Twice-daily antibiotics in the treatment of acute otitis media: trimethoprim-sulfamethoxazole versus amoxicillin-clavulanate.

Twice-daily trimethoprim-sulfamethoxazole has been shown to be effective in the treatment of acute otitis media except that caused by group A beta-streptococci. Amoxicillin-clavulanate potassium is effective in vitro against all bacterial pathogens causing acute otitis media and has been reported to be effective when given twice daily for urinary tract infections, acute otitis media and respiratory tract infections. To determine whether the in-vitro efficacy of amoxicillin-clavulanate carries over clinically, we conducted a prospective randomized double-blind trial in 219 children presenting at a pediatric walk-in clinic. Diagnosis and follow-up assessments were made by means of examination of the tympanic membrane and acoustic otoscopy. Of the 219 children 202 (101 in either group) were assessed by a specially trained nurse at a follow-up visit 12 to 16 (mean 14) days after treatment was begun. Cure was defined as absence of symptoms and normal results of both visual inspection of the tympanic membrane and acoustic reflectometry; improvement was defined as absence of symptoms and either normal appearance of the tympanic membrane or normal results of acoustic reflectometry; treatment failure was defined as abnormal appearance of the tympanic membrane along with an acoustic reflectometry reading of 5 units or more. There were no differences in age (mean 60 months), sex or proportion of subjects with unilateral versus bilateral disease between the two groups. The combined rate of cure an improvement was significantly higher with trimethoprim-sulfamethoxazole (93%) than with amoxicillin-clavulanate (82%) (p = 0.03). The rate of compliance (more than 80% of the drug taken) did not differ significantly between the two groups. Gastrointestinal side effects were more common with amoxicillin-clavulanate (p less than 0.0001). Our results suggest that for acute otitis media twice-daily trimethoprim-sulfamethoxazole is more effective clinically and produces fewer side effects than twice-daily amoxicillin-clavulanate.     

Acute otitis media: clinical course among children who received a short course of high dose antibiotic.

A prospective study was carried out in 274 children aged 3 to 10 years with acute otitis media. They were randomly allocated to one of two treatment regimens: (a) a seven day course of amoxycillin 125 mg three times a day, and (b) a two day course of amoxycillin 750 mg twice a day. They were followed up by symptom diaries and clinical examination. The findings in the 243 children who completed the trial showed that the short course of treatment was as effective as the seven day course in the speed of resolution of symptoms and signs, irrespective of previous history of otitis media or of episodes in which bulging of the eardrums was observed at presentation. A subgroup of 185 children was followed up for one year after entry to the trial. During this period no appreciable differences emerged between the two antibiotic regimens, either in recurrence rate of otitis media or in the frequency of hearing loss at one month and six months after entry to the study. Side effects of treatment were few, and those that could be attributed to antibiotic use occurred with equal frequency in the two treatment groups.     

Xylitol chewing gum in prevention of acute otitis media: double blind randomised trial.

OBJECTIVE: To examine whether xylitol, which reduces the growth of Streptococcus pneumoniae, might have clinical importance in the prevention of acute otitis media. DESIGN: A double blind randomised trial with xylitol administered in chewing gum. SETTING: Eleven day care nurseries in the city of Oulu. Most of the children had had problems with recurrent acute otitis media. SUBJECTS: 306 day care children: 149 children in the sucrose group (76 boys; mean (SD) age 4.9 (1.5) years) and 157 in the xylitol group (80 boys; 5.0 (1.4) years). INTERVENTION: Either xylitol (8.4 g a day) or sucrose (control) chewing gum for two months. MAIN OUTCOME MEASURES: The occurrence of acute otitis media and antimicrobial treatment received during the intervention and nasopharyngeal carriage of S pneumoniae. RESULTS: During the two month monitoring period at least one event of acute otitis media was experienced by 31/149 (20.8%) children who received sucrose compared with 19/157 (12.1%) of those receiving chewing gum containing xylitol (difference 8.7%; 95% confidence interval 0.4% to 17.0%; P = 0.04). Significantly fewer antimicrobials were prescribed among those receiving xylitol: 29/157 (18.5%) children had at least one period of treatment versus 43/149 (28.9%) (difference 10.4%; 0.9% to 19.9%; P = 0.032). The carriage rate of S pneumoniae varied from 17.4% to 28.2% with no difference between the groups. Two children in the xylitol group experienced diarrhoea, but no other adverse effects were noted among the xylitol users. CONCLUSION: Xylitol seems to have a preventive effect against acute otitis media.     

Diagnosis and antibiotic treatment of acute otitis media: report from International Primary Care Network.

STUDY OBJECTIVE--The relation between a history of disorders suggestive of acute otitis media, symptoms, and findings of an examination of the tympanic membrane and doctors'' certainty of diagnosis. Also, to examine differences in prescribing habits for acute otitis media among doctors from different countries. DESIGN--Questionnaires were completed by participating doctors for a maximum of 15 consecutive patients presenting with presumed acute otitis media. SETTING--General practices in Australia, Belgium, Great Britain, Israel, The Netherlands, New Zealand, Canada, Switzerland, and the United States. PATIENTS--3660 Children divided into the three age groups 0-12 months, 13-30 months, and greater than or equal to 31 months. MAIN OUTCOME MEASURES--General practitioners'' responses to questions on their diagnostic certainty and resolution of patients'' symptoms after two months. RESULTS--The diagnostic certainty in patients aged 0-12 months was 58.0%. This increased to 66.0% in those aged 13-30 months and 73.3% in those aged greater than or equal to 31 months. In all age groups diagnostic certainty was positively associated with the finding of a tympanic membrane that was discharging pus or bulging. Redness of the membrane and pain were also associated with certainty in patients aged 13-30 months, and a history of decreased hearing or recent upper respiratory infection was positively associated in patients aged greater than or equal to 31 months. The proportion of patients prescribed antibiotics varied greatly among the countries, from 31.2% in The Netherlands to 98.2% in both Australia and New Zealand, as did the duration of treatment. Patients who did not take antibiotics had a higher rate of recovery than those who did; the rate of recovery did not differ between different types of antibiotic. CONCLUSIONS--Doctors'' certainty of diagnosis of acute otitis media was linked to patient''s age. Improved criteria or techniques for diagnosing acute otitis media, especially in very young children, need to be developed. Antibiotic treatment did not improve the rate of recovery of patients in this study.     

Are antibiotics indicated as initial treatment for children with acute otitis media? A meta-analysis.

OBJECTIVE: To determine the effect of antibiotic treatment for acute otitis media in children. DESIGN: Systematic search of the medical literature to identify studies that used antibiotics in randomised controlled trials to treat acute otitis media. Studies were examined blind, and the results of those of satisfactory quality of methodology were pooled. SUBJECTS: Six studies of children aged 7 months to 15 years. MAIN OUTCOME MEASURES: Pain, deafness, and other symptoms related to acute otitis media or antibiotic treatment. RESULTS: 60% of placebo treated children were pain free within 24 hours of presentation, and antibiotics did not influence this. However, at 2-7 days after presentation, by which time only 14% of children in control groups still had pain, early use of antibiotics reduced the risk of pain by 41% (95% confidence interval 14% to 60%). Antibiotics reduced contralateral acute otitis media by 43% (9% to 64%). They seemed to have no influence on subsequent attacks of otitis media or deafness at one month, although there was a trend for improvement of deafness at three months. Antibiotics were associated with a near doubling of the risk of vomiting, diarrhoea, or rashes (odds ratio 1.97 (1.19 to 3.25)). CONCLUSIONS: Early use of antibiotics provides only modest benefit for acute otitis media: to prevent one child from experiencing pain by 2-7 days after presentation, 17 children must be treated with antibiotics early.     

Effect of recolonisation with "interfering" alpha streptococci on recurrences of acute and secretory otitis media in children: randomised placebo controlled trial

ObjectiveTo study the effect of recolonisation with α streptococci with the ability to inhibit the growth of otopathogens (“interfering” activity) on the recurrence of acute otitis media in susceptible children and the effect on the frequency of secretory otitis media.DesignDouble blind, randomised, placebo controlled study.SettingEar, nose, and throat clinic with three doctors.Participants130 children prone to otitis media aged between 6 months and 6 years, 108 of whom were eligible and followed for 3 months.InterventionsChildren with no recurrences during the last month received phenoxymethylpenicillin (n=22), and those with a recurrence within 1 month received amoxicillin clavulanic acid (n=86), both twice daily for 10 days. These were followed by a streptococcal or placebo solution sprayed into the nose for a further 10 days. At day 60 the same spray was started for another 10 days.ResultsAt 3 months 22 children (42%) given the streptococcal spray were healthy and had a normal tympanic membrane compared with 12 (22%) of those given placebo. This difference was shown separately for recurrences of both acute otitis media and secretory otitis media.ConclusionsSelected bacteria with the ability to inhibit the growth of common otopathogens can be used to protect against recurrent acute otitis media and secretory otitis media in children.     

Policies on antibiotics of south east London general practitioners for managing acute otitis media in children.

Questionnaires on antibiotic treatment of acute otitis media in children were sent to the general practitioners who make regular referrals to clinics in the King''s College Hospital group. The most popular first choice of drug was amoxycillin (44%), but 37% of general practitioners said that they often used oral phenoxymethylpenicillin. This drug has relatively low activity against Haemophilus influenzae and many strains of Staphylococcus aureus. It is poorly absorbed from the stomach, does not penetrate the middle ear well, and its use may be one factor in the development of chronic middle ear effusions after acute otitis media. Sixty two per cent of the doctors who replied never treated acute otitis media with intramuscular antibiotics, but 57% used oral loading doses. Ninety seven per cent never treated their patients without antibiotics.     

Co-amoxiclav in recurrent acute otitis media: placebo controlled study.

OBJECTIVE--To determine the efficacy of coamoxiclav in children aged 6 months to 12 years with recurrent acute otitis media. DESIGN--A randomised double blind placebo controlled clinical trial. SETTING--General practice in the Netherlands. PATIENTS--121 children with recurrent acute otitis media, defined by onset of otalgia and otoscopic signs of middle ear infection within four to 52 weeks after the previous attack. Confirmation of diagnosis and randomisation was done by otolaryngologists. INTERVENTION--Oral co-amoxiclav or placebo in weight related doses for seven days. MAIN OUTCOME MEASURE--An irregular clinical course defined as the presence of otalgia or a body temperature greater than or equal to 38 degrees C, or both, after three days. RESULTS--Eleven (16%; 95% confidence interval 9% to 28%) children had an irregular course in the co-amoxiclav group and 10 (19%; 9% to 31%) in the placebo group (difference not significant). Age, dichotomised at 2 years, was the only significant prognostic factor for irregular course of the disease (odds ratio 5.9; 1.8 to 19.1). Among children aged below 2 years, 28% (4/14) in the co-amoxiclav group and 58% (7/12) in the placebo group had irregular courses. For children 2 years and older these percentages were 13% (7/52) and 7% (3/41). CONCLUSION--Children with recurrent acute otitis media are at greater risk of an irregular clinical course of the disease than children with a first episode of acute otitis media. Co-amoxiclav has no significant benefit over placebo in treating children over 2 years with acute otitis media.     

Influence of Pneumococcal Conjugate Vaccine on Acute Otitis Media with Severe Middle Ear Inflammation: A Retrospective Multicenter Study

The Japanese guidelines for acute otitis media in children recommend classifying acute otitis media by age, manifestations and local findings, and also recommend myringotomy for moderate-grade cases with severe local findings, severe-grade cases, and treatment-resistant cases. The heptavalent pneumococcal conjugate vaccine was released in Japan in February 2010. In Hiroshima City, public funding allowing free inoculation with this vaccine was initiated from January 2011, and the number of vaccinated individuals has since increased dramatically. This study investigated changes in the number of myringotomies performed to treat acute otitis media during the 5-year period from January 2008 to December 2012 at two hospitals and five clinics in the Asa Area of Hiroshima City, Japan. A total of 3,165 myringotomies for acute otitis media were performed. The rate of procedures per child-year performed in <5-year-old children decreased by 29.1% in 2011 and by 25.2% in 2012 compared to the mean rate performed in the 3 years prior to the introduction of public funding. A total of 895 myringotomies were performed for 1-year-old infants. The rate of myringotomies per child-year performed for acute otitis media in 1-year-old infants decreased significantly in the 2 years after the introduction of public funding for heptavalent pneumococcal conjugate vaccine compared to all years before introduction (p<0.000001). Our results suggest a benefit of heptavalent pneumococcal conjugate vaccine for acute otitis media in reducing the financial burden of myringotomy. In addition, this vaccine may help prevent acute otitis media with severe middle ear inflammation in 1-year-old infants.     

Study of middle ear disease using tympanometry in general practice.

Tympanometry was used to provide evidence of middle ear effusions in a prospective study of middle ear disease in 264 children aged 3 months to 6 years in general practice. Adequate measurements on both ears were obtained in 220 children, of whom 68 (31%) had evidence of middle ear effusion in one ear (29 children) or both ears (39 children) at entry to the study. In 28 (42%) of the 68 children persistence of the tympanometric findings was recorded for at least three months. Children of European descent were more likely to have evidence of middle ear effusion at the initial examination compared with African and West Indian children, as were those children whose siblings had a positive history of otitis media compared with those whose siblings had no such history. Children under 3 years were more likely to have evidence of an effusion than older children. Middle ear effusion as shown by tympanometry was not associated with a previous history of otitis media in the child but was associated with recent symptoms of respiratory infection or otalgia. A previous consultation for otitis media was, however, strongly associated with a greater likelihood of a consultation for otitis media during the follow up period. Comparing evidence of effusion by tympanometry with that by pneumatic otoscopy showed that using the appearance of the eardrum alone the sensitivity of otoscopy was 55%; the addition of mobility improved the sensitivity to 76% with little reduction in specificity. Further studies on populations using tympanometry are needed to determine the natural history, aetiology, and indications for referring children with middle ear effusion.     

腺样体手术治疗儿童分泌性中耳炎的临床疗效观察

目的:观察腺样体手术治疗儿童分泌性中耳炎的临床效果。方法:选择分泌性中耳炎合并腺样体肥大患儿80例(160耳),将其随机分为手术组和对照组,每组40例,手术组患儿给予腺样体消融手术治疗,而对照组患儿进行保守治疗,观察和比较两组治疗1个月后的临床疗效。结果:治疗1个月后,手术组治愈72耳,好转6耳,治疗总有效率为97.5%,而对照组治愈8耳,好转20耳,治疗总有效率为35%,较手术组显著降低(P0.05)。结论:腺样体切除是治疗分泌性中耳炎的有效途径,治疗中应尽可能避免并发症的发生,恢复和保护咽鼓管的生理功能。     

儿童腺样体肥大程度与分泌性中耳炎发生的相关性研究(英文)

目的:探讨儿童腺样体肥大程度与分泌性中耳炎发生及预后的相关性,指导临床医师对分泌性中耳炎作出早期诊断和治疗。方法:239例住院手术切除腺样体的儿童,常规行鼻咽侧位片、声导抗检查;部分伴耳部症状、声导抗显示C型曲线或查体可疑鼓室积液征者行颞骨CT检查或术中行鼓室穿刺。经统计学分析,比较分泌性中耳炎与腺样体肥大程度及咽鼓管咽口情况的相关性。结果:在239例腺样体肥大儿童中,经鼓室穿刺证实合并分泌性中耳炎者34例(63耳,14.2%),其中鼓室曲线呈B型者33耳(52.4%),C型(-200 dapa)者10耳(15.9%),C型(-200 dapa)者20耳(31.7%)。结果表明分泌性中耳炎的发生与腺样体肥大程度及咽鼓管园枕受压迫的程度呈正相关。结论:声导抗检查不能作为分泌性中耳炎诊断的金标准,必要时可行颞骨CT明确诊断;对腺样体肥大伴分泌性中耳炎的儿童鼻内镜下腺样体切除为其主要疗法,配合鼓室穿刺多可治愈,对反复发作的分泌性中耳炎行鼓室置管术,避免术后并发症的发生。     

Chronic granulomatous otitis media in bottle-fed Inuit children.

Otitis media in Inuit children is a problem of relatively recent origin and unknown cause. The prevalence of otitis media in 238 Inuit and 47 Caucasian children in Nain, a small community in Labrador, was determined by examination, and the history of breast-feeding or bottle-feeding was obtained. The prevalence of otitis media was found to be inversely related to the age at which bottle-feeding was started. Clinical observations suggest that otitis media in Inuit children is part of a process leading to chronic foreign body granuloma of the middle ear, and that the granuloma is formed from milk introduced into the relatively short and straight eustachian tubes of Inuit infants by the high negative intraoral pressure necessary for bottle-feeding.     

IgG Responses to Pneumococcal and Haemophilus Influenzae Protein Antigens Are Not Impaired in Children with a History of Recurrent Acute Otitis Media

Background

Vaccines including conserved antigens from Streptococcus pneumoniae and nontypeable Haemophilus influenzae (NTHi) have the potential to reduce the burden of acute otitis media. Little is known about the antibody response to such antigens in young children with recurrent acute otitis media, however, it has been suggested antibody production may be impaired in these children.

Methods

We measured serum IgG levels against 4 pneumococcal (PspA1, PspA 2, CbpA and Ply) and 3 NTHi (P4, P6 and PD) proteins in a cross-sectional study of 172 children under 3 years of age with a history of recurrent acute otitis media (median 7 episodes, requiring ventilation tube insertion) and 63 healthy age-matched controls, using a newly developed multiplex bead assay.

Results

Children with a history of recurrent acute otitis media had significantly higher geometric mean serum IgG levels against NTHi proteins P4, P6 and PD compared with healthy controls, whereas there was no difference in antibody levels against pneumococcal protein antigens. In both children with and without a history of acute otitis media, antibody levels increased with age and were significantly higher in children colonised with S. pneumoniae or NTHi compared with children that were not colonised.

Conclusions

Proteins from S. pneumoniae and NTHi induce serum IgG in children with a history of acute otitis media. The mechanisms in which proteins induce immunity and potential protection requires further investigation but the dogma of impaired antibody responses in children with recurrent acute otitis media should be reconsidered.     

腺样体手术治疗儿童分泌性中耳炎的临床疗效观察

目的：观察腺样体手术治疗儿童分泌性中耳炎的临床效果。方法：选择分泌性中耳炎合并腺样体肥大患儿80例（160耳）,将其随机分为手术组和对照组,每组40例,手术组患儿给予腺样体消融手术治疗,而对照组患儿进行保守治疗,观察和比较两组治疗1个月后的临床疗效。结果：治疗1个月后,手术组治愈72耳,好转6耳,治疗总有效率为97．5％,而对照组治愈8耳,好转20耳,治疗总有效率为35％,较手术组显著降低（P〈0．05）。结论：腺样体切除是治疗分泌性中耳炎的有效途径,治疗中应尽可能避免并发症的发生,恢复和保护咽鼓管的生理功能。     

Complicaciones de la otitis media con parálisis del sexto par craneal contralateral en pediatría

Otitis media is a frequent infection during childhood. Complications may be present in up to 4 of 100 children including serious neurological complications, particularly in developing countries.We report the case of a 9-year-old girl with no disease history who presented with otitis media, otorrhea, intracranial hypertension syndrome, and paralysis of the VI cranial nerve contralateral to the lesion. A computed tomography scan of the skull and a brain magnetic resonance imaging revealed chronic otomastoiditis, petrous apicitis, and thrombosis of the transverse and sigmoid sinus, the jugular bulb, and the right internal jugular vein. She received antibiotics and surgical treatment.This case shows the spectrum of intra and extracranial complications associated with acute otitis media in the antibiotic era. The physical examination allows early identification of intracranial hypertension with signs such as papilledema and sixth contralateral nerve palsy as an unusual finding.     

Sulfisoxazole Chemoprophylaxis and Recurrent Otitis Media

Sulfisoxazole, 75 mg per kg per day, was administered for 13 weeks to all children with otitis media recurring at a rate of at least once every other month. The first 26 patients began prophylaxis during the months of January and February of 1979. To compare rates of otitis media with those in children not receiving concurrent prophylaxis during the same season, a matched control was randomly chosen as a child who began prophylaxis on the day nearest that when a study patient completed prophylaxis. The rates of otitis media during this same period were determined as the number of episodes per patient-month. Of the 26 treated patients, 11 had 16 episodes of otitis media in 72 patient-months (0.22 episodes per patient-month), in contrast to the 26 untreated patients who had 63 episodes in the same period (0.88 episodes per patient-month). This 75% reduction in incidence was statistically significant by X² analysis (P<.005). The two groups of children were comparable in age, sex, nursery school attendance, family history of allergy and number of episodes in the three months preceding chemoprophylaxis. These findings support the short-term chemoprophylactic use of sulfisoxazole for recurrent otitis media.     

PROPER USE OF ANTIBIOTICS IN TREATMENT OF ACUTE OTITIS MEDIA

The problem of preventing loss of hearing following acute otitis media has been made more complex by the use of penicillin and other antibiotic agents which may apparently cure yet leave dangerous residual disease. The causes of loss of hearing must be recognized early if remedial treatment is to be effective. In children particularly, loss of hearing may go unnoticed for some time.Physicians who treat otitis media should feel the responsibility not only of bringing an acutely ill child back to health but of preserving the function of the hearing mechanism. Careful examination of the ear after apparent subsidence of infection is mandatory. It is of the utmost importance to be able to recognize the ear drum in its normal state and its various pathological states and to be alert to the early signs of changes associated with loss of hearing. Antibiotics should not be expected to do more than help combat the acute infection in otitis media. Adequate follow-up demands strong suspicion of residual pathologic process in the ear. The prevention of loss of hearing still requires knowledge of the established clinical facts and therapeutic procedures and the application of this knowledge to treatment of acute infections of the middle ear.