Antimicrobial treatment of acute otitis media

Estimating amoxicillin influx/efflux in chinchilla middle ear fluid and simultaneous measurement of antibacterial effect

Understanding the transport process and the factors that control the influx/efflux of antibiotics between plasma and middle ear fluid is essential in optimizing the antimicrobial efficacy in the treatment of acute otitis media. In this study, an experimental chinchilla model with the application of a microdialysis technique was utilized to evaluate amoxicillin middle ear distribution kinetics. Amoxicillin solutions at various doses were instilled into the middle ear with a simultaneous intravenous bolus dose. Unbound amoxicillin levels were monitored by microdialysis in both ears. Serial phlebotomy provided samples for the measurement of unbound amoxicillin concentration in plasma ultrafiltrates. In infected chinchillas, discrete middle ear fluid samples were plated and cultured to characterize Streptococcus pneumoniae growth-kill kinetics. Noncompartmental analysis was used to estimate distributional and elimination clearances assuming linear pharmacokinetics. A nonlinear Michaelis-Menten equation was also used to determine the efflux clearance (from middle ear fluid to plasma) in a mammillary compartment model. No difference was observed in amoxicillin pharmacokinetics between control and infected chinchillas. Influx clearance was (4.6 +/- 2.4) x 10(-3) ml/min-kg and significantly lower than the efflux clearance estimated as (19.2 +/- 9.7) x 10(-3) ml/min-kg (P < 0.002). Nonlinear kinetics was observed in the locally dosed ear. The microdialysis procedure did not interfere with the bacterial growth-kill profile, thereby enabling pharmacokinetic and pharmacodynamic evaluation concurrently. In conclusion, the results suggested that the distribution equilibrium of amoxicillin in the middle ear favors efflux to plasma over influx. An active transport mechanism across middle ear mucosal epithelium may be involved in amoxicillin distribution.

Microdialysis studies of the distribution of antibiotics into chinchilla middle ear fluid

For conditions such as acute otitis media, in which antibiotic penetration into middle ear fluid (MEF) may be slow or limited, antibiotic plasma levels may not reflect the concentrations at the site of infection that are relevant to clinical outcome. In such cases, a model is needed that will enable prediction of the time course of unbound, pharmacologically active antibiotic levels in MEF. We describe the use of microdialysis as a sampling tool for measurement of unbound antibiotic concentrations in the MEF of the awake, freely moving chinchilla. Results of studies of MEF penetration of the beta-lactam antibiotic, cefdinir, with use of this technique are also described. Preliminary results of studies of the penetration of antibiotics into MEF of the chinchilla appear consistent with clinical findings and suggest that the chinchilla microdialysis model may prove to be a useful tool for predicting antibiotic efficacy in patients.

The chinchilla microdialysis model for the study of antibiotic distribution to middle ear fluid

In cases of slow or limited penetration of an antibiotic to the site of infection such as in acute otitis media (the middle ear), plasma levels of the agent may not reflect the concentrations that are relevant in determining clinical outcome. There is a need for a model that allows prediction of the time-course of unbound, pharmacologically active drug levels in middle ear fluid (MEF). This article introduces microdialysis as a sampling tool to measure unbound antibiotic concentrations in the MEF of the chinchilla, and briefly summarizes the results of studies of MEF penetration of a cephalosporin, a macrolide, and a ketolide antibiotic using this technique. The general concurrence of preliminary results of the chinchilla studies with clinical findings suggests that the chinchilla microdialysis model may be useful in predicting efficacy in patients.

Microdialysis studies of the middle ear distribution kinetics of amoxicillin in the awake chinchilla

This work was performed to develop an experimental animal model for the study of antibiotic drug distribution into middle ear fluid (MEF) and to evaluate its relevance and significance to the clinical treatment of otitis media (OM). Chinchillas were assigned to normal or infected ear groups after Eustachian tube obstruction (ETO) or direct trans-bullar inoculation with type 3 Streptococcus pneumoniae. Following survival surgery to implant microdialysis (MD) probes in the jugular vein and middle ear (ME), amoxicillin was given intravenously (iv) as a bolus or infusion. Drug concentrations in blood and MEF were continuously monitored by microdialysis. The measured concentrations were corrected for probe recovery by simultaneous retrodialysis. Multiple MEF and blood sampling was also performed to validate the animal model and MD sampling technique. Bacterial infection was successfully induced 3-7 days after the inoculation, whereas the control group gave negative bacterial culture results. The beta-lactam antibiotic, amoxicillin, exhibited an elimination half-life of 0.33+/-0.23 h (n = 9) in chinchilla blood, 1.46+/-0.50 h (n = 5) and 1.75+/-0.84 h (n = 4) in MEF of normal and infected ears (p = 0.6), respectively. MEF-to-blood amoxicillin concentration ratios at steady state following iv infusion were 0.26+/-0.06 (n = 5) and 0.28+/-0.11 (n = 4) for normal and infected ears (p = 0.7), respectively. MD allows continuous monitoring of drug concentration-time profiles in blood and MEF in an awake chinchilla model. The concentrations measured by MD were validated by direct sampling. The ratio of the area under the curve (AUC) of drug concentration in MEF versus time to that in blood after iv bolus doses was less than unity, as was the steady-state concentration ratio following constant-rate iv infusion, suggesting an active transport mechanism was involved in the efflux of amoxicillin from the ME of chinchilla. The results of studies involving infected ears were not significantly different from those in normal ears in terms of amoxicillin distribution across the ME mucosal membrane after systemic administration.

Cefprozil and respiratory tract infections in children

Respiratory tract infections are the leading cause of children's visits to physicians. Antibiotic resistance is increasing among the three most common bacterial respiratory pathogens, Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis, which cause acute otitis media and sinusitis. Therefore clinicians may need to reexamine their treatment strategies because these infections may cause complications. Antibiotic selection in such infections should take into account local bacterial resistance patterns, anticipated clinical efficacy against S. pneumoniae, H. influenzae and M. catarrhalis, including penicillin-resistant and beta-lactamase-producing strains, as well as the safety profile and compliance-enhancing features of the drug.

Amoxicillin middle ear fluid penetration and pharmacokinetics in children with acute otitis media

BACKGROUND

Acute otitis media (AOM) is a common childhood infectious disease. The efficacy of antibiotic dosing regimens is usually assessed by antibiotic plasma pharmacokinetics or middle ear fluid (MEF) concentration at one or two time points. Viral coinfection in AOM reduced antibacterial efficacy of antibiotics.

OBJECTIVE

To determine amoxicillin MEF penetration and pharmacokinetics in bacterial and combined bacterial and viral AOM.

METHODS

Thirty-four children with AOM were enrolled, and MEF was collected by tympanocentesis for bacterial culture and viral studies. Nasal wash and venous blood were also obtained for viral culture and serologic studies, respectively. Subjects were treated with amoxicillin 40 mg/kg/day orally, divided in equal doses every 8 h. During the second visit (48 to 72 h later) the subjects, with the regular morning amoxicillin dose withheld, were given an oral amoxicillin dose of 25 mg/kg. Thereafter two blood samples and one MEF sample by tympanocentesis were collected from each child at selected times between 0.5 and 4.0 h after dosing for bacterial and viral studies and amoxicillin concentration determination by high performance liquid chromatography.

RESULTS

Eleven (37%) children had only bacterial infection, 6 (20%) had viral infection only, 6 (20%) had both bacterial and viral infections and in 7 (23%) neither bacterial nor viral pathogens were recovered. MEF bacterial culture was positive in 23 of 40 ears (57.5%) before treatment with amoxicillin (40 mg/kg/day) and was still positive in 4 of 38 ears (10.5%) after 2 to 3 days of treatment. Amoxicillin plasma concentration reached its peak at 1.0 to 1.5 h after a 25-mg/kg oral dose. The estimated MEF concentration peak occurred 3.0 h after the dose with MEF concentrations ranging from undetectable to 20.6 microg/ml and a mean of approximately 9.5 microg/ml. Geometric mean amoxicillin concentrations were lowest in virus-infected children (2.7 microg/ml), nearly the same in culture-negative samples from children without viral infection (2.9 microg/ml), higher in children with combined bacterial and viral infection (4.1 microg/ml) and highest in children with bacterial-only infection (5.7 microg/ml).

CONCLUSIONS

MEF amoxicillin penetration tended to be lower in children with viral infection. The current amoxicillin dosing recommendation of 40 mg/kg/day in three divided dose is inadequate to effectively eradicate resistant Streptococcus pneumoniae, particularly during viral coinfection. A dosing regimen of 75 to 90 mg/kg/day is recommended for AOM.

Chlamydia pneumoniae in acute otitis media

BACKGROUND

Aerobic bacterial pathogens are recovered from 65 to 85% of patients with acute otitis media (AOM). Although Chlamydia pneumoniae is a common pathogen of pediatric pneumonia, it has rarely been cultured from children with chronic otitis media and its role in AOM is unknown.

METHODS

We cultured for C. pneumoniae in tympanocentesis aspirates and nasopharyngeal swabs from 101 consecutive, otherwise healthy children with AOM or refractory AOM. A control group of 50 similarly aged, healthy children was evaluated for nasopharyngeal carriage of C. pneumoniae. Specimens were also evaluated by PCR for C. pneumoniae.

RESULTS

C. pneumoniae was recovered by tympanocentesis in 8 (8%) of 101 children with AOM. Among the 8 children with C. pneumoniae-positive-AOM, 5 had C. pneumoniae detected by PCR in middle ear fluid, none had C. pneumoniae recovered by nasopharyngeal culture or PCR and 5 were younger than 16 months. C. pneumoniae was the sole pathogen isolated in 2 patients. Copathogens included beta-lactamase-positive positive Haemophilus influenzae (2), beta-lactamase positive Moraxella catarrhalis (1), penicillin-resistant Streptococcus pneumoniae (2) and penicillin-susceptible S. pneumoniae (1). C. pneumoniae was recovered from nasopharyngeal culture in 2 additional patients with C. pneumoniae-negative AOM and in none of 50 healthy control children, although 2 controls were positive by PCR from the nasopharynx.

CONCLUSIONS

This is the first study to report the isolation of C. pneumoniae in middle ear fluid of children with AOM.

High-performance liquid chromatographic analysis of amoxicillin in human and chinchilla plasma, middle ear fluid and whole blood

We extended the application of a sensitive high-performance liquid chromatography assay of amoxicillin developed in this laboratory for human plasma and middle ear fluid (MEF) to other sample matrices including chinchilla plasma or MEF and human and chinchilla whole blood with minor modification and validated the limit of quantitation at 0.25 microg/ml with a 50-microl sample size for human and chinchilla plasmas or MEFs. Amoxicillin and cefadroxil, the internal standard, were extracted from 50 microl of the samples with Bond Elut C18 cartridges. The extract was analyzed on a Keystone MOS Hypersil-1 (C8) column with UV detection at 210 nm. The mobile phase was 6% acetonitrile in 5 mM phosphate buffer, pH 6.5 and 5 mM tetrabutylammonium. The within-day coefficients of variation were 2.7-9.9 (n=4) and 1.7-7.2% (n=3) for chinchilla plasma and MEF samples, respectively; 2.8-8.1% (n=3) and 2.9-4.7% (n=3) for human and chinchilla whole blood, respectively. An alternative mobile phase composition for chinchilla plasma and MEF samples reduced the analysis time significantly.

The antibiotic treatment of acute otitis media and sinusitis in children

The development of resistance among the bacterial pathogens causing acute otitis media and sinusitis in children is causing considerable concern. Although normally a mild infection, acute otitis media can produce serious complications with sequelae that can have long-lasting effects. High levels of resistance are now being seen in the three principal pathogens. Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. Most clinical trials comparing the efficacy of different antibiotics have failed to show differences in clinical efficacy. To overcome this problem, alternative methods of assessing antibiotics have been developed including the "in-vivo sensitivity test" proposed by Howie and retrospective analyses of treatment failures. The treatment of sinusitis is complicated by the difficulty in establishing a clear differential diagnosis. To date, no definitive trials of bacteriologic efficacy in children have been published.

Sensitive assay for measuring amoxicillin in human plasma and middle ear fluid using solid-phase extraction and reversed-phase high-performance liquid chromatography

We developed a sensitive assay to measure amoxicillin in human plasma and middle ear fluid (MEF) using solid-phase extraction and reversed-phase HPLC. Amoxicillin and cefadroxil, the internal standard, were extracted from 50-200 microliters of sample with Bond Elut C18 cartridges. The extract was analyzed on a 15 cm x 2 mm, 5 micron Keystone MOS Hypersil-1 (C8) column with UV detection at 210 nm. The mobile phase was 6% acetonitrile in 5 mM phosphate buffer (pH = 6.5) and 5 mM tetrabutylammonium. The average absolute recovery of amoxicillin and cefadroxil were 91.2 +/- 16.6% and 91.0 +/- 6.8%, respectively. The limit of quantitation was 0.125 microgram/ml with 200 microliters sample size. The linear range was from 0.125 to 35.0 micrograms/ml with correlation coefficients greater than 0.999. These analytic conditions produced a highly sensitive amoxicillin assay in human body fluids without derivatization.

Acute otitis media in childhood: a study of 20,532 cases

We present a study of acute otitis media among 20,532 Spanish children during a 6-month period from January through June 1991. The study was done by distributing a questionnaire to all Spanish pediatricians. Of the patients 51.7% were girls and 48.3% boys; 68.7% of all children were younger than 5 years. The most frequent symptoms were otalgia or irritability, 92.7%; fever, 63.5%; otorrhea, 24.9%; vomiting, 21.4%; and another concomitant upper respiratory tract infection, 65.5%. Otitis was bilateral in 45.6% of the cases. The most frequently used antibiotic was cefixime (38%), followed by amoxicillin-clavulanate (22.2%), amoxicillin (15.3%), 2nd-generation cephalosporins (13.5%) and macrolides (8.8%). In 11.8% of the patients, a change in the initial antibiotic therapy was required due to adverse effects. Resolution of symptoms occurred in 77.8% of the patients.

Outcome of acute otitis media with abnormal tympanometric patterns in children

OBJECTIVE

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.

METHODS

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.

RESULTS

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.

CONCLUSION

ED tympanometry of children with acute otitis media is unable to provide prognostic information regarding treatment failure, recurrent infection, or persistent middle ear effusion.

Comparison of two otitis media models for the study of middle ear antimicrobial pharmacokinetics

We compared two models of acute otitis media that estimate middle ear antimicrobial pharmacokinetics. Using a crossover study design, we compared a systemic drug administration model with a diffusion model we devised that measures the disappearance of antimicrobials from the middle ear. We induced acute otitis media in 14 chinchillas by inoculating S. pneumoniae into the middle ear, then administered 3 antimicrobials: amoxicillin, trimethoprim, and sulfamethoxazole. Next we collected middle ear fluid samples to analyze drug concentrations and compare rate constants for the systemic and diffusion models by analysis of variance. We found that amoxicillin K values were not affected by model testing sequence (p = 0.827) or model type (systemic versus diffusion, p = 0.310), nor were sulfamethoxazole K values: model testing sequence (p = 0.917), model type (p = 0.963). Trimethoprim K values were also not affected by model testing sequence (p = 0/760), but were by model type (p = 0.0001). Trimethoprim elimination from the diffusion model was faster (K = 0.33 +/- 0.17 versus 0.57 +/- 0.09 hr-1) than from the systemic model, although it appears this was caused by sampling before drug distribution into the middle ear was complete. In conclusion, it appears K values derived from either systemic antimicrobial administration or direct middle ear instillation are similar for assessing middle ear antimicrobial pharmacokinetics, and these models can be used interchangeably to study factors affecting otitis media treatment response.

Effect of Streptococcus pneumoniae and influenza A virus on middle ear antimicrobial pharmacokinetics in experimental otitis media

Antimicrobial treatment failures in children with acute otitis media and concomitant viral respiratory tract infection prompted us to study the effects of influenza A virus infection on middle ear antimicrobial drug penetration. Using a chinchilla model of Streptococcus pneumoniae we compared middle ear elimination rates in 4 groups of chinchillas: (1) control, (2) influenza A virus inoculation alone intranasally, (3) both influenza A and S. pneumoniae inoculation directly into the middle ear, and (4) S. pneumoniae inoculation alone into the middle ear. After infection was established, a solution containing amoxicillin, sulfamethoxazole, and trimethoprim was instilled into the middle ear and removed 4 hours later. The rate constant of elimination and half-life were calculated from measured drug concentrations initially and at 4 hours. S. pneumoniae infection alone significantly shortened the middle ear elimination half-life compared with the control group: amoxicillin, 2.65 +/- 0.73 vs. 6.63 +/- 2.55 hr; sulfamethoxazole, 1.75 +/- 0.28 vs. 2.74 +/- 0.6 hr; and trimethoprim, 1.06 +/- 0.14 vs. 1.56 +/- 0.34 hr (n = 16 ears, p values all < 0.01). The combined influenza virus and S. pneumoniae infection significantly lengthened the half-life compared with the S. pneumoniae infection alone: amoxicillin, 5.65 +/- 6.44 vs. 2.65 +/- 0.73 hr; sulfamethoxazole, 2.5 +/- 0.85 vs. 1.75 +/- 0.28 hr; and trimethoprim, 1.26 +/- 0.42 vs. 1.06 +/- 0.14 hr (n = 16 ears, p values all < 0.01). Influenza virus produced the longest half-lives for all 3 antimicrobials: amoxicillin 25.52 +/- 14.96 hr; sulfamethoxazole, 5.46 +/- 0.87 hr; and trimethoprim, 2.57 +/- 0.75 hr.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute mastoiditis--relevant once again

During recent years, a significantly increased incidence of acute mastoiditis was observed at the University Children's Hospital, Tübingen, Germany (1975-1979: 1.4 patients/year; 1987-1992: 4.2 patients/year; p < 0.05). We therefore reviewed the records of all patients with acute mastoiditis (n = 58) that had been treated at the Children's Hospital between 1975 and 1992 and at the Clinic of Otorhinolaryngology between 1978 and 1992. The male to female ratio was 1.8:1 and 60.4% of the patients were younger than 24 months. Retroauricular swelling was more often observed (n = 49) than protrusion of the pinna (n = 45) and retroauricular redness (n = 38). Streptococcus pneumoniae was the most frequently isolated pathogen. Several factors predisposing for the development of acute mastoiditis were identified. These included withholding antimicrobials for treatment of the preceding episode of otitis media; use of suboptimal agents for therapy of otitis media (penicillin and, possibly, erythromycin ethylsuccinate); and insufficient duration of treatment.

Determination of cefpodoxime levels in chinchilla middle ear fluid and plasma by high-performance liquid chromatography

A high-performance liquid chromatographic method has been developed to determine cefpodoxime levels in chinchilla plasma and middle ear fluid (MEF) to be used in studying otitis media. Cefpodoxime and the internal standard, cefuroxime, were separated on an ODS column (250 x 2.1 mm I.D., 5 microns Hypersil), using a mobile phase of 25 mM acetate buffer (pH 4.3)/15 mM triethylamine-acetonitrile (92.5:7.5, v/v). Following elution of cefpodoxime and the internal standard, at 3.5 and 5.9 min respectively, the acetonitrile concentration was increased to 1:1 (v/v) in a step function to elute endogenous compounds retained on the column. Sample preparation involved protein precipitation with acetonitrile. This fast, efficient protein precipitation procedure together with UV detection allows a quantitation limit of 50 ng/ml with a 50-microliters sample size. Recoveries (mean +/- S.D., n = 3) at 0.1 microgram/ml in MEF were 90.3 +/- 2.9% and 88.6 +/- 1.2% for cefpodoxime and cefuroxime respectively. Recoveries (mean +/- S.D., n = 3) at 0.1 microgram/ml in plasma were 72.1 +/- 7.3% and 81.1 +/- 1.1% for cefpodoxime and cefuroxime respectively. The method was evaluated with biological samples taken from chinchillas with middle ear infections after administering cefpodoxime proxetil.

Clinical efficacy of antimicrobial drugs for acute otitis media: metaanalysis of 5400 children from thirty-three randomized trials

OBJECTIVE

To reconcile conflicting published reports concerning the absolute and comparative clinical efficacy of antimicrobial drugs for acute otitis media in children.

STUDY SELECTION

Articles were identified by MEDLINE search, Current Contents, and references from review articles, textbook chapters, and retrieved reports. Randomized, controlled trials of therapeutic antimicrobial drugs used in the initial empiric therapy for simple acute otitis media were selected by independent, blinded observers, and scored on 11 measures of study validity. Thirty English and three foreign-language articles met all inclusion criteria.

DATA EXTRACTION

Data were abstracted for an end point of complete clinical resolution (primary control), exclusive of middle ear effusion, within 7 to 14 days after therapy started.

DATA SYNTHESIS

The spontaneous rate of primary control--without antibiotics or tympanocentesis--was 81% (95% confidence interval, 69% to 94%). Compared with placebo or no drug, antimicrobial therapy increased primary control by 13.7% (95% confidence interval, 8.2% to 19.2%). No significant differences were found in the comparative efficacy of various antimicrobial agents. Extending antimicrobial coverage to include beta-lactamase-producing organisms did not significantly increase the rates of primary control or resolution of middle ear effusion. Pretreatment tympanocentesis was positively associated with individual group primary control rates, negatively associated with the ability to detect differences in clinical efficacy and unassociated with resolution of MEE.

CONCLUSIONS

Antimicrobial drugs have a modest but significant impact on the primary control of acute otitis media. Treatment with beta-lactamase-stable agents does not increase resolution of acute symptoms or middle ear effusion; initial therapy should be guided by considerations of safety, tolerability, and affordability, and not by the theoretical advantage of an extended antibacterial spectrum.

Determination of ciprofloxacin levels in chinchilla middle ear effusion and plasma by high-performance liquid chromatography with fluorescence detection

An isocratic high-performance liquid chromatographic method has been developed to determine ciprofloxacin levels in chinchilla plasma and middle ear fluid. Ciprofloxacin and the internal standard, difloxacin, were separated on a Keystone ODS column (100 x 2.1 mm I.D., 5 microns Hypersil) using a mobile phase of 30 mM phosphate buffer (pH 3), 20 mM triethylamine, 20 mM sodium dodecyl sulphate-acetonitrile (60:40, v/v). The retention times were 3.0 min for ciprofloxacin and 5.2 min for difloxacin. This fast, efficient protein precipitation procedure together with fluorescence detection allows a quantification limit of 25 ng/ml with a 50 microliters sample size. The detection limit is 5 ng/ml with a signal-to-noise ratio of 5:1. Recoveries (mean +/- S.D., n = 5) at 100 ng/ml in plasma and middle ear fluid were 89.4 +/- 1.2% and 91.4 +/- 1.6%, respectively. The method was evaluated with biological samples taken from chinchillas with middle ear infections after administering ciprofloxacin.

Recent advances in the treatment of otitis media

Otitis media (OM) continues to be a major cause of morbidity in infants and children. Antibiotics are presently the mainstay of treatment. A variety of agents including vaccinations against the most common causative organisms, prednisone, non-steroidal anti-inflammatory agents, intravenous immune globulin, antihistamines, decongestants, and topical antibiotics have been investigated. This review will address the recent developments in the treatment and prevention of OM.