Outcome Of Acute Otitis Media Research Articles

Characteristics and Outcomes OF Acute Otitis Media in Children Carrying Streptococcus Pneumoniae or Haemophilus Influenzae in Their Nasopharynx as a Single Otopathogen After Introduction of the Heptavalent Pneumococcal Conjugate Vaccine

After PCV7 implementation, clinical characteristics were investigated in 832 young children with acute otitis media, carrying a single S. pneumoniae or H. influenzae in their nasopharynx. As compared with H. influenzae, S. pneumoniae-associated acute otitis media was less frequently associated with treatment failure (odds ratio = 0.5; 95% confidence interval: 0.36-0.83) and recurrence (odds ratio = 0.4; 95% confidence interval: 0.22-0.75). Post-PCV7 serotype replacement seemed not to affect the acute otitis media characteristics in these children.

Impact of Pneumococcal Conjugate Vaccines on Microbial Epidemiology and Clinical Outcomes of Acute Otitis Media

Acute otitis media (AOM) is the leading bacterial infection in childhood and the main reason for antibiotic prescriptions in children. The success of pneumococcal conjugate vaccines (PCVs) in reducing invasive pneumococcal disease has been demonstrated in many studies. Because Streptococcus pneumoniae is one of the two main bacterial species implicated in AOM, the incidence and characteristics of AOM might also be modified by PCVs. Pre-licensure controlled studies showed that the effect was modest. However, after PCV7 implementation, the impact on the AOM burden appeared to be more marked, despite the fact that serotype replacement in the nasopharynx was almost complete. Most data on the impact of PCVs on nasopharyngeal flora have been drawn from studies with PCV7. No difference was observed with PCV10 compared with PCV7 concerning S.pneumoniae and Haemophilusinfluenza carriage. For PCV13 compared with PCV7, additional reduction of carriage of serotypes 1, 6A, 7F, 6C, 19A, and 19F was observed, but for the other serotypes, the two PCVs seemed to have the same effect.

Clinical features and outcome of acute otitis media in early infancy

Acute otitis media (AOM) is common in childhood, but little is known on its course very early in infancy. In this study we investigated predisposing factors, clinical characteristics, and long-term outcomes of AOM in very young infants. One hundred sixty infants aged less than 12 months with AOM hospitalized in two general hospitals during 2005-2006 were included in the study and followed-up for 3 years. Demographics, history, clinical manifestations, and further AOM episodes were studied in two infant groups defined by age at the first AOM episode: the very young infants, aged less than 60 days, and the older infants aged 61-365 days. Of the 147/160 infants successfully followed-up, 48 (32.7%) were aged less than 60 days and 99 (67.3%) were aged 61-365 days. The very young infants with AOM had more siblings (1.25 vs. 0.87; p=0.047) and used pacifiers less often (45.8% vs. 75.8%; RR 0.61, 95% CI 0.44-0.84; p=0.0007). Purulent otorrhea and irritability were more common in the early AOM onset group (52.1% vs. 32.3%; risk ratio (RR) 1.61, 95% confidence interval (CI) 1.09-2.39; p=0.03, and 60.4% vs. 38.4%; RR 1.57, 95% CI 1.12-2.21; p=0.01, respectively). AOM was complicated with meningitis in two infants, both in the very young group, and with mastoiditis in a further two infants, one in each group. No difference in further AOM episodes, use of ventilation tubes, or hearing impairment was observed between the two infant groups. AOM in the first 2 months of life may have different predisposing factors and clinical presentations, but not different recurrence rates or long-term outcomes.

Burden and outcome of acute otitis media in children aged under 2 in rural Bangladesh

Objectives. To report on the burden and outcome of episodes of acute otitis media (AOM) based on awareness of AOM and compliance to referral by community health workers (CHWs) in rural children aged under 2 in Bangladesh. Study design. Retrospective population-based cohort study. Method. Secondary data analysis on episodes of AOM, care-seeking pattern, compliance with referral, antibiotic use and duration of episodes from morbidity data collected by CHWs on 252 children aged under 2 who completed biweekly household surveillance starting from birth. Results. A total of 375 episodes of AOM were observed in 45.6% (115/252) of the study subjects; 19.4% (49/252) experienced single and 26.2% (66/252) recurrent episodes. Just over 34% (129/375) of episodes were recognised by caregivers and reported to CHWs, and the remaining 246 episodes, unrecognised by caregivers, were detected by CHWs during home visits. CHWs referred all subjects with AOM to the study doctor. The caregivers complied with referral in all episodes they had recognised, but in only 21.5% (53/246) of episodes they had not recognised (p<0.0001). Compliance was best among caregivers of babies in the first 3 months of life. Resolution occurred in 95.0% (356/375) of acute episodes of AOM in ≤6 weeks, comprising 176/182 of antibiotic-treated and 180/193 of untreated episodes (p<0.13). Five per cent of episodes (19/375) progressed to chronic suppurative otitis media (CSOM). Doctor visits resulting in antibiotic use resulted in a 51% lower progression to CSOM (relative risk 0.49, 95% confidence interval 0.19 - 1.26). Conclusion. AOM in rural children aged under 2 in Bangladesh is a disease of public health importance. Early assessment, community awareness of AOM intensified by motivational activities, and increased compliance with referral to the doctor in caregiver-unreported cases may help to decrease morbidity and burden from the disease.

Spontaneously draining acute otitis media in children: An observational study of clinical findings, microbiology and clinical course

To study the outcome of acute otitis media (AOM) with otorrhoea in children managed initially without antibiotics, in relation to bacterial and clinical findings, and to identify those who may benefit from antibiotics. Otherwise healthy, not otitis prone children aged 2-16 y, presenting with AOM with spontaneous otorrhoea, were recruited from primary care and followed at selected ear, nose and throat (ENT) clinics. Specimens for bacterial investigations were obtained; symptoms were registered on a daily basis. The main outcomes measured were the frequency of children treated with antibiotics due to persisting AOM within 9 days in relation to clinical and bacteriological findings, and new AOM within 3 months. Twelve of 71 children who completed the trial received antibiotics during the first 9 days due to lack of improvement. One received antibiotics after 16 days due to relapsing AOM and 6 received antibiotics after 30 days due to new AOM. At 2-4 days following inclusion, over 70% of children showed normalized eardrum status and markedly reduced secretion. Alloiococcus otitidis was found in 23 samples, Streptococcus pneumoniae in 12, Streptococcus pyogenes in 6, and Fusobacterium nucleatum in 5. Mycoplasma pneumoniae, Chlamydia pneumoniae, and Fusobacterium necrophorum were not detected. Antibiotics were prescribed more extensively to children with a pulsating eardrum and abundant purulent secretion. All children with S. pyogenes received antibiotics, whereas children with only A. otitidis did not. The results suggest that antibiotics are indicated in AOM with otorrhoea and the presence of abundant purulent secretion, a pulsating eardrum, or the presence of S. pyogenes. The presence of only A. otitidis was not associated with a more prolonged course or the need for antibiotics.

Treatment outcome of acute otitis media in children treated with the newly released guideline in Japan

Treatment outcome of acute otitis media in children treated with the newly released guideline in Japan

Effectiveness of Centers for Disease Control and Prevention Recommendations for Outcomes of Acute Otitis Media

Effectiveness of Centers for Disease Control and Prevention Recommendations for Outcomes of Acute Otitis Media

Effectiveness of Centers for Disease Control and Prevention Recommendations for Outcomes of Acute Otitis Media

To determine whether we could increase adherence to the Centers for Disease Control and Prevention (CDC) recommendations with well-accepted approaches to improving quality of care and adherence to the CDC recommendations resulted in improved outcomes for acute otitis media (AOM). A cluster randomization study was conducted in 12 pediatric practices (6 intervention and 6 control sites). The main outcome measures were adherence to the CDC recommendations (modified to include 2 additional antimicrobial agents) and a subsequent antibiotic prescription for AOM within 30 days after diagnosis. Of 3152 patients referred to research assistants, 2584 (82%) were eligible. Of those eligible, 1368 (99%) of 1382 at the intervention sites and 1138 (99%) of 1146 at the control sites consented to participate. Rates of adherence to the CDC recommendations were not significantly higher at the intervention sites than at the control sites, for initial enrollment episodes (78.2% vs 70.6%) or second episodes (62.6% vs 59.9%). After controlling for clustering according to site and covariates, children who were not treated in adherence to the CDC recommendations for both episodes had 1.60 times the odds of a subsequent prescription within 12 days, compared with those treated in adherence at both episodes. Despite using evidence-based approaches that are known to influence physician behavior, we were unable to increase adherence to the CDC recommendations for treatment of AOM. However, we did establish that prescription of antimicrobial therapy consistent with the CDC recommendations for a second episode of AOM was associated with improved outcomes, measured as the need for subsequent antibiotic prescription. Because of the selection of resistant otopathogens, adherence to the CDC recommendations is likely more important in subsequent episodes of AOM than in the initial episode.

Matrix metalloproteinases and their inhibitors in non-neoplastic otorhinolaryngological disease

Matrix metalloproteinases (MMPs) are a family of zinc and calcium-dependent endopeptidases that play a key role in extracellular matrix (ECM) degradation. MMPs are known to be important in normal remodelling processes. Overexpression and activation of MMPs or an imbalance of active MMPs and tissue inhibitors of metalloproteinases (TIMPs) has been linked with a number of specific disease states associated with the breakdown and remodelling of the extracellular matrix. MMPs and TIMPs play a role in the development and progression of conditions such as acute and chronic otitis media, nasal polyposis and Sjogren's disease of salivary glands. Their role in allergic rhinitis has not been proven although they do appear to have a role in asthma, a condition closely linked to rhinitis. The use of a broad spectrum MMP inhibitor has been shown to alter the outcome of acute otitis media and otitis media with effusion. Therapeutic strategies with anti-MMP molecules are currently being developed and may play a role in modulating the course of non-neoplastic otorhinolaryngological disease in the future.

A randomized, placebo-controlled trial of the effect of antihistamine or corticosteroid treatment in acute otitis media

Objectives To determine whether the adjunctive drugs antihistamine and corticosteroid improve immediate and long-term outcomes of acute otitis media (AOM).Study design Children with AOM (3 mos-6 y) were enrolled in a randomized, double-blind, placebo-controlled trial. All 179 children received one dose of intramuscular ceftriaxone and were assigned to receive either chlorpheniramine maleate (0.35 mg/kg/d) and/or prednisolone (2 mg/kg/day) or placebo for 5 days. Main outcome measures were rate of treatment failure during the first 2 weeks, duration of middle ear effusion, and rate of recurrences of AOM to 6 months.Results Clinical outcomes and recurrence rates did not differ significantly with treatment. Children who received antihistamine alone had significantly longer duration of middle ear effusion (median, 73 days) than subjects in other treatment groups (median, 23 to 36 days, P=.04). Temporary normalization of tympanometric findings on day 5 occurred more frequently in the corticosteroid-treated group (P=.04).Conclusions Five-day treatment with antihistamine or corticosteroid, in addition to antibiotic, did not improve AOM outcomes. Antihistamine use during an acute episode of OM should be avoided, since the drug may prolong the duration of middle ear effusion. The efficacy of 7- to 10-day treatment of AOM with corticosteroid, in addition to antibiotic, deserves further investigation.

Mechanisms of resistance to macrolides and lincosamides: nature of the resistance elements and their clinical implications.

Resistance to macrolides and lincosamides is increasingly reported in clinical isolates of gram-positive bacteria. The multiplicity of mechanisms of resistance, which include ribosomal modification, efflux of the antibiotic, and drug inactivation, results in a variety of phenotypes of resistance. There is controversy concerning the clinical relevance of in vitro macrolide resistance. Recent data, however, have shown that eradication of bacteria correlates with clinical outcome of acute otitis media in children and that macrolide therapy results in delayed eradication of macrolide-resistant pneumococci. These results support the need for in vitro detection of macrolide resistance and correct interpretation of susceptibility tests to guide therapy.

Outcome of Acute Otitis Media and its Relation to Clinical Features and Nasopharyngeal Colonization at the Time of Diagnosis

Outcome of Acute Otitis Media and its Relation to Clinical Features and Nasopharyngeal Colonization at the Time of Diagnosis

Outcome of Acute Otitis Media and its Relation to Clinical Features and Nasopharyngeal Colonization at the Time of Diagnosis

Children ( n = 115; age range 1-9 years) with a diagnosis of acute otitis media (AOM) were eligible for this study and were enrolled within 24 h of the onset of symptoms signs. A nasopharyngeal culture was obtained at the initial visit. Children were treated with a single oral antibiotic for 7 days. Changes in symptoms signs and tympanic membrane features assessed by a scoring system were monitored for 1 month and related to the nasopharyngeal pathogen recovered on Day 1. More than 80% of children had no symptoms signs by Day 3, and 60% of cases had normal tympanic membranes by Day 29. Children without any symptoms signs on Day 3 had significantly lower symptom sign scores on Day 1 ( p = 0.005). Seventy-nine percent of cases carried middle ear pathogens in the nasopharynx at diagnosis: Streptococcus pneumoniae (48%); Haemophilus influenzae (24%); and Moraxella catarrhalis (16%). Children with S. pneumoniae showed significantly higher tympanic membrane scores than children with no pathogen at Days 8, 15 and 29 ( p < 0.01 for each comparison). Multivariate regression analysis revealed that lower tympanic membrane score on Day 1, the absence of S. pneumoniae in the nasopharynx and treatment with amoxillin were independent factors for rapid normalization of the tympanic membrane. These data suggest that the clinical course of AOM may be predicted, in part, at the time of diagnosis by means of careful evaluation of symptoms signs and the tympanic membrane as well as knowledge of pathogens harbored in the nasopharynx.

Prognosis of Acute Otitis Media: Factors Associated with Poor Outcome

Factors associated with poor outcome of acute otitis media (AOM) were analysed in 131 children aged 1/4 to 7 1/2 (median 21/2) years. After AOM, altogether 37 (28%) of the children had poor outcome: 15 children (12%) clinical failure (unimprovement or worsening of pre-treatment signs and symptoms within 2 weeks of onset of therapy) and 31 (24%) persistent middle ear effusion (MEE) 1 month post-treatment. Of the different variables studied in multivariate analysis, age <2 years (p <0.01), history of allergic skin or respiratory symptoms (p =0.02), 6 h duration of pre-treatment earache (p =0.01) and B. catarrhalis in MEE (p = 0.05) were associated with clinical failure. Children with previous adenotomy or unilateral AOM had no failures. Persistence of MEE at 1 month was associated with age < 2 years (p = 0.05), otitis proneness (p = 0.03), bilaterality of AOM (p < 0.01) and S. pneumoniae in MEE (p = 0.01) in univariate but not in multivariate analysis.

Outcome of acute otitis media with abnormal tympanometric patterns in children.

To assess the ability of ED tympanometry to identify those children with acute otitis media who are at greater risk for treatment failure, recurrent infection, or persistent middle ear effusion. A prospective observational study was performed in the EDs of a county hospital and a university medical center. One hundred seventeen children, aged 5 months to 5 years, with acute otitis media and abnormal tympanometric patterns were categorized into three groups--low compliance, high pressure, and low pressure--based on the initial patterns. All the children received oral amoxicillin for ten days. They had repeat tympanometry and otoscopy at 14- and 60-day follow-up visits, and were followed to determine clinical outcomes. Initial treatment success was equivalent for all groups: low compliance 93% (95% confidence interval 81%-97%), high pressure 91% (95% CI 71%-98%), low pressure 89% (95% CI 59%-99%). Rates of relapse, reinfection, 90-day non-recurrence, and persistent otoscopic and tympanometric middle ear effusion did not differ significantly between groups. ED tympanometry of children with acute otitis media is unable to provide prognostic information regarding treatment failure, recurrent infection, or persistent middle ear effusion.

Effect of patient characteristics and disease manifestations on the outcome of acute otitis media at 2 months.

Optimal therapy for acute otitis media (AOM) is controversial and there is no consensus regarding which antibiotic to use, how long to administer it, or whether antibiotics are effective at all. Knowledge of the effects of patient characteristics and disease manifestations is needed to individualize treatment and to evaluate large-scale trials. Data originated from 2251 patients with AOM, aged newborn to 15 years, who participated in a prospective primary care study in eight countries. At the initial visit, medical history, symptoms, physical findings, and treatment data were recorded. Follow-up 2 months later identified changes in treatment and outcome. Patients younger than 13 months were less likely to have recovered than those aged 13 months to 15 years (P = .05). Using univariate analysis for infants aged 12 months or younger, male sex, prior episodes of AOM, and serous otitis media were associated with poor outcome. For older patients, poor outcome was associated with initial history of ear tubes, prophylactic antibiotic use, ear discharge, decreased hearing, serous otitis media; and past episodes of AOM; the symptom of decreased hearing; and the finding of pus exuding from the tympanic membrane. Using multivariate analysis for infants aged 12 months or younger, a history of serous otitis media (odds ratio [OR], 2.3; 95% confidence interval [CI], 0.95-5.7), past episodes of AOM (OR, 1.9; 95% CI, 0.82-4.5), and male sex (OR, 1.7; 95% CI, 1.0-3.0) made independent contributions to poor outcome. For children aged 13 months to 15 years, significant variables included pus drainage (OR, 2.2; 95% CI, 1.5-3.3), a history of ear tubes (OR, 2.3; 95% CI, 1.5-3.6), past episodes of AOM (OR, 1.8; 95% CI, 1.3-2.34), and a history of serous otitis media (OR, 1.4; 95% CI, 1.0-1.9). Patient characteristics and disease manifestations are significant determinants of AOM outcome.

Effect of viral respiratory tract infection on outcome of acute otitis media

We prospectively studied 271 infants and children (2 months to 7 years of age) with acute otitis media (AOM) for viral and bacterial causes, outcome at the end of therapy, and frequency of recurrence within 1 month. Comprehensive virologic methods, including viral antigen detection, cell culture, and serologic studies, were used to diagnose viral infection of the respiratory tract, middle ear, or both. Evidence of viral infection was found in 46% (124/271) of patients with AOM. Sixty-six patients (24%) had virus or viral antigen in the middle ear fluid; 50 of these patients (76%) also had bacteria in middle ear fluid, and 16 (24%) had virus alone. More patients with AOM and combined bacterial and viral infection (51%) had persistent otitis (3 to 12 days after institution of antibiotic treatment), compared with those with only bacterial otitis (35%; p = 0.05) or patients with only viral infection (19%; p less than 0.01). Of patients with only viral infection, 4 of 10 with virus in middle ear fluid had persistent otitis, compared with none of 11 patients who had virus only in nasal wash specimens or whose viral infection was diagnosed only by serologic studies. Our data suggest that viruses interact with bacteria and that concurrent viral infection can significantly worsen the clinical course of bacterial AOM. The presence of virus in middle ear fluid may contribute to the pathogenesis and outcome of bacterial AOM. The mechanism of these interactions deserve further investigation.

Acute Otitis Media in Human Immunodeficiency Virus-Infected Children

To evaluate the occurrence and outcome of acute otitis media (AOM) in human immunodeficiency virus (HIV)-infected children, a prospective comparative cohort study was performed. Twenty-seven HIV-infected children were individually matched with paired control subjects and followed up for 543 months (mean 19.4 +/- 11). Data collected were evaluated considering HIV-infected children both as a whole and as P1 and P2 patients according to Centers for Disease Control classification. During the observation period, 46 episodes of AOM were diagnosed in 15 HIV patients and 22 in 16 control children: 11 P1 had 27 AOM episodes vs 17 in 13 control children; 6 P2 had 19 AOM episodes vs 5 in 4 control children. Human immunodeficiency virus infection does not seem to modify the occurrence of AOM. Recurrent AOM (3 or more episodes in 6 months) was, however, significantly more common in P2 children. Amoxicillin, to which the bacteria isolated in P2 children were sensitive in vitro, cured 33 of 46 episodes in HIV-infected children compared with 20 of 22 in control children. Cure rate was similar in P1 children compared with control children but was significantly lower in P2 versus control children (47.3% vs 100%). Reasons for higher occurrence of failures in P2 children remain to be investigated.

Cellular Events in Relation to Bacteria-specific Antibodies in Middle Ear Effusion during Acute Otitis Media

The proportions of neutrophils and lymphocytes, the total number of viable lymphocytes and their spontaneous proliferating activity as well as the proportion of B-cells were determined in 238 middle ear effusion (MEE) samples from 124 ears and in 40 serum samples of 85 children in relation to the presence of bacteria-specific antibodies in MEE and the clinical outcome of acute otitis media (AOM) during the course of AOM. The percentage of lymphocytes was higher, and that of the neutrophils lower, in the ears with bacteria-specific antibodies than in the ears with no antibodies. The higher proportion of MEE lymphocytes and the presence of antibodies correlated to the faster resolution of AOM. Moreover, the total number of viable lymphocytes and the proliferating activity of these cells were related to the presence of specific antibodies in MEE. The findings of this study underline the importance of local mucosal immunity taking place in the middle ear in connection with bacteria-specific antibodies in resting AOM.

The outcome of acute otitis media. (A report to the Medical Research Council).

The outcome of acute otitis media. (A report to the Medical Research Council).