Pharmacological treatment of acute otitis media in children. A comparison among seven locations: Tenerife, Barcelona and Valencia (Spain), Toulouse (France), Smolensk (Russia), Bratislava (Slovakia) and Sofia (Bulgaria)

Therapeutic efficacy of azithromycin and acetylcysteine in chronic otitis media with effusion

Otitis media with effusion (OME) is a common disease in childhood. There is no consensus on the optimal therapeutic option for OME. Considering the known efficacy of acetylcysteine (AC) and azithromycin (AZ) in the treatment of middle ear mucosa, the aim of the study was to assess their efficacy in the management of chronic OME. The study included 90 children with OME, both ears. They are divided into three groups of 30 children. Group 1 (AC) patients were treated with acetylcysteine per os, 3 × 100 mg, for 3 weeks; group 2 (AZ) with body weight adjusted dose of azithromycin for 3 days; and group 3 (AC + AZ) with a combination of acetylcysteine and azithromycin at doses described above. Three measurements were performed. On second measurement, tympanogram improvement was recorded in 45% of 60 ears in group I, 53.3% of 60 ears in group II, and 61.7% of 60 ears in group III. The percentage of improvement was highest in group III. Although between-group differences did not reach statistical significance, the results obtained appear to be clinically relevant. In conclusion, conservative therapy for chronic OME is reasonable. Although study results don't have a strong statistical differences and may not refer clinical improvement results suggest that this combination of drugs (antibiotics, bronchosecretolytics) can be useful in the treatment of OME.

Provider and patient drivers of ototopical antibiotic prescription variability

OBJECTIVE

To determine if providers prescribe more affordable topical antibacterial therapy for patients who are economically disadvantaged or come from economically disadvantaged communities.

STUDY DESIGN

Prescription drug database review.

SETTING

Large academic hospital network.

SUBJECTS AND METHODS

Ototopical prescription records of 2416 adults and children presenting with acute and chronic otologic infections from 2009 to 2013 were reviewed. Prescription, patient, provider, and institution variables including diagnosis, prescription type, demographics, health insurance status, healthcare provider type and setting were analyzed.

RESULTS

Otitis externa and acute otitis media were the most common diagnoses. Non-OHNS (Otolaryngology-Head and Neck Surgery) providers served 82% of all patients. OHNS providers prescribed proportionally less fluoroquinolone, and more brand-name antibiotics compared to non-OHNS providers. Adults were more likely to receive a non-fluoroquinolone antibiotic and a generic prescription versus pediatric patients. Patients who self-identified as 'white' ethnicity received proportionally more fluoroquinolone prescriptions than patients who identified as 'non-white,' but there was no difference in provider type. The proportion of fluoroquinolone prescriptions was significantly higher in patients from low-poverty counties, however poverty level was not associated with patients seeing a particular provider type. The majority of our patients had commercial insurance, followed by Medicaid. Medicare patients had the lowest proportion of fluoroquinolone antibiotic prescriptions, and were less likely to receive fluoroquinolone prescriptions versus commercial insurance. Non-insured patients received proportionally more generic versus brand prescriptions than insured patients.

CONCLUSION

Our results indicate potential provider, patient demographic, and financial factors producing considerable variability in the prescribing patterns for topical antibiotics for common otologic infections.

WITHDRAWN: Decongestants and antihistamines for acute otitis media in children

BACKGROUND

Acute otitis media (AOM) is a common and important source of morbidity in children, although the majority of cases resolve spontaneously. While frequently recommended, decongestant and antihistamine therapy is of unclear benefit.

OBJECTIVES

To determine the efficacy of decongestant and antihistamine therapy in children with AOM on outcomes of AOM resolution, symptom resolution, medication side effects, and complications of AOM.

SEARCH STRATEGY

In this updated review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2007, Issue 2); MEDLINE (January 2004 to May 2007); and EMBASE (July 2003 to May 2007).

SELECTION CRITERIA

Randomized controlled trials (RCTs) evaluating decongestant or antihistamine treatment for children with AOM were included. Patient-oriented outcomes were considered most relevant.

DATA COLLECTION AND ANALYSIS

The review authors independently evaluated studies for inclusion, performed validity assessments and completed data extraction. Dichotomous data were pooled to generate relative risks; homogeneity was assessed using approximate chi-square tests.

MAIN RESULTS

No new studies were included following this updated search. Fifteen trials involving 2695 people were included. Only the combined decongestant-antihistamine group demonstrated statistically lower rates of persistent AOM at the two week period (fixed relative risk (RR) 0.76; 95% confidence interval (CI) 0.60 to 0.96; number needed to treat (NNT) 10). No benefit was found for early cure rates, symptom resolution, prevention of surgery or other complications. There was a five to eight -fold increased risk of side effects for those receiving an intervention, which reached statistical significance for all decongestant groupings. Validity sub analyses demonstrated that lower quality studies found benefit, while analysis of those studies with higher validity scores found no benefit of treatment.

AUTHORS' CONCLUSIONS

Given lack of benefit and increased risk of side effects, these data do not support the use of decongestant treatment in children with AOM. There was a small statistical benefit from combination medication use but the clinical significance is minimal and study design may be biasing the results. Thus, the routine use of antihistamines for treating AOM in children cannot be recommended.

Decongestants and antihistamines for acute otitis media in children

BACKGROUND

Acute otitis media (AOM) is a common and important source of morbidity in children, although the majority of cases resolve spontaneously. While frequently recommended, decongestant and antihistamine therapy is of unclear benefit.

OBJECTIVES

To determine the efficacy of decongestant and antihistamine therapy in children with AOM on outcomes of AOM resolution, symptom resolution, medication side effects, and complications of AOM.

SEARCH STRATEGY

In this updated review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2007, Issue 2); MEDLINE (January 2004 to May 2007); and EMBASE (July 2003 to May 2007).

SELECTION CRITERIA

Randomized controlled trials (RCTs) evaluating decongestant or antihistamine treatment for children with AOM were included. Patient-oriented outcomes were considered most relevant.

DATA COLLECTION AND ANALYSIS

The review authors independently evaluated studies for inclusion, performed validity assessments and completed data extraction. Dichotomous data were pooled to generate relative risks; homogeneity was assessed using approximate chi-square tests.

MAIN RESULTS

No new studies were included following this updated search. Fifteen trials involving 2695 people were included. Only the combined decongestant-antihistamine group demonstrated statistically lower rates of persistent AOM at the two week period (fixed relative risk (RR) 0.76; 95% confidence interval (CI) 0.60 to 0.96; number needed to treat (NNT) 10). No benefit was found for early cure rates, symptom resolution, prevention of surgery or other complications. There was a five to eight -fold increased risk of side effects for those receiving an intervention, which reached statistical significance for all decongestant groupings. Validity sub analyses demonstrated that lower quality studies found benefit, while analysis of those studies with higher validity scores found no benefit of treatment.

AUTHORS' CONCLUSIONS

Given lack of benefit and increased risk of side effects, these data do not support the use of decongestant treatment in children with AOM. There was a small statistical benefit from combination medication use but the clinical significance is minimal and study design may be biasing the results. Thus, the routine use of antihistamines for treating AOM in children cannot be recommended.

Identifying how age and gender influence prescription drug use in a primary health care environment in Catalonia, Spain

What is already known about this subject. Knowledge of prescription patterns in primary health care is an important tool in rational drug therapy. Age and gender are the principal determining factors of cost variability between medical practices, due to drug prescriptions. Age and gender are the principal determining factors of cost variability in relation to the therapeutic group. What this study adds. This study provides specific information on the use of drugs in the primary health care environment of the Catalan Health System, and the differences observed are analyzed with respect to age and gender of the population receiving care. The study shows that there is a high prevalence of drugs in the under 5 year old age group, and also in persons over 54 years of age. The variability found in the cost per patient suggests that adjustment should be made for age in practitioners' prescription evaluation procedures in primary health care in Catalonia.

AIMS

To determine the prevalence and usage patterns of prescription drugs according to patients' age and gender, and to identify their relative importance in the prescription costs, in primary health care within the Catalan Health Institute.

METHODS

This was a cross-sectional study using computerized pharmacy dispensing records for 5 474 274 members registered, during 2002. Twenty age-gender categories were established. Use of a drug group was defined as filling at least one prescription. The variables studied were age, gender, number of prescriptions and net cost. The prevalence of use, the number of prescriptions and cost issued to each age category were reported.

RESULTS

The overall prevalence of drug use was 74.53% (women 80.93%, men 67.84%). This was higher in the group of 0-4 year-olds, and in the >or= 55 year-olds. Age (P < 0.001) produced a statistically more significant effect than gender (P < 0.05). The most used therapeutic groups were analgesics, nonsteroidal anti-inflammatory drugs, antiulcer drugs, anxiolytics, expectorants and mucolytics. The number of prescriptions and costs per patient rose with age and showed great variation in the use of these groups for patients in different age groups. The risk of prescription in women was 23% higher than in men (RR 1.23, 95% CI 1.11, 1.37, P < 0.001).

CONCLUSIONS

The majority of subjects were exposed to one or more drugs. The variability in the number of prescriptions and in the prescribing cost per patient between the different age groups suggests that adjustments should be made for age in practitioners' prescription evaluation processes in primary health care in Catalonia.

Study of nasopharyngeal bacterial flora. Variations in nasopharyngeal bacterial flora in schoolchildren and adults when administered antimicrobial agents

Changes in nasopharyngeal bacterial flora in adults with acute upper respiratory tract infection on administration of antimicrobial agents were investigated, and how these changes contrasted with those in children. Many patients with acute sinusitis due to allergies, and patients with malignancy and diabetes mellitus were included in the investigation. The detection rates of Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis, the major bacteria of acute otitis media (AOM), were 22%, 10%, and 7% respectively, which were significantly lower than those for children. Gram stain examination of nasopharyngeal swab samples showed a significant relation between leukocyte infiltration and the detection amount of S. pneumoniae (P = 0.0086). A significant relation (P = 0.0134) was also observed when H. influenzae was simultaneously detected. No significant change in the three major AOM bacteria present in nasopharyngeal bacterial flora after administration of antimicrobial agents was observed. However, all S. pneumoniae and H. influenzae detected after antimicrobial agent administration had the beta-lactam-resistance gene. It was observed that a significant improvement in leukocyte infiltration occurred 6 to 10 days after antimicrobial agent administration. In contrast, a significant improvement in children was observed at 2 to 5 days. In the adult subjects, this improvement was probably due to spontaneous remission rather than the effect of the antimicrobial agents. Although investigation of the long-term administration of antimicrobial agents was also conducted, its benefits for the patients were not elucidated.

Primary care management of respiratory tract infections in Dutch preschool children

OBJECTIVE

To determine age-specific antibiotic prescription and referral rates in preschool children diagnosed with acute respiratory tract infection (RTI) in primary care.

DESIGN

Retrospective cohort study.

SETTING

Research database of the Netherlands University Medical Center Utrecht Primary Care Network.

SUBJECTS

All children aged 0-5 years within the database were included, covering 1998 to 2002 (18,801 child-years).

MAIN OUTCOME MEASURES

Antibiotic prescription and referral rates were determined as percentage of children with at least one prescription or referral within a year, as total number of prescriptions per 1000 child-years, and as percentage of all RTI episodes.

RESULTS

Antibiotics, mostly beta-lactam (80%) and macrolides (16%), were prescribed in 35% of RTI episodes. Annually 13% of the children received at least one antibiotic following an RTI. Antibiotics were prescribed in more than half of episodes of LRTI, sinusitis, AOM, and acute tonsillitis, and in 12-15% of episodes of asthma exacerbation, acute laryngitis, influenza acute, and acute upper respiratory infection (including common cold and pharyngitis). Almost 98% of RTIs were managed in primary care. On average 1% of the children were referred to a paediatrician or ENT specialist following RTI per year, especially after AOM (59% of referrals). Compared with older children, those under two years of age were more often treated with antibiotics (relative risk [RR] 1.4, 95% CI 1.3-1.6) and referred (RR 2.3; 95% CI 1.8-3.0).

CONCLUSION

In the Netherlands most episodes of RTIs in preschool children were managed in primary care and this often involves prescription of antibiotics. Children younger than two years of age receive more often antibiotics for RTI and are also referred more, especially for AOM.

Severe acute middle ear infections: microbiology and treatment

OBJECTIVE

The database at the ENT-Department, Aarhus University Hospital describing the specific local flora of acute otitis media (AOM) and acute mastoiditis (AM) in Aarhus County has become the key element in securing a rational and specific antibiotic treatment. We present our data concerning AOM, mastoidismus and AM. Our purpose is to determine (I) clinical presentation, (II) causative pathogens, (III) resistance patterns, (IV) type of antibiotic treatment, and (V) accuracy of the antibiotic treatment.

METHODS

Patients under the age of 18 years, treated for AOM with extensive affected well-being and AM, at the ENT-Department, Aarhus University Hospital during 3 years from January 2001 to December 2003.

RESULTS

A total of 106 patients were identified. Sixty-seven patients with AOM and 39 patients with AM. The overall bacterial flora found is dominated by S. pneumococci all 100% susceptible to penicillin. However, Staphylococcus aureus is the primary bacterial pathogens cultured from patients treated with preadmission antibiotics.

CONCLUSION

If a specimen from an AOM patient is obtained after the initiation of antibiotic treatment one should consider the possibility of the culture found being a result of the initial led treatment and not the causative AOM pathogen. Our data suggest that a restricted use of antibiotics in children with AOM may be associated with a higher incidence of acute mastoiditis. Significant higher leucocytes count and CRP are found in the acute mastoiditis group compared to the AOM group.

Emerging therapies for the treatment and prevention of otitis media

Otitis media is one of the most common disorders occurring in children, and there is growing concern that bacteria are quickly becoming resistant to antimicrobials. As a result, global antibiotic treatment is no longer the standard of care and treatment of otitis media has changed dramatically in the last decade. In addition to new antimicrobials currently in development, the effects of the pneumococcal conjugate vaccine are just beginning to be understood. Furthermore, new surgical techniques are for the first time being tested as alternatives for tympanostomy tubes for recurrent acute otitis media. This review discusses current and emerging otitis media therapeutics, with particular attention to acute otitis media. Topics include antimicrobial use, antimicrobial resistance, effects of vaccination and new surgical techniques.

Analysis of under- and overprescribing of antibiotics in acute otitis media in general practice

OBJECTIVES

To assess clinical determinants of under- and overprescribing of antibiotics according to the Dutch national guideline for patients with acute otitis media (AOM) in general practice.

PATIENTS AND METHODS

A total of 146 general practitioners (GPs) from the Netherlands included all patients with AOM during a 4 week period in winter, and recorded patient characteristics, clinical presentation and management. Under- and overprescribing of antibiotics in AOM was assessed using the Dutch national guideline.

RESULTS

A total of 458 AOM consultations were recorded. In seven out of 10 consultations (310/439; excluding 19 consultations in which patients were referred to secondary care), antibiotic prescribing decisions were according to the national guideline. In 11% of all consultations (50/439), there was underprescribing and in 18% (79/439) there was overprescribing. Patients with an antibiotic indication but without an antibiotic prescription (underprescribing; n=50) had more short-term symptoms (OR: 0.93), relatively few inflammation signs (OR: 0.47) and were less severely ill (OR: 0.30), compared with patients with an antibiotic indication and an antibiotic prescription (n=167). Patients without an antibiotic indication but with an antibiotic prescription (overprescribing; n=79) were more often younger than 24 months (OR: 0.34), more severely ill (OR: 3.30) and expected more often an antibiotic as perceived by their GP (OR: 2.11), compared with patients without an antibiotic indication and without an antibiotic prescription (n=143).

CONCLUSIONS

Clinical determinants which are stated as criteria for antibiotic treatment of AOM in the Dutch national guideline were recognized by GPs as important items, but were frequently given too much weight.