Clinical manifestations and microbiology of acute otitis media with spontaneous otorrhea in children

Pneumococcal serotype prevalence and antibiotic resistance in children in South and Southeast Asia, 2012-2024

This narrative review describes pneumococcal serotype prevalence for invasive disease and carriage and antibiotic resistance among specimens collected from children in countries across South and Southeast Asia from 2012 to 2024. Literature search retrieved 326 articles; 96 were included. The prevalence of pneumococcal serotypes varied geographically and over time after introduction of pneumococcal conjugate vaccine. Serotypes common in both pneumococcal carriage and disease were 6A, 6B, 14, 15B/15C, 19F, and 23F; serotypes 1, 3, 5, 19A, 15A, 10A, and 35B were also common in disease. Most of these serotypes are included in the 13-valent and 10-valent PCV. Carriage and disease isolates remained generally highly susceptible to vancomycin (mostly 100%) and levofloxacin (mostly >97%). These findings indicate that vaccine-preventable serotypes contribute significantly to pneumococcal disease burden in children in South and Southeast Asia. Consistency of national immunization programs with World Health Organization recommendations may reduce rates of pneumococcal disease in this region.

Common infectious morbidity and white blood cell count in middle childhood predict behavior problems in adolescence

We examined the associations of middle childhood infectious morbidity and inflammatory biomarkers with adolescent internalizing and externalizing behavior problems. We recruited 1018 Colombian schoolchildren aged 5-12 years into a cohort. We quantified white blood cell (WBC) counts and C-reactive protein at enrollment and prospectively recorded incidence of gastrointestinal, respiratory, and fever-associated morbidity during the first follow-up year. After a median 6 years, we assessed adolescent internalizing and externalizing behavior problems using child behavior checklist (CBCL) and youth self-report (YSR) questionnaires. Behavior problem scores were compared over biomarker and morbidity categories using mean differences and 95% confidence intervals (CI) from multivariable linear regression. Compared with children without symptoms, CBCL internalizing problem scores were an adjusted 2.5 (95% CI: 0.1, 4.9; p = .04) and 3.1 (95% CI: 1.1, 5.2; p = .003) units higher among children with moderate diarrhea with vomiting and high cough with fever rates, respectively. High cough with fever and high fever rates were associated with increased CBCL somatic complaints and anxious/depressed scores, respectively. WBC >10,000/mm³ was associated with both internalizing problem and YSR withdrawn/depressed scores. There were no associations with externalizing behavior problems. Whether or not decreasing the burden of common infections results in improved neurobehavioral outcomes warrants further investigation.

From Evidence to Clinical Guidelines in Antibiotic Treatment in Acute Otitis Media in Children

Acute otitis media (AOM) in children represents a public health concern, being one of the leading causes of health care visits and antibiotic prescriptions worldwide. The overall aim of this paper is to unravel the major current insights into the antibiotic treatment of AOM in children. Our approach is three-fold: 1. a preclinical evaluation of antibiotics in animal models of AOM stressing on the advantages of different species when testing for different schemes of antibiotics; 2. an overview on the new antimicrobial agents whose efficacy has been demonstrated in refractory cases of AOM in children; and 3. an analysis of the different guidelines stressing on the differences and similarities between the various schemes of antibiotic treatment. The preferred therapeutic agents remain amoxicillin and the amoxicillin-clavulanate combination for AOM caused by Streptococcus pneumoniae, whereas oral cephalosporin is preferred in AOM due to Moraxella catarrhalis and Haemophilus influenzae. As for the second and third line antimicrobial treatments, there is a wide variety of suggested antibiotic classes with variations in duration and posology. The decision to prescribe antimicrobial treatment as a first-line choice is based on the severity of the symptoms in 16 of the guidelines included in this review.

Streptococcus pneumoniae Serotypes Carried by Young Children and Their Association With Acute Otitis Media During the Period 2016-2019

Background: Streptococcus pneumoniae (Sp) is a major cause of acute otitis media (AOM). Pneumococcal conjugate vaccine (PCV) programs have altered pneumococcal serotype epidemiology in disease and carriage. In this study, we used samples collected during a cross-sectional study to examine if the clinical picture of acute otitis media (AOM) in young children exposed to the PCV program in Belgium was related to the carried pneumococcal strains, and if their carriage profile differed from healthy children attending daycare centers. Material/Methods: In three collection periods from February 2016 to May 2018, nasopharyngeal swabs and background characteristics were collected from children aged 6-30 months either presenting at their physician with AOM (AOM-group) or healthy and attending day care (DCC-group). Clinical signs of AOM episodes and treatment schedule were registered by the physicians. Sp was detected, quantified, and characterized using both conventional culture analysis and real-time PCR analysis. Results: Among 3,264 collected samples, overall pneumococcal carriage and density were found at similar rates in both AOM and DCC. As expected non-vaccine serotypes were most frequent: 23B (AOM: 12.3%; DCC: 17.4%), 11A (AOM: 7.5%; DCC: 7.4%) and 15B (AOM: 7.5%; DCC: 7.1%). Serotypes 3, 6C, 7B, 9N, 12F, 17F, and 29 were more often found in AOM than in DCC (p-value < 0.05), whereas 23A and 23B were less often present in AOM (p-value < 0.05). Antibiotic non-susceptibility of Sp strains was similar in both groups. No predictors of AOM severity were identified. Conclusion: In the present study, overall carriage prevalence and density of S. pneumoniae were found similar in young children with AOM and in healthy children attending day-care centers in Belgium. Certain serotypes not currently included in the PCV vaccines were found to be carried more often in children with AOM than in DCC, a finding that might suggest a relationship between these serotypes and AOM.

Inflammatory Mediator Profiles in Secretory Otitis Media in Relationship to Viable Bacterial Pathogens and Bacterial and Viral Nucleic Acids

Secretory otitis media (SOM) is characterized by persistence of fluid in the middle ear, often following an episode of acute otitis media. Our hypothesis is that failure to eliminate bacterial or viral pathogens may result in persistent low-grade inflammation. In this study, we analyzed inflammatory mediators in middle ear fluids from 67 children with SOM. This was combined with determinations of viable bacteria by culture along with detection of bacterial and viral genetic material by real-time polymerase chain reaction (PCR). The inflammatory mediators found at the highest concentrations (>30 ng/mL) were stem cell growth factor-β (median 110 ng/mL), CXCL1, IL-16, IL-8, migration inhibitory factor, CXCL10, and CXCL9. Among bacterial pathogens, Moraxella catarrhalis and Haemophilus influenzae dominated, regardless of detection methods, while rhinovirus dominated among viral pathogens. Middle ear fluid levels of interleukin (IL)-1α, IL-17, IL-1β, fibroblast growth factor basic, and tumor necrosis factor correlated strongly with presence of bacteria detected either by culture or PCR, while IL-1RA, IL-3, IL-6, IL-8, CCL3, CCL4, and granulocyte-colony stimulating factor correlated significantly with real-time PCR values. CXCL10, CXCL9, CCL2, and TRAIL correlated significantly with viral nucleic acid levels. To conclude, persistence of viral and bacterial pathogens may fuel persistent inflammation in SOM. Bacteria caused a broad inflammatory response, while viruses chiefly elicited the interferon-induced chemokines CXCL9 and CXCL10.

Study on the correlation between ambient environment-meteorological factors and the number of visits of acute otitis media, Lanzhou, China

To investigate the correlation between environmental-meteorological factors and daily visits for acute otitis media (AOM) in Lanzhou, China.

METHODS

Data were collected in 2014-2016 by the Departments of Otolaryngology-Head and Neck Surgery at two hospitals in Lanzhou. Relevant information, including age, sex and visiting time, was collected. Environmental data included air quality index, PM10, PM2.5, O3, CO, NO2 and SO2, and meteorological data included daily average temperature (T, °C), daily mean atmospheric pressure (AP, hPa), daily average relative humidity (RH, %) and daily mean wind speed (W, m/s). The SPSS22.0 software was used to generate Spearman correlation coefficients in descriptive statistical analysis, and the R3.5.0 software was used to calculate relative risk (RR) and to obtain exposure-response curves. The relationship between meteorological-environmental parameters and daily AOM visits was summarized.

RESULTS

Correlations were identified between daily AOM visits and CO, O3, SO2, CO, NO2, PM2.5 and PM10 levels. NO2, SO2, CO, AP, RH and T levels significantly correlated with daily AOM visits with a lag exposure-response pattern. The effects of CO, NO2, SO2 and AP on daily AOM visits were significantly stronger compared to other factors (P < 0.01). O3, W, T and RH were negatively correlated with daily AOM visits. The highest RR lagged by 3-4 days.

CONCLUSIONS

The number of daily AOM visits appeared to be correlated with short-term exposure to mixed air pollutants and meteorological factors from 2014 through 2016 in Lanzhou.

Clinical practice guidelines for acute otitis media in children: a systematic review and appraisal of European national guidelines

OBJECTIVES

To appraise European guidelines for acute otitis media (AOM) in children, including methodological quality, level of evidence (LoE), astrength of recommendations (SoR), and consideration of antibiotic stewardship.

DESIGN

Systematic review of the literature.

DATA SOURCES

Three-pronged search of (1) databases: Medline, Embase, Cochrane library, Guidelines International Network and Trip Medical Database; (2) websites of European national paediatric associations and (3) contact of European experts. Data were collected between January 2017 and February 2018.

ELIGIBILITY CRITERIA

National guidelines of European countries for the clinical management of AOM in children aged <16 years.

DATA EXTRACTION AND SYNTHESIS

Data were extracted using tables constructed by the research team. Guidelines were graded using AGREE II criteria. LoE and SoR were compared. Guidelines were assessed for principles of antibiotic stewardship.

RESULTS

AOM guidelines were obtained from 17 or the 32 countries in the European Union or European Free Trade Area. The mean AGREE II score was ≤41% across most domains. Diagnosis of AOM was based on similar signs and symptoms. The most common indication for antibiotics was tympanic membrane perforation/otorrhoea (14/15; 93%). The majority (15/17; 88%) recommended a watchful waiting approach to antibiotics. Amoxicillin was the most common first-line antibiotic (14/17; 82%). Recommended treatment duration varied from 5 to 10 days. Seven countries advocated high-dose (75-90 mg/kg/day) and five low-dose (30-60 mg/kg/day) amoxicillin. Less than 60% of guidelines used a national or international scale system to rate level of evidence to support recommendations. Under half of the guidelines (7/17; 41%) referred to country-specific microbiological and antibiotic resistance data.

CONCLUSIONS

Guidelines for managing AOM were similar across European countries. Guideline quality was mostly weak, and it often did not refer to country-specific antibiotic resistance patterns. Coordinating efforts to produce a core guideline which can then be adapted by each country may help improve overall quality and contribute to tackling antibiotic resistance.

Pneumococcal Conjugate Vaccines Turning the Tide on Inequity: A Retrospective Cohort Study of New Zealand Children Born 2006-2015

BACKGROUND

Hospitalization rates for infectious diseases in New Zealand (NZ) children have increased since 1989. The highest burden is among Māori and Pacific children, and the most socioeconomically deprived. New Zealand introduced pneumococcal conjugate vaccine (PCV)7 in June 2008, PCV10 in 2011, and PCV13 in 2014.

METHODS

A retrospective cohort study of NZ children aged <6 years between 2006 and 2015 was performed using administrative databases. Demographics and hospitalizations were linked to evaluate the impact of the PCV vaccination program on cases of invasive pneumococcal disease (IPD), all-cause pneumonia (ACP), and otitis media (OM), defined by ICD-10-AM codes, and to explore the effect by ethnicity and deprivation.

RESULTS

Between 2006 and 2015, there were 640 children hospitalized with IPD, 26589 for ACP, and 44545 for OM. IPD hospitalizations declined by 73% between 2005 and 2015 for children <6 years of age, whereas ACP and OM declined by 8% and 25%, respectively. The highest rates for all diseases were among Māori and Pacific children and those from high deprivation. However, the declines were highest among Māori and Pacific children and those from socioeconomically deprived areas. IPD hospitalizations declined by 79% and 67% for Māori and Pacific children, respectively, between 2006 and 2015. ACP declined by 12% in Māori and 21% in Pacific children. OM declined by 51% in Māori children.

CONCLUSION

In contrast to the increasing trend of hospitalization rates for infectious disease in New Zealand, the use of PCV appears associated with reductions in ethnic and socioeconomic disparities in hospitalization for IPD, ACP, and OM.

Pneumococcal serotype 19A is the major cause of pediatric acute otitis media with ruptured tympanic membrane in Addis Ababa, Ethiopia, 5 years after the introduction of the ten-valent pneumococcal conjugate vaccine

INTRODUCTION

In Ethiopia, there is a lack of data on pneumococcal serotypes causing acute otitis media (AOM) in children. We aimed to study the etiology, pneumococcal serotypes and antimicrobial resistance patterns of isolates from children with AOM with spontaneous perforation of the tympanic membrane (SPTM).

METHODS

We carried out a prospective observational study in children with AOM with SPTM, aged 0-15 years in Addis Ababa, Ethiopia. Middle ear fluid was collected using sterile swabs, cultured and antibiotic susceptibility testing was performed. Serotypes of Streptococcus pneumoniae were determined by sequencing the cpsB gene and by the Quellung reaction.

RESULTS

A total of 55 children were enrolled. Out of 55 samples that were cultured, 52 (94.5%) were culture positive for a total of 66 bacterial species, and 56.4% (31/55) samples were positive for 41 (62.1%) known pathogenic bacterial species. The most common pathogenic bacterial isolates were S. pneumoniae (36.6%), Staphylococcus aureus (19.5%), Streptococcus pyogenes (14.6%) and Haemophilus influenzae (12.2%). Serotype 19A (73.3%) was the predominant pneumococcal serotype. There was a high rate of non-susceptibility to penicillin (86.6%) and trimethoprim/sulfamethoxazole (80%) among pneumococcal isolates. Out of 21 different isolates tested for amoxicillin susceptibility, 15 (71.4%) were resistant.

CONCLUSIONS

Pneumococcal serotype 19A was the predominant cause of AOM with SPTM in children in Addis Ababa, Ethiopia, 5 years after introduction of PCV10. There was a high rate of resistance to commonly prescribed antibiotics. The study highlights the need for wide scale surveillance of the etiology and antimicrobial susceptibility of AOM in Ethiopian children.

A systematic review and meta-analysis of antimicrobial resistance in paediatric acute otitis media

OBJECTIVE OF REVIEW

Acute otitis media (AOM) is the largest cause of antimicrobial prescriptions amongst children in developed countries. Excessive and inappropriate prescribing is known to drive antimicrobial resistance, but less is known of antimicrobial resistance in AOM-associated bacteria.

TYPE OF REVIEW & SEARCH STRATEGY

We conducted a systematic review and meta-analysis of bacterial prevalence and antimicrobial resistance in studies of paediatric AOM identified from Ovid Medline, Embase and the Cochrane library.

RESULTS

From 48 unique studies, 15,871 samples were included. Only 0.67 (CI 0.63-0.71) of all ear samples grew a bacterial pathogen. The most common bacterial causes of AOM in children were Streptococcus pneumoniae 0.30 (CI 0.27-0.32), Haemophilus influenza 0.23 (CI 0.20-0.26), and Moraxella catarrhalis 0.05 (CI 0.04-0.06). Resistance patterns varied amongst organisms and antimicrobial agents. The pooled proportion of bacterial culture-positive episodes of AOM that could be effectively treated with amoxicillin was 0.85 (CI 0.76-0.94), erythromycin was 0.64 (0.48-0.78) and amoxicillin-clavulanate was 0.95 (CI 0.85-0.98).

CONCLUSION

We have demonstrated the bacteriology and antimicrobial resistance patterns of AOM. Of samples which grew bacteria, on average approximately 15% of isolates demonstrated resistance to amoxicillin; a typical first-line agent. Greater understanding of local bacteriology and resistance patterns is needed to enable improved antimicrobial stewardship.

Molecular characterization and antimicrobial susceptibility of Staphylococcus aureus isolated from children with acute otitis media in Liuzhou, China

BACKGROUND

There have been few studies focused on the prevalence, bacterial etiology, antibiotic resistance, and genetic background of Staphylococcus aureus (S. aureus) in children with acute otitis media (AOM) in China.

METHODS

A retrospective study was conducted in Liuzhou Maternity and Child Healthcare Hospital. Patients younger than 18 years diagnosed with AOM were enrolled in the study. Middle ear fluid specimens were collected and cultured for bacterial pathogens. The antibiotic susceptibility, virulence genes, macrolide resistant genes and sequence types of S. aureus were identified.

RESULTS

From January 1, 2013 to December 31, 2015, a total of 228 cases of AOM were identified. Pathogenic bacteria were positive in 181 (79.4%) of 228 specimens. Streptococcus pneumoniae was the most common bacteria (36.4%), followed by S. aureus (16.2%). Among the 37 S. aureus isolates, 12 (23.5%) were methicillin-resistant S. aureus (MRSA), and 25 (77.5%) were methicillin-susceptible S. aureus (MSSA). A total of 23 isolates (62.2%) were resistant to erythromycin, 40.5% of isolates were resistant to clindamycin, and 37.8% isolates were resistant to tetracycline. Twenty-three isolates were multi-drug resistant (MDR) S. aureus. Eighteen isolates carried the pvl gene. Up to 22 (59.4%) isolates expressed ermA gene, 8 (21.6%) isolates expressed both ermA and ermC genes, and only 8.1% expressed ermB. Among all S.aureus isolates, 7 sequence types (STs) were identified by multilocus sequence typing (MLST). The most common ST was ST59 (16/37, 43.2%), followed by ST45 (7/37, 18.9%) and ST30 (7/37, 18.9%). The predominant MSSA isolates were ST59-t437-MSSA (5/25, 20.0%), the prevailing MRSA isolates were Taiwan related strains ST59-SCCmec-IVa/V (5/12, 41.6%).

CONCLUSIONS

S. aureus was the second most common cause for AOM in children in Liuzhou. Most of the S. aureus was MDR which carried a high proportion of ermA and ermC gene. CA-MRSA (ST59-SCCmec-IV/V-t437) is circulating in children with AOM. These findings support continued surveillance of S. aureus infections in children with AOM in both communities and hospitals.

Invasive pneumococcal pneumonia caused by 13-valent pneumococcal conjugate vaccine types in children with different schedules

BACKGROUND

In Taiwan, the age group with the greatest incidence of invasive pneumococcal disease is 2-5 years of age, which is different from other countries. This study was conducted to identify risk factors and different 13-valent pneumococcal conjugate vaccine (PCV13) schedules associated with vaccine-type invasive pneumococcal pneumonia (IPP) despite prior vaccination.

METHODS

A case-control study was conducted prospectively between August 2012 and December 2015 at five participating medical centers. The study enrolled children <15 years of age who were admitted to one of the five medical centers for CAP. Blood samples and acute-phase serum specimens were collected and Streptococcus pneumoniae was identified by using a real-time polymerase-chain-reaction (RT-PCR) assay targeting the lytA gene.

RESULTS

A total of 25 children diagnosed with vaccine-type IPP and 124 controls were enrolled. Vaccine-type IPP occurred in 6 (28.6%), 14 (24.1%), and 5 (7.1%) children receiving vaccines on a not-age-appropriate schedule (n = 21), primary infant schedule (n = 58), and toddler catch-up schedule (n = 70) (P = 0.008), respectively. Of 25 children, the mean age at disease onset was 36 ± 11 months; serotype 19A was responsible for 84% (21/25).

CONCLUSION

After adjustment for confounding factors, the risk of vaccine-type IPP was significantly higher among children receiving vaccines on a not-age-appropriate schedule, or on a primary infant schedule, compared with children receiving vaccines on a toddler catch-up schedule. Duration of vaccine immunity should be investigated to direct strategies for maintaining individual and population immunity against pneumococcal disease.

Serotypes not Included in 13-Valent Pneumococcal Vaccine as Causes of Acute Otitis Media with Spontaneous Tympanic Membrane Perforation in a Geographic Area with High Vaccination Coverage

In 177 children living in an area with high 13-valent pneumococcal conjugate vaccine 13 coverage, who had acute otitis media complicated with spontaneous tympanic membrane perforation, Streptococcus pneumoniae was identified in the middle ear fluid of 48 (27.1%) subjects, with 37 (77.1%) cases caused by nonpneumococcal conjugate vaccine 13 serotypes.

Acute otitis media caused by Streptococcus pneumoniae serotype 19A ST320 clone: epidemiological and clinical characteristics

BACKGROUND

Streptococcus pneumoniae serotype 19A ST320, a highly multiresistant and virulent clone, has emerged as a common pathogen causing acute otitis media (AOM) in children.

METHODS

Patients aged 0-18 years with AOM who presented at Mackay Memorial Hospital, Taipei, Taiwan were prospectively enrolled between December 1, 2009, and November 30, 2012. For each patient, a specimen of middle-ear fluid was obtained and cultured. S. pneumoniae isolates were tested by serotyping, antibiotic-resistance profiling, and multilocus sequence typing. Demographic characteristics and clinical history of patients with pneumococcal AOM were recorded.

RESULTS

Pneumococcal AOM was observed in 108 (24.8%) of 436 episodes. One hundred and four isolates of S. pneumoniae were available for study. The most common serotypes were 19A (67 isolates, 64.4%), followed by 19F (16 isolates, 15.4%), and 3 (7 isolates, 6.7%). Among the 85 sequence-typed isolates, Serotype 19A ST320 (50, 58.8%) was the most frequent. Children with AOM caused by Serotype 19A ST320 were younger (33.9 ± 21.4 months vs. 46.7 ± 35.9 months, p = 0.04) and had a higher rate of spontaneous rupture of the tympanic membrane (64.0% vs. 40%, p = 0.05) than those caused by isolates of other sequence types. Serotype 19A ST320 caused 90% of AOM episodes in children aged ≤ 12 months and had had higher resistance rates to penicillin according to meningeal breakpoints (p = 0.011), amoxicillin (p < 0.001) and trimethoprim/sulfamethoxazol (p < 0.001).

CONCLUSIONS

It is better to use pneumococcal conjugate vaccine effective against Serotype 19A in early infancy to prevent the first and subsequent episodes of AOM in children in Taiwan.

What are the leading causative pathogens in acute otitis media with tympanic membrane perforation?

OBJECTIVES

Acute otitis media (AOM) is a common infectious disease in children. Data regarding the distribution of causative pathogens are not universal. Tympanic perforation due to AOM may occur in 5-30% of AOM patients. The causative pathogens for AOM with tympanic perforation are limited.

METHODS

This was a prospective study conducted at the Department of Otolaryngology, Faculty of Medicine, Chiang Mai University, Thailand. All consecutive children diagnosed as having AOM with tympanic perforation were enrolled. The age of the eligible patients was between 3 months and 5 years. Pus from the middle ear of each patient was swabbed and tested for culture/sensitivity.

RESULTS

There were 40 eligible patients diagnosed with AOM with tympanic perforation in this study. The mean age of all patients was 24.3 months and the patients were predominantly male (26 male; 65.0%). None of these patients received S. pneumoniae or H. influenzae vaccination. All specimens were culture positive (100%) and 13 organisms were identified. There were 53 identified pathogens; the most common pathogen was H. influenzae (19 times or 35.8%), followed by Staphylococcus aureus (14 times or 26.4%). H. influenzae was 100% sensitive to chloramphenicol, amoxicilllin/clavulanic acid, cefotaxime, and ciprofloxacin, while S. aureus was also 100% sensitive to oxacillin, vancomycin, and fusidic acid.

CONCLUSIONS

The two most common pathogens for AOM with tympanic perforation were H. influenzae and Staphylococcus aureus. Both pathogens were mostly sensitive to antibiotics.

Cost-effectiveness and Health Benefits of Pediatric 23-valent Pneumococcal Polysaccharide Vaccine, 7-valent Pneumococcal Conjugate Vaccine and Forecasting 13-valent Pneumococcal Conjugate Vaccine in China

BACKGROUND

Each year in China, approximately 700,000 children under 5 years old are diagnosed with pneumonia, and 30,000 die of the disease. Although 7-valent pneumococcal conjugate vaccine (PCV-7) and 23-valent pneumococcal polysaccharide vaccine (PPV-23) are available in China, the costs are borne by the consumer, resulting in low coverage for PCV-7. We aimed to conduct a simulation study to assess the cost-effectiveness and health benefits of PCV-7, 13-valent pneumococcal conjugate vaccine (PCV-13) and PPV-23 to prevent childhood pneumonia and other vaccine-preventive diseases in China.

METHODS

An economic evaluation was performed using a Markov simulation model. Parameters including demographic, epidemiological data, costs and efficacy of vaccines were obtained from previous studies. A hypothetical cohort of 100,000 newborns (focusing on pneumococcal diseases ≤7 years old) was followed up until death or 100 years of age. The model incorporated the impact of vaccination on reduction of incidence of pneumococcal diseases and mortality of children ≤7 years. Outcomes are presented in terms of disease cases averted, quality-adjusted life years (QALYs) and incremental cost-effectiveness ratio.

RESULTS

Under baseline assumptions, PPV-23 is currently the only cost-effective option, whereas PCV-13 showed the greatest impact on pneumococcal disease burden, reducing invasive pneumococcal diseases by 31.3%, pneumonia by 15.3% and gaining 73.8 QALYs (10,000 individuals at discount rate of 3%). Incremental cost-effectiveness ratios of PCV-13 and PCV-7 are US$29,460/QALY and US$104,094/QALY, respectively, showing no cost-effectiveness based on the World Health Organization recommended willingness-to-pay threshold. On the other hand, the incremental cost-effectiveness ratios of PCVs were most sensitive to vaccination costs; if it reduces 4.7% and 32.2% for PCV-7 and PCV-13, respectively, the vaccination will be cost-effective.

CONCLUSIONS

To scale up current vaccination strategies and achieve potential health benefits, the replacement of PCV-7 with PCV-13 should be considered. As well, PCV's costs need to be reduced by increasing public subsidies and providing financial support to poor families.

Bacterial and Respiratory Viral Interactions in the Etiology of Acute Otitis Media in HIV-infected and HIV-uninfected South African Children

BACKGROUND

Bacteria and respiratory viruses are implicated in the pathogenesis of acute otitis media (AOM); however, data from low-middle income countries are sparse. We investigated the etiology of AOM in HIV-infected (HIV+), HIV-uninfected (HIV-) and HIV-exposed clinically asymptomatic for HIV-infection (HEU) South African children.

METHODS

Children ≥3 months to <5 years of age with AOM were enrolled between May 2009 and April 2010 (NCT01031082). Middle ear fluid samples were cultured for bacteria; antibacterial susceptibility was done and serotyping undertaken for Streptococcus pneumoniae and Haemophilus influenzae. Nasopharyngeal aspirates were analyzed for respiratory viruses using immunofluorescence assay and polymerase chain reaction.

RESULTS

Of 260 AOM episodes (HIV+:15; HIV-:182; HEU:63), bacteria were found in 54.6%, including Haemophilus influenzae (30.8%), 98.8% of which were nontypeable, and Streptococcus pneumoniae (20.4%), Staphylococcus aureus (15.8%), Moraxella catarrhalis (5.0%) and Streptococcus pyogenes (1.5%). Nonsusceptibility of Streptococcus pneumoniae to penicillin was 64.2%. Respiratory viruses were detected in 74.2% of cases. Human rhinovirus was most frequently detected (37.7%), followed by adenovirus (14.2%) and human bocavirus (11.5%) overall and irrespective of HIV status. Respiratory viruses were identified concurrently with S. pneumoniae, H. influenzae, M. catarrhalis (76.9-78.8%) and Staphylococcus aureus (63.4%) cultured from middle ear fluid, as well as in 72.0% of episodes negative for any bacteria.

CONCLUSION

The study suggests that respiratory viruses and pathogenic bacteria play an important role in the development of AOM in children. A similar spectrum of pathogens was observed independently of HIV status. Vaccines targeting both nontypeable Haemophilus influenzae and S. pneumoniae may have a broad impact on AOM in South Africa.

Vitamin A deficiency is associated with gastrointestinal and respiratory morbidity in school-age children

Infection is an important cause of morbidity throughout childhood. Poor micronutrient status is a risk factor for infection-related morbidity in young children, but it is not clear whether these associations persist during school-age years. We examined the relation between blood concentrations of micronutrient status biomarkers and risk of gastrointestinal and respiratory morbidity in a prospective study of 2774 children aged 5-12 y from public schools in Bogotá, Colombia. Retinol, zinc, ferritin, mean corpuscular volume, hemoglobin, erythrocyte folate, and vitamin B-12 concentrations were measured in blood at enrollment into the cohort. Children were followed for 1 academic year for incidence of morbidity, including diarrhea with vomiting, cough with fever, earache or ear discharge with fever, and doctor visits. Compared with adequate vitamin A status (≥30.0 μg/dL), vitamin A deficiency (<10.0 μg/dL) was associated with increased risk of diarrhea with vomiting [unadjusted incidence rate ratio (IRR): 2.17; 95% CI: 0.95, 4.96; P-trend = 0.03] and cough with fever (unadjusted IRR: 2.36; 95% CI: 1.30, 4.31; P-trend = 0.05). After adjustment for several sociodemographic characteristics and hemoglobin concentrations, every 10 μg/dL plasma retinol was associated with 18% fewer days of diarrhea with vomiting (P < 0.001), 10% fewer days of cough with fever (P < 0.001), and 6% fewer doctor visits (P = 0.01). Every 1 g/dL of hemoglobin was related to 17% fewer days with ear infection symptoms (P < 0.001) and 5% fewer doctor visits (P = 0.009) after controlling for sociodemographic factors and retinol concentrations. Zinc, ferritin, mean corpuscular volume, erythrocyte folate, and vitamin B-12 status were not associated with morbidity or doctor visits. Vitamin A and hemoglobin concentrations were inversely related to rates of morbidity in school-age children. Whether vitamin A supplementation reduces the risk or severity of infection in children over 5 y of age needs to be determined.

Update on otitis media - prevention and treatment

Acute otitis media and otitis media with effusion are common childhood disorders, a source of significant morbidity, and a leading cause of antibiotic prescription in primary health care. Although effective treatments are available, some shortcomings remain, and thus better treatments would be welcome. Recent discoveries within the field of otitis media research relating to its etiology and pathogenesis have led to further investigation aimed at developing novel treatments. This article provides a review of the latest evidence relating to the understanding of acute otitis media and otitis media with effusion, current treatment strategies, their limitations, new areas of research, and novel strategies for treatment.