompted concern about treatment options during pregnancy, leading to referral to infectious disease specialists. The findings raised questions about the clinical significance of the cultured organism and appropriate management strategies in the pregnant patient.

Final Diagnosis

The case presented a diagnostic challenge regarding the clinical significance of Staphylococcus capitis colonization versus true infection. Infectious disease consultation revealed that S. capitis is typically a commensal organism and coagulase-negative staphylococci are generally not considered pathogenic in sinus cultures. The patient's symptoms were more likely related to her underlying chronic rhinosinusitis with nasal polyps and the disruption in her anti-inflammatory therapy rather than a true bacterial infection requiring antimicrobial treatment.

Treatment Plan

Based on infectious disease evaluation, antimicrobial therapy was not recommended as the cultured organism was likely representing normal flora rather than a pathogenic infection. The treatment plan focused on: 1) Continuation of Dupixent therapy for polyp control, 2) Daily sinus irrigations with mupirocin ointment for symptom management, 3) Close monitoring throughout pregnancy, 4) Coordination with obstetrics team for pregnancy management considerations.

Outcome and Follow-up

The patient was educated about the non-pathogenic nature of the cultured organism and the importance of avoiding unnecessary antibiotic exposure during pregnancy. She continued with conservative management including daily sinus rinses and maintenance of her Dupixent therapy. The case highlighted the importance of proper interpretation of culture results and the risk of overtreatment of colonizing organisms, particularly in the setting of pregnancy where medication risks require careful consideration.