Flaws in design and conduct of clinical trials in acute otitis media

Pediatric Community-acquired Pneumonia: What is it, and How Do We Study It?

Pediatric community-acquired pneumonia in pre-school aged children is a common diagnosis, frequently treated with antibiotics although most often caused by viruses. An accurate assessment of treatment-related clinical outcomes is dependent on identifying the pathogen(s) and their susceptibility to treatment interventions.

Preventing unnecessary tympanostomy tube placement in children

OBJECTIVE

In 2013 the American Academy of Otolaryngology published tympanostomy tube guidelines for children; Action Statement 6 recommends against tube placement without middle ear effusion (MEE) at time of assessment. To date, little research has directly evaluated this recommendation in reducing the need for ear tubes. We evaluated the effectiveness of this recommendation and potential risk factors that influence the success of watchful waiting.

METHODS

Retrospective chart review collecting demographics, daycare status, smoking exposure, and time of year of visit. Children aged 6 months to 12 years without MEE on presentation, but with 3 or more episodes of acute otitis media (AOM) in 6 months or 4 or more episodes in 12 months, were assigned to watchful waiting (WW) treatment. These patients were followed every 4 months or returned sooner with additional infections. Any continued AOM, or MEE on follow up leading to tube placement, defined WW failure.

RESULTS

123 patients met criteria, with 81 still in WW to date (66% success rate). 42 children failed WW and received tympanostomy tubes (34% failure rate). There were no statistically significant associations between age, race, gender, smoking exposure, daycare, or month of presentation between children who failed WW compared to children receiving tubes.

CONCLUSIONS

Tympanostomy tube guidelines mitigate unnecessary tube placement in a majority of children with recurrent AOM without MEE. To our knowledge, this is the first study supporting the 2013 recommendations, with a 66% success rate. Additionally, no significant associations between modifying risk factors in those who failed watchful waiting were identified.

Shortened Antimicrobial Treatment for Acute Otitis Media in Young Children

BACKGROUND

Limiting the duration of antimicrobial treatment constitutes a potential strategy to reduce the risk of antimicrobial resistance among children with acute otitis media.

METHODS

We assigned 520 children, 6 to 23 months of age, with acute otitis media to receive amoxicillin-clavulanate either for a standard duration of 10 days or for a reduced duration of 5 days followed by placebo for 5 days. We measured rates of clinical response (in a systematic fashion, on the basis of signs and symptomatic response), recurrence, and nasopharyngeal colonization, and we analyzed episode outcomes using a noninferiority approach. Symptom scores ranged from 0 to 14, with higher numbers indicating more severe symptoms.

RESULTS

Children who were treated with amoxicillin-clavulanate for 5 days were more likely than those who were treated for 10 days to have clinical failure (77 of 229 children [34%] vs. 39 of 238 [16%]; difference, 17 percentage points [based on unrounded data]; 95% confidence interval, 9 to 25). The mean symptom scores over the period from day 6 to day 14 were 1.61 in the 5-day group and 1.34 in the 10-day group (P=0.07); the mean scores at the day-12-to-14 assessment were 1.89 versus 1.20 (P=0.001). The percentage of children whose symptom scores decreased more than 50% (indicating less severe symptoms) from baseline to the end of treatment was lower in the 5-day group than in the 10-day group (181 of 227 children [80%] vs. 211 of 233 [91%], P=0.003). We found no significant between-group differences in rates of recurrence, adverse events, or nasopharyngeal colonization with penicillin-nonsusceptible pathogens. Clinical-failure rates were greater among children who had been exposed to three or more children for 10 or more hours per week than among those with less exposure (P=0.02) and were also greater among children with infection in both ears than among those with infection in one ear (P<0.001).

CONCLUSIONS

Among children 6 to 23 months of age with acute otitis media, reduced-duration antimicrobial treatment resulted in less favorable outcomes than standard-duration treatment; in addition, neither the rate of adverse events nor the rate of emergence of antimicrobial resistance was lower with the shorter regimen. (Funded by the National Institute of Allergy and Infectious Diseases and the National Center for Research Resources; ClinicalTrials.gov number, NCT01511107 .).

Quality-of-Life Differences among Diagnostic Subgroups of Children Receiving Ventilating Tubes for Otitis Media

OBJECTIVE

The pathological picture may differ considerably between diagnostic subgroups of children with otitis media receiving ventilating tubes. The aims of this study are to investigate differences in quality of life among diagnostic subgroups of children treated with ventilating tubes and to investigate possible predictors for clinical success.

STUDY DESIGN

Longitudinal observational study.

SETTING

Secondary care units.

METHODS

Four hundred ninety-one families were enrolled in the study. The Otitis Media-6 questionnaire was applied in the assessment of child quality of life. Caregivers completed questionnaires at 7 time points from before treatment to 18-month follow-up. Logistic regression analysis was used to investigate possible predictors for clinical success.

RESULTS

Response rates ranged from 96% to 81%; diagnostic distribution: 15% recurrent acute otitis media (rAOM), 47% otitis media with effusion (OME), and 38% mixed diagnosis of rAOM and OME (rAOM/OME). There were no significant differences between children diagnosed with rAOM and children diagnosed with rAOM/OME. However, these children had a significantly poorer quality of life at baseline compared with children diagnosed with only OME. Factors associated with clinical success included a diagnosis of rAOM, number of interrupted nights, physician visits, and canceled social activities due to OM.

CONCLUSIONS

Results highlight the importance of distinguishing between diagnostic subgroups of children having ventilating tube treatment. A diagnosis of rAOM was found to predict baseline quality of life. Children with rAOM with or without OME were found to suffer significantly more than children with only OME before treatment. Factors associated with disease severity were found to predict clinical success.

The importance of being specific--a meta-analysis evaluating the effect of antibiotics in acute otitis media

BACKGROUND

Whether acute otitis media (AOM) should be the cause for antibiotic treatment has been a matter of debate during the last decades. Treatment guidelines are based on less than twenty trials that have found the effect of antibiotics on symptomatic outcomes in AOM, such as pain, to be very modest. Two recent trials found a more substantial effect of antibiotics when they looked at treatment failure as the outcome. That the effect varies with the chosen outcome may not only be because the true effect is different but also because different outcomes are more or less specific for the disease in question.

OBJECTIVE

The purpose of this study was to perform a meta-analysis to calculate a composite risk ratio for treatment failure in AOM and also to investigate whether the specificity of treatment failure as an outcome differs from that of symptomatic outcomes, such as pain.

METHODS

Trials evaluating the effect of antibiotics in AOM and reporting the number of treatment failures were identified and a fixed-effects meta-analysis was performed. In addition, the literature was searched for articles providing direct or indirect figures on the specificity of different outcomes in AOM trials. A hypothetical study was designed to show how differences in sensitivity/specificity of inclusion/outcome criteria affect the results of a trial.

RESULTS

The meta-analysis yielded a composite risk ratio of 0.4 (95% CI 0.35-0.48), p<0.001 for the effect of antibiotics on treatment failure. Based on data from the literature, the specificity of treatment failure was estimated to 92-100%. The hypothetical study showed how a non-specific outcome biases the effect estimate towards the null, whereas other kinds of misclassification only decrease precision.

CONCLUSION

Future trials should focus on improving diagnostic criteria to increase precision but primarily, they should focus on choosing a specific outcome in order not to get a biased effect estimate.

Systematic review on antibiotic therapy for pneumonia in children between 2 and 59 months of age

Community-acquired pneumonia (CAP) remains a force to reckon with, as it accounts for 1.1 million of all deaths in children less than 5 years of age globally, with disproportionately higher mortality occurring in the low and middle income-countries (LMICs) of Southeast Asia and Africa. Existing strategies to curb pneumonia-related morbidity and mortality have not effectively translated into meaningful control of pneumonia-related burden. In the present systematic review, we conducted a meta-analysis of trials conducted in LMICs to determine the most suitable antibiotic therapy for treating pneumonia (very severe, severe and non-severe). While previous reviews, including the most recent review by Lodha et al, have focused either on single modality of antibiotic therapy (such as choice of antibiotic) or children under the age of 16 years, the current review updates evidence on the choice of drug, duration, route and combination of antibiotics in children specifically between 2 and 59 months of age. We included randomised controlled trials (RCTs) and quasi-RCTs that assessed the route, dose, combination and duration of antibiotics in the management of WHO-defined very severe/severe/non-severe CAP. Study participants included children between 2 and 59 months of age with CAP. All available titles and abstracts were screened for inclusion by two review authors independently. All data was entered and analysed using Review Manager 5 software. The review identified 8122 studies on initial search, of which 22 studies which enrolled 20,593 children were included in meta-analyses. Evidence from these trials showed a combination of penicillin/ampicillin and gentamicin to be effective for managing very severe pneumonia in children between 2 and 59 months of age, and oral amoxicillin to be equally efficacious, as other parenteral antibiotics for managing severe pneumonia in children of this particular age group. Oral amoxicillin was also found to be effective in non-severe pneumonia as well. The review further found a short 3 day course of antibiotics to be equally beneficial as 5 day course for managing non-severe pneumonia in children between 2 and 59 months of age. This review updates evidence on the general spectrum of antibiotic recommendation for CAP in children between 2 and 59 months of age, which is an age group that warrants special focus owing to its high disease and mortality burden. Evidence derived from the review found oral amoxicillin to be equally effective as parenteral antibiotics for severe pneumonia in the 2-59 month age group, which holds important implications for LMICs where parenteral drug administration is an issue. Also, the review's finding that 3 day course of antibiotic is equally effective as 5 day course for non-severe pneumonia for 2-59 months of age is again beneficial for LMICs, as a shorter therapy will be associated with a lower cost. The review addresses some research gaps in antibiotic treatment for CAP as well, and this crucial information is presented with the aim of providing a targeted cure for the middle and low income setting.

A pilot study of single-dose azithromycin versus three-day azithromycin or single-dose ceftriaxone for uncomplicated acute otitis media in children

BACKGROUND

The pharmacokinetic profile of azithromycin supports its use as single-dose therapy for uncomplicated acute otitis media (AOM) in children.

OBJECTIVE

This study was designed to (1) compare the safety of single-dose oral azithromycin, 3 daily doses of oral azithromycin, and a single dose of intramuscular ceftriaxone for the treatment of uncomplicated AOM in children, and (2) provide preliminary efficacy data to support initiation of a larger, comparative trial of single-dose azithromycin for the treatment of uncomplicated acute otitis media in children.

METHODS

In this single-center pilot study, children with uncomplicated AOM were randomly assigned to receive single-dose oral azithromycin (30 mg/kg), 3-day oral azithromycin (10 mg/kg once daily), or single-dose intramuscular ceftriaxone (50 mg/kg). Tympanocentesis was performed before administration of the first dose, and clinical response was assessed on days 14-15 and 28-30.

RESULTS

Between September 1995 and May 1997, 198 children (mean age, 2.5 years) were enrolled. All of the patients were evaluable for the safety and clinical intent-to-treat (ITT) analyses, and 98 were evaluable for the microbiologic ITT analysis. On day 14-15, rates of clinical success (cure or improvement) for the 3 treatment groups were: 62/64 (97%) for single-dose azithromycin, 60/63 (95%) for 3-day azithromycin, and 61/62 (98%) for single-dose ceftriaxone. On day 28-30, the corresponding clinical success rates were 61/65 (94%), 61/66 (92%), and 62/64 (97%). For the 98 microbiologically evaluable patients, clinical success rates at day 14-15 were 28/30 (93%) for single-dose azithromycin, 31/35 (89%) for 3-day azithromycin, and 33/33 (100%) for single-dose ceftriaxone. On day 28-30, the corresponding clinical success rates were 27/30 (90%), 30/35 (86%), and 32/33 (97%). Treatment-related adverse event rates for single-dose azithromycin, 3-day azithromycin, and single-dose ceftriaxone were 10.6%, 9.1%, and 9.1%, respectively.

CONCLUSION

In this pilot study comparing single-dose azithromycin, 3-day azithromycin, and single-dose ceftriaxone for the treatment of uncomplicated AOM in children, no differences were detected among the 3 regimens.

Reducing the frequency of acute otitis media by individualized care

OBJECTIVE

We sought to determine if use of more stringent diagnostic criteria for acute otitis media (AOM) than currently advocated by the American Academy of Pediatrics, tympanocentesis and pathogen-specific antibiotic treatment (individualized care) would result in reducing the incidence of recurrent AOM and consequent tympanostomy tube surgery.

METHODS

A 5-year longitudinal, prospective study in Rochester, NY, was conducted from July 2006 to July 2011 involving 254 individualized care children. When this individualized care group developed symptoms of AOM, strict diagnostic criteria were applied and a tympanocentesis was performed. Pathogen resistance to empiric high-dose amoxicillin/clavulanate (80 mg/kg of amoxicillin component) caused a change in antibiotic to an optimized choice. Legacy controls (n = 208) were diagnosed with the same diagnostic criteria by the same physicians as the individualized care group and received the same empiric amoxicillin/clavulanate (80 mg/kg of amoxicillin component) but no tympanocentesis or change in antibiotic. Community control children (n = 1020) were diagnosed according to current American Academy of Pediatrics guidelines and treated with high-dose amoxicillin (80 mg/kg) without tympanocentesis as guideline recommended.

RESULTS

5.9% of children of the individualized care group compared with 14.4% of Legacy controls and 27.3% of community controls became otitis prone, defined as 3 episodes of AOM within a 6-month time span or 4 AOM episodes within a 12-month time span (P < 0.0001). 2.4% of the individualized care group compared with 6.3% of Legacy controls, and 14.8% of community controls received tympanostomy tubes (P < 0.0001).

CONCLUSIONS

Individualized care of AOM significantly reduces the frequency of AOM and tympanostomy tube surgery. Use of strict diagnostic criteria for AOM and empiric antibiotic treatment using evidence-based knowledge of circulating otopathogens and their antimicrobial susceptibility profile also produces improved outcomes.

Diagnosis and treatment of acute otitis media: review

BACKGROUND

Acute otitis media is very common, but diagnostic criteria and treatment recommendations vary considerably.

METHODS

Medline, the Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials were searched using the key words 'acute otitis media' AND 'diagnosis' OR 'diagnostic criteria' OR 'definition', and by combining the terms 'acute otitis media' AND 'guidelines'. PubMed was searched using the key words 'mastoiditis' and 'prevalence'.

RESULTS

The 11 most recently published guidelines unanimously agreed that adequate analgesia should be prescribed in all cases. The majority recommended that routine antibiotic prescription should be avoided in mild to moderate cases and when there was diagnostic uncertainty in patients two years and older. Antibiotics were recommended in children two years and younger, most commonly a 5-day course of amoxicillin (or a macrolide in patients allergic to penicillin).

CONCLUSION

Level 1A evidence shows that selected cases of acute otitis media benefit from antibiotic prescription.

A simple scoring system to improve clinical assessment of acute otitis media

OBJECTIVE

To evaluate an easy to use 10-point scoring system in clinical assessment of acute otitis media (AOM). Study design. Symptoms of AOM observed by validated otoscopists were tabulated and scored with a 10-point and a 30-point system at acute onset of illness and at the test-of-cure (TOC) 3 weeks later.

RESULTS

A total of 330 children (mean age = 13.1 months) with AOM were studied. At AOM onset, the mean 10-point and 30-point scores; were highly correlated (P < .001). At TOC, 256 children were cured, 69 failed, and 5 were lost to follow-up. The 10-point scores were 0.5 and 4.4 for children with cure and failure. The 10-point score had a sensitivity of 87%, specificity of 98%, positive predictive value of 91%, and negative predictive value of 97% compared with the diagnosis by validated otoscopists.

CONCLUSION

A simple, easy-to-use 10-point AOM scoring system was shown to discriminate AOM cure and failure at TOC.

Antibiotic treatment of acute otitis media in pediatrics

Evaluation of: Hoberman A, Paradise JL, Rockette HE et al.: Treatment of acute otitis media in children under 2 years of age. N. Engl. J. Med. 364, 105–115 (2011). A recently published study by Hoberman et al. concluded that 10 days’ treatment with amoxicillin–clavulanate tended to reduce the overall symptom burden, the time to symptom resolution, and the rate of persistent signs of acute infection upon otoscopic examination in children aged 6–23 months with acute otitis media (AOM). This study seems to put an end to the controversy between American and European experts concerning the best approach to the treatment of AOM in younger children. However, although treating all children aged less than 2 years with antimicrobial drugs is the lesser of two evils, it is not an ideal solution. Furthermore, the future more widespread use of some already available vaccines against respiratory pathogens could significantly reduce the total number of new episodes of AOM, thus limiting the risk of therapeutic error.

Clinical spectrum of acute otitis media complicating upper respiratory tract viral infection

BACKGROUND

acute otitis media (AOM) often occurs as a complication of upper respiratory tract infection (URI).

OBJECTIVE

to describe otoscopic findings during URI, the full clinical spectrum of AOM, and outcome of cases managed with watchful waiting.

METHODS

: In a prospective study of 294 healthy children (6 months-3 years), characteristics of AOM complicating URI were studied. Otoscopic findings were categorized by tympanic membrane (TM) position, color, translucency, and mobility. Otoscopic score was assigned based on McCormick otoscopy scale (OS)-8 scale.

RESULTS

during days 1 to 7 of URI, otoscopic findings at 1114 visits were consistent with AOM in 22%; myringitis (inflamed TM, no fluid) was diagnosed in 7%. In AOM episodes diagnosed within 28 days of URI onset, TM position was described as: nonbulging (19%), mild bulging (45%), bulging (29%), and TM perforation occurred in (6%). OS-8 scale showed mild TM inflammation (OS, 2-3) in 6%, moderate (OS, 4-5) in 59%, and severe (OS, 6-8) in 35%. In 54% of 126 bilateral AOM episodes, inflammation of both TMs was at different stages. Of 28 cases of nonsevere AOM managed with watchful waiting, 4 progressed and 3 later required an antibiotic.

CONCLUSIONS

AOM is a spectrum of infection that may present at various stages, even in the same child with bilateral disease. During URI, otoscopic changes are observed from the first day of onset. Understanding the wide clinical spectrum of AOM is needed to help with future clinical trial design and development of a scoring system to establish treatment criteria that will minimize antibiotic use.

A placebo-controlled trial of antimicrobial treatment for acute otitis media

BACKGROUND

The efficacy of antimicrobial treatment in children with acute otitis media remains controversial.

METHODS

In this randomized, double-blind trial, children 6 to 35 months of age with acute otitis media, diagnosed with the use of strict criteria, received amoxicillin-clavulanate (161 children) or placebo (158 children) for 7 days. The primary outcome was the time to treatment failure from the first dose until the end-of-treatment visit on day 8. The definition of treatment failure was based on the overall condition of the child (including adverse events) and otoscopic signs of acute otitis media.

RESULTS

Treatment failure occurred in 18.6% of the children who received amoxicillin-clavulanate, as compared with 44.9% of the children who received placebo (P<0.001). The difference between the groups was already apparent at the first scheduled visit (day 3), at which time 13.7% of the children who received amoxicillin-clavulanate, as compared with 25.3% of those who received placebo, had treatment failure. Overall, amoxicillin-clavulanate reduced the progression to treatment failure by 62% (hazard ratio, 0.38; 95% confidence interval [CI], 0.25 to 0.59; P<0.001) and the need for rescue treatment by 81% (6.8% vs. 33.5%; hazard ratio, 0.19; 95% CI, 0.10 to 0.36; P<0.001). Analgesic or antipyretic agents were given to 84.2% and 85.9% of the children in the amoxicillin-clavulanate and placebo groups, respectively. Adverse events were significantly more common in the amoxicillin-clavulanate group than in the placebo group. A total of 47.8% of the children in the amoxicillin-clavulanate group had diarrhea, as compared with 26.6% in the placebo group (P<0.001); 8.7% and 3.2% of the children in the respective groups had eczema (P=0.04).

CONCLUSIONS

Children with acute otitis media benefit from antimicrobial treatment as compared with placebo, although they have more side effects. Future studies should identify patients who may derive the greatest benefit, in order to minimize unnecessary antimicrobial treatment and the development of bacterial resistance. (Funded by the Foundation for Paediatric Research and others; ClinicalTrials.gov number, NCT00299455.).

Efficacy of short course (<4 days) of antibiotics for treatment of acute otitis media in children: a systematic review of randomized controlled trials

OBJECTIVE

To determine the efficacy of a short course of antibiotics (<4 days) in comparison to a longer course (>4 days) for the treatment of acute otitis media in children.

DATA SOURCES

Electronic databases, hand search of reviews, bibliographies of books, abstracts and proceedings of international conferences.

REVIEW METHODS

Randomized controlled trials of the empiric treatment of acute otitis media comparing antibiotic regimens of <4 days versus > 4 days in children between four weeks to eighteen years of age were included. The trials were grouped by pharmacokinetic behavior of short-course antibiotics into short-acting antibiotics, parenteral ceftriaxone, and long-acting azithromycin.

RESULTS

We reviewed 35 trials, which provided 38 analytic components. Overall, there was no evidence of an increased risk of treatment failure until one month with a short-course of antibiotics (RR=1.06, 95% CI 0.95 to 1.17, P=0.298). Use of short-acting oral antibiotic in short-course was associated with a significantly increased risk of treatment failure (RR=2.27, 95% CI: 1.04 to 4.99). There was a slightly increased risk of treatment failure with parenteral ceftriaxone (RR=1.13, 95% CI 0.99 to 1.30). The risk of adverse effects was significantly lower with short-course regimens (RR=0.58, 95% CI: 0.48 to 0.70).

CONCLUSION

There is no evidence of an increased risk of treatment failure with short course of antibiotics for acute otitis media. Among the short course regimens, azithromycin use was associated with a lower risk of treatment failure while short acting oral antibiotics and parenteral ceftriaxone may be associated with a higher risk of treatment failure.

Development and preliminary evaluation of a parent-reported outcome instrument for clinical trials in acute otitis media

BACKGROUND

Acute otitis media (AOM) is the most common childhood diagnosis, leading to prescription of an antibiotic in the United States. Although antibiotics are used in children with AOM, in part, to shorten the duration of symptoms, no instruments have been developed to track early changes in symptoms from the parent's point of view. The goal of the present study was to develop and evaluate a parent-reported symptom scale for children with AOM (AOM-SOS) for use as an outcome measure in AOM treatment trials.

METHODS

From a pool of 28 potential symptoms, we selected 7 on the basis of parent questionnaire, expert interviews, and review of the literature for inclusion in the AOM-SOS. We administered the AOM-SOS to a primary-care sample of children aged 6-25 months enrolled in a study of nasopharyngeal bacterial colonization. Children were seen for well visits, illness visits, and AOM follow-up visits. At each visit, parents completed the AOM-SOS and their children were examined by trained otoscopists. As part of the evaluation of the AOM-SOS, we examined the association between each item on the questionnaire and the clinical diagnosis of AOM while adjusting for the presence of upper respiratory tract infection. To assess responsiveness, we examined the change in AOM-SOS scores in patients with AOM who were seen for follow-up within 3 weeks of diagnosis.

RESULTS

We evaluated 264 children (mean age, 12.5 months at entry) at a total of 642 visits. We diagnosed AOM at 24% of the visits. Each item on the questionnaire was significantly associated with the clinical diagnosis of AOM (P < 0.001 for each), before and after adjusting for the presence or absence of upper respiratory infection. The mean AOM-SOS score at visits when AOM was diagnosed was 3.71, compared with 0.96 at visits when AOM was not diagnosed (P < 0.001). Internal reliability of the scale as measured by Cronbach's alpha was 0.84. AOM-SOS scores in children with AOM who were otoscopically improved decreased by an average of 2.81 points (standardized response mean = 0.73).

CONCLUSIONS

We have developed a short symptom scale for children with AOM. This study provides preliminary data on the performance of the AOM-SOS in a primary care sample of children.

Pharmacodynamic target attainment of oral beta-lactams for the empiric treatment of acute otitis media in children

OBJECTIVE

To determine the probability of oral beta-lactam regimens achieving bactericidal pharmacodynamic exposure against pathogens causing acute otitis media (AOM) given contemporary prevalence and resistance rates.

METHODS

A 5000-patient Monte Carlo simulation was used to recreate steady-state concentration-time profiles for oral drug administration regimens of amoxicillin, amoxicillin/clavulanic acid, cefpodoxime, cefprozil, ceftibuten, and cefuroxime in a population of 12.5-month-old children. The percent of simulated children in whom free drug concentrations above the minimum inhibitory concentration (MIC) for 50% of the drug administration interval (50% fT>MIC) were achieved was determined; 180 middle ear fluid isolates (56 Haemophilus influenzae and 124 Streptococcus pneumoniae) collected during the 2004 Global Respiratory Antimicrobial Surveillance Project (GRASP) were used. The cumulative fraction of response (CFR) was calculated and weighted against the prevalence of organisms causing AOM extrapolated from the literature. The contribution of a 'Pollyanna phenomenon' for each organism was also incorporated to estimate clinical effectiveness.

RESULTS

Against S. pneumoniae isolates, amoxicillin 30 mg/kg every 8 hours (84.7%) achieved the greatest CFR followed by amoxicillin/clavulanic acid and the other amoxicillin-based regimens. Against H. influenzae isolates, cefpodoxime, ceftibuten, and amoxicillin/clavulanic acid each achieved a CFR of >90%. When weighted by the prevalence of AOM-causing pathogens, CFR was highest for cefpodoxime (87.5%), amoxicillin/clavulanic acid (85.7%), and amoxicillin 30 mg/kg every 8 hours (70.8%). The contribution of a 'Pollyanna phenomenon' increased the probability of clinical effectiveness for all agents, with amoxicillin/clavulanic acid (90.2%) and cefpodoxime (90.1%) having the highest weighted CFR.

CONCLUSIONS

Based on the recent epidemiologic and resistance profiles of S. pneumoniae and H. influenzae, amoxicillin/clavulanic acid (45 mg/kg every 12 hours) and cefpodoxime (5 mg/kg every 12 hours) provide the greatest likelihood of achieving optimal pharmacodynamic exposures empirically in children with AOM.

[Acute otitis media--rational antibiotic treatment]

Acute otitis media is the most common reason for which antibiotics are prescribed to children. Because use of antibiotics has been implicated in the selection and progression of resistance among upper respiratory tract pathogens a concerted effort has been established to promote their judicious use. To reduce use of antibiotics recently published guidelines recommend observation option (watchful waiting) to children >2 years of age and non severe illness. Amoxicillin at conventional or high-doses remains an appropriate choice for first-line therapy. Appropriate options for second-line therapy include high-dose amoxicillin/clavulanate and ceftriaxon. Tympanocentesis is useful for identifying causative pathogen and may be beneficial for those who have failed second-line therapy. Natural history of untreated otitis media, most common pathogens and their resistance pattern are presented in the paper.

Acute otitis media in children: association with day care centers--antibacterial resistance, treatment, and prevention

Children attending day care centers (DCCs) frequently carry antibacterial-resistant organisms in their nasopharynx, leading to acute otitis media (AOM) that may be refractory to antibacterial treatment. The development and spread of resistant organisms are facilitated in DCCs as a result of the following: (i) large numbers of children; (ii) frequent close person-to-person contact; and (iii) a wide use of antimicrobial medications. Intensive antimicrobial usage provides the selection pressure that favors the emergence of resistant organisms, while DCCs provide an ideal environment for transmission of these organisms. The American Academy of Pediatrics and American Academy of Family Physicians' guidelines recommend high-dose amoxicillin/clavulanic acid (rather than amoxicillin alone) as the first therapeutic choice in the treatment of AOM in children attending DCCs. The introduction of the 7-valent pneumococcal conjugated vaccine (PCV7) had a major role in decreasing the number of episodes of Streptococccus pneumoniae AOM secondary to the serotypes included in the vaccine. It also had a major role in reducing the nasopharyngeal carriage of vaccine-type S. pneumoniae (and in particular of antibacterial-resistant organisms), preventing, in this way, its spread to contacts in the community. However, the recent observation of increased rates of antibacterial-resistant non-vaccine serotype S. pneumoniae may erode the success of PCV7.

Comparison of study designs for acute otitis media trials

BACKGROUND

A framework for evaluating the efficacy of antibiotics in development as well as those currently approved for acute otitis media (AOM) is needed.

OBJECTIVE

Review strengths and limitations of various antibiotic trial designs and their outcome measures.

METHODS

A review of 157 published trials involving 36,710 subjects for the treatment of AOM.

RESULTS

AOM trials have three designs: (1) clinical, clinical diagnosis and assessment of outcomes; (2) single tympanocentesis, microbiologic diagnosis (by middle ear fluid culture) and clinical assessment of outcomes; and (3) double tympanocentesis, microbiologic diagnosis and microbiologic outcome assessment. Identifiable strengths and limitations of each design are reviewed. Case definitions for entry of children in trials of AOM vary widely. The lack of stringent diagnostic criteria in a clinical design allows for inclusion of a significant proportion of children with a non-bacterial etiology (i.e., viral AOM or otitis media with effusion). Tympanocentesis increases diagnostic accuracy at study entry; however, the procedure is confounding because of its potentially therapeutic benefit and the procedure is not performed in a uniform manner. A second tympanocentesis allows a high sensitivity to detect microbiologic eradication, but it does not correlate with clinical outcomes in half of the cases. The timing of outcome assessment also varies widely among trials.

CONCLUSIONS

Improved clinical diagnosis criteria for AOM are needed to enhance specificity; emphasis on a bulging tympanic membrane has the best evidence base. Tympanocentesis within study designs has merits. At study entry it assures diagnostic accuracy but may alter outcomes and it is useful to document microbiologic outcomes but lacks specificity for clinical outcomes. For all designs, test of cure assessment 2-7 days after completion of therapy seems most appropriate.

Persistence of pathogens despite clinical improvement in antibiotic-treated acute otitis media is associated with clinical and bacteriologic relapse

BACKGROUND

Pathogen eradication in patients with acute otitis media (AOM) is associated with a reduced risk of clinical failures, but most children in whom middle ear fluid (MEF) culture remains positive show clinical improvement or clinical cure. We investigated the relationship between MEF culture-positivity during treatment in patients with clinical improvement/cure, and the occurrence of subsequent AOM.

METHODS

A total of 673 patients with culture-positive MEF were enrolled in double-tympanocentesis studies and followed for 3 weeks after completion of treatment.

RESULTS

On day 4-6, 189/673 (28%) patients had culture-positive MEFs. Patients with clinical improvement/cure on day 11-14 (end of treatment) despite having culture-positive MEF on day 4-6 more often had recurrent AOM episodes (53/151, 35%) than those with culture-negative MEF (114/476, 24%; P = 0.007). 41/53 (77%) culture-positive patients with clinical improvement/cure on day 11-14 underwent tympanocentesis when AOM recurred and 29/41 (71%) were culture-positive. Pulsed field gel electrophoresis identity between pathogens at recurrence and those persisting on day 4-6 was found in 19/29 (66%) compared with 31/86 (36%) of the evaluable patients with recurrence and culture-negative MEF on day 4-6 (P = 0.005).

CONCLUSIONS

(1) Failure to eradicate MEF pathogens during antibiotic treatment is associated with clinical recurrences, even in patients showing clinical improvement/cure at end of treatment; (2) these recurrences are mostly caused by pathogens initially present in MEF and persisting during treatment.

Failure to achieve early bacterial eradication increases clinical failure rate in acute otitis media in young children

BACKGROUND

The objective of this study was to determine the association between early bacteriologic failure and clinical failure in acute otitis media (AOM).

METHODS

Children with AOM aged 3-35 months enrolled in studies documenting both bacteriologic outcomes by tympanocentesis on day 4-6 and clinical outcomes on day 11-16 (immediate posttreatment visit) constituted our study group. Bacteriologic outcomes were studied for children with AOM caused by Streptococcus pneumoniae, nontypeable Haemophilus influenzae or both. The relative risk (RR) for clinical failure of children with bacteriologic failure compared with children with bacteriologic eradication was the main outcome measure.

RESULTS

Nine hundred seven episodes were analyzed. Clinical failure occurred in 7.3% of 660 patients with bacterial eradication versus 32.8% of 247 patients with bacteriologic failures. The overall RR (95% confidence interval) for clinical failure was 4.41 (95% CI: 3.19-6.11), with little variation between pathogens. After correction for age, gender, ethnic origin, previous otitis history, and previous antibiotic treatment, the rate was 6.52 (95% CI: 4.26-9.99). Across clinical studies with 8 antibiotic drug regimens for AOM, the rate of clinical failure correlated with bacteriologic failure (r = 0.8967; P = 0.003).

CONCLUSIONS

In young children with culture-positive AOM, failure to eradicate the pathogen from middle ear fluid within the first few days of treatment leads to a significant risk for clinical failure.

Clinical/otologic score before and during treatment of acute otitis media

OBJECTIVES

To determine clinical characteristics of AOM at presentation and during therapy according to specific etiologies.

PATIENTS AND METHODS

1003 patients studied during 1996-2001 in antibiotic efficacy studies underwent tympanocentesis and middle ear fluid culture at enrollment and on Day 4-6 (in initially culture-positive patients only). We used a clinical/otologic (CO) score for evaluating severity of fever, irritability and tympanic membrane redness and bulging (0-3 each parameter, maximal score=12).

RESULTS

Seven hundred sixty-three patients had positive cultures with 392 (39%) Haemophilus influenzae, 198 (20%) Streptococcus pneumoniae and 173 (17%) mixed H. influenzae and S. pneumoniae infection. Mean CO score was higher in culture-positive versus culture-negative patients (8.21+/-2.17 vs. 7.73+/-2.32, p=0.003) regardless of isolated organism. A marked improvement in CO score was observed on Day 4-6 in all patients: 1.83+/-2.18 in children initially culture-positive and 0.9+/-1.67 in those initially culture-negative (p<0.001). The improvement was greater in patients with eradication versus those with bacteriological failure (CO score 1.52+/-1.82 vs. 2.77+/-2.85, p<0.001).

CONCLUSIONS

CO score before treatment, after bacterial eradication or in bacteriologic failures are similar in bacterial AOM and are not predictive of the etiology of the disease.

Acute otitis media in children aged less than 2 years: drug treatment issues

The management of acute otitis media (AOM) in childhood has evolved considerably during recent years as a result of the new insights provided by publication (in 2004) of the American Academy of Pediatrics and the American Academy of Family Physicians guidelines for the treatment of AOM. The new treatment guidelines establish a clear hierarchy among the various antibacterials used in the treatment of this disease and also the use of an age-stratified approach to AOM by recommending an observation strategy ('watchful waiting') without the use of antibacterials for some groups of patients with AOM. Infants and young children aged <2 years represent a target population characterized by a high incidence of AOM (and in particular of recurrent disease), lack of anatomic and physiologic maturity of airways, age-related immune humoral and cellular deficiencies, the presence of antibacterial-resistant pathogens, and a less efficient response to antibacterial treatment. Presently, the evidence accumulated in the literature is not sufficient to conclude that the role of antibacterials is only minimal in the management of AOM and that the watchful waiting policy is the most appropriate choice for patients aged <2 years with a certain AOM diagnosis. However, adherence to such a policy in patients with an uncertain or questionable AOM diagnosis and/or mild-to-moderate symptoms, in addition to its implementation in patients aged >2 years, could reduce substantially the use of antibacterials in children and play a major role in the strategy of decreasing antibacterial resistance.

Acute otitis media and respiratory viruses

The present study was performed to elucidate the clinical outcome, and etiology of acute otitis media (AOM) in children based on virologic and bacteriologic tests. The study group consisted of 120 children aged 6 to 144 months with AOM. Middle ear fluid (MEF) was tested for viral pathogens by reverse transcriptase polymerase chain reaction (RT-PCR) and for bacteria by gram-staining and culture. Clinical response was assessed on day 2 to 4, 11 to 13, 26 to 28. Respiratory viruses were isolated in 39 patients (32.5%). Respiratory syncytial virus (RSV) (46.5%) was the most common virus identified in MEF samples, followed by human rhinovirus (HRV) (25.6%), human coronavirus (HCV) (11.6%), influenza (IV) type A (9.3%), adenovirus type sub type A (AV) (4%), and parainfluenza (PIV) type -3 (2%) by RT-PCR. In total 69 bacterial species were isolated from 65 (54.8%) of 120 patients. Streptococcus pneumoniae (S. pneumoniae) was the most frequently isolated bacteria. Viral RNA was detected in 31 (56.3%) of 55 bacteria-negative specimens and in 8 (12.3%) of 65 bacteria-positive MEF samples. No significant differences were found between children representing viral infection alone, combined viral and bacterial infection, bacterial infection alone, and neither viral nor bacterial infection, regarding clinical cure, relapse and reinfection rates. A significantly higher rate of secretory otitis media (SOM) was observed in alone or combined RSV infection with S. pneumonia or Haemophilus influenzae (H. influenzae) than in other viruses infection. Conclusion. This study provides information about etiologic agents and diagnosis of AOM in Turkish children. The findings highlight the importance of common respiratory viruses and bacterial pathogens, particularly RSV, HRV, S. pneumoniae and H. influenzae, in predisposing to and causing AOM in children.

Acute otitis media guidelines: review and update

In 2004, the Subcommittee on Management of Acute Otitis Media of the American Academy of Pediatrics and American Academy of Family Physicians published evidence-based clinical practice guidelines on the "Diagnosis and Management of Acute Otitis Media." The guidelines included a definition of acute otitis media (AOM) that included three components: 1) a history of acute onset of signs and symptoms; 2) the presence of middle-ear effusion; and 3) signs and symptoms of middle-ear inflammation. An option to observe selected children with AOM for 48 to 72 hours without initial antibiotic therapy was proposed. This option was based on age, severity of illness, and certainty of diagnosis. Despite the changing prevalence of bacterial pathogens and increasing resistance of Streptococcus pneumoniae, amoxicillin remains the first-line antibiotic for initial antibacterial treatment of AOM. The guideline also addresses the management of otalgia, choice of antibiotics after initial treatment failure, and methods for preventing AOM.

Pathogen shifts and changing cure rates for otitis media and tonsillopharyngitis

Pneumococcal conjugate vaccine use has caused a decrease in the incidence of recurrent and refractory acute otitis media in the United States and a shift in the predominant pathogens. Now Haemophilus influenzae is the most commonly isolated organism (about 60% of the total), and more than half the strains make beta-lactamase, rendering them resistant to amoxicillin. Penicillin nonsusceptible pneumococci, the main target of antibiotic therapy in the 1990s, has become a much less common isolate (10%- 25% of the total). These changes impact antibiotic selection for acute otitis media. Penicillin treatment of group A streptococcal tonsillopharyngitis does not meet the minimum United States Food and Drug Administration standards for first-line treatment, which is 85% or greater eradication at the end of therapy. Recent results with amoxicillin suggest its efficacy is also waning. Cephalosporins have the highest bacteriologic and clinical efficacy. This has implications for optimal antibiotic therapy.

Bacterial etiology of acute otitis media and clinical efficacy of amoxicillin-clavulanate versus azithromycin

BACKGROUND

Acute otitis media (AOM) is one of the most common acute bacterial infection in childhood and also the most frequent reason for outpatient antibiotic therapy. Little recent information about susceptibility patterns of AOM bacterial pathogens in Turkish children has been reported.

OBJECTIVE

To determine the bacterial etiology of acute otitis media in children and to compare the efficiency of 3 days course of azithromycin with a 10 days course of amoxicillin-clavulanate.

METHODS

This prospective, single blind, randomised comparative study was carried out in 180 children with AOM. Paracentesis was performed for middle ear fluid culture before the first dose antibiotic therapy. Children with acute otitis media were randomised to receive either low dose amoxicillin-clavulanate (45/6.4 mg/kg/day in two divided doses for 10 days) or low dose azithromycin (10mg/kg/day for 3 days). Clinical response was assessed on days 2-4, 11-13, 26-28.

RESULTS

Bacterial pathogens were isolated from 108 (60%) of 180 children. Streptococcus pneumoniae was the most common isolated pathogen (39.7%), followed by Haemophilus influenzae (20.7%), Moraxella catarrhalis (15.5%), Staphylococcus aureus (13.8%), Group A beta-hemolytic streptococcus (5.1%), Escherichia coli (3.4%) and Enterococcus faecalis (1.7%). This study demonstrated low resistance rates compared to studies of different countries. Although clinical response rates were better in patients treated with amoxicillin-clavulanate, this was not statistically significant [86.6% (78 of 90)] versus [95.2% (80 of 84)]. Success rates of amoxicillin-clavulanate were high for both S. pneumoniae and H. influenzae. Difference between success rates was not statistically significant (P=0.144 and 0.352).

CONCLUSIONS

Bacteria were isolated in 60% of AOM cases. The clinical efficiency of amoxicillin-clavulanate was found to be equal compared to azithromycin in children with acute otitis media.

Comparison of amoxicillin with alternative agents for the treatment of acute otitis media in children

Expert panels have recommended high-dose amoxicillin (80-90 mg/kg/day) as the therapy of choice for uncomplicated acute otitis media in children. This recommendation is based primarily on pharmacokinetic data predicting bacteriologic cure of most middle ear infections by using amoxicillin at the recommended dosage. However, comparisons of aminopenicillin-containing regimens with alternative treatments, particularly azithromycin, have not consistently demonstrated superiority of the former, even in recent trials with stringent designs. Moreover, amoxicillin exposure may perturb nasopharyngeal colonization more profoundly than do alternative agents. These perturbations may theoretically promote the dissemination of beta-lactam-resistant pneumococci in the community more than other drugs approved for use in otitis media. Such findings suggest that several factors should be considered when choosing an agent to treat otitis media and that reexamination of high-dose amoxicillin as the superior first-line agent for this condition might be warranted.

Predictive value of double tympanocentesis in acute otitis media

Advances in the understanding of acute otitis media (AOM), lessons learned from antibacterial trials, and the emergence of pathogens with decreased susceptibility to commonly used antibiotics explain the need to redefine the role of tympanocentesis. The diagnostic value of tympanocentesis at baseline to establish the bacterial cause of AOM is well accepted. However, relevant ethical and scientific arguments conclude that repeat (or double) tympanocentesis cannot be recommended as routine procedure, either for the individual patient or for each treatment trial. Relevant aspects on trial design for AOM, with special emphasis on the value of double tympanocentesis, are reviewed.

Acute otitis media-diagnosis and treatment in the era of antibiotic resistant organisms: updated clinical practice guidelines

The treatment of children with AOM has to rely on an accurate diagnosis and a clear discrimination between AOM and serous otitis media. The last decade has seen major changes in the epidemiology of AOM with an earlier onset of disease and a greater proportion of children with recurrent/complicated AOM. The processes of changing susceptibility of bacterial pathogens added a major problem in treatment selection. Tastier, more efficient, safe and conveniently-dosing as well as cost effective drugs are required to achieve adherence to therapy. The recent published guidelines for the treatment of AOM in the present era of pneumoccocal resistance represent a major step forward in the approach to the management of this disease by establishing a clear hierarchy among the various therapeutic agents. A 48-72 h observation option without use of antibacterial therapy in selected children with uncomplicated AOM should be promoted. Immunization against S. pneumoniae with the heptavalent pneumococcal conjugated vaccines was showed to result in a decrease in the frequency of AOM caused by this pathogen, including AOM caused by antibiotic-resistant S. pneumoniae.

Amoxicillin-sulbactam versus amoxicillin-clavulanic acid for the treatment of non-recurrent-acute otitis media in Argentinean children

Streptococcus pneumoniae (Sp) and Haemophilus influenzae (Hi) are the leading bacterial cause of acute otitis media (AOM), having the nasopharynx (NP) as their reservoir. In October 2001 we began a prospective, multicenter, randomized, evaluator blind study, comparing the efficacy of amoxicillin-sulbactam (Ax/S) and amoxicillin-clavulanic acid (Ax/C) for the treatment of non-recurrent AOM (nr-AOM). Both antimicrobial susceptibility (AS) to Ax/S and Ax/C from Sp and Hi carried by study children (aged 6-48 months with nr-AOM) and, clinical outcome after treatment with high dose of either Ax/C (7:1) or Ax/S (4:1) (amoxicillin dose: 80 mg/(kg day), b.i.d. for 10 days) were assessed. Nasal cultures (NCs) were taken at Day 0. Follow-up NCs, were done only for Sp carriers. On final analysis 247/289 pts (85.5%) were fully evaluable (120 Ax/S and 127 Ax/C). NP carriage rate of Hi and Sp at Day 0 was 32.2% (93/289 pts) and 28.7% (83/289 pts), respectively. Persistent Sp carriage was detected only in 2 pts. Hi betalactamase positive rate was 13% (12/93). MICs for Ax/S and Ax/C were identical when tested against Sp and Hi isolates (range < or = 0.016-1.0 and < or = 0.016-0.25 mg/L, respectively). Clinical efficacy at Days 12-14 and 28-42 were 98.3% (115/117) and 94.2% (97/103) for Ax/S; and 98.3% (115/117) and 95.1% (98/103) for Ax/C, respectively (pNS). We conclude, that Sp and Hi isolated from NCs of nr-AOM pts were highly sensitive to both drugs and correlated with high clinical efficacy rate.

Medical home, obesity, acute otitis media, and otitis media with effusion

Four areas of pediatric office practice are reviewed: the medical home concept, obesity, acute otitis media, and otitis media with effusion. The concept of the medical home in the care of children with special health care needs, its effect on health care outcomes, and its application to office practice are discussed. The epidemiology and causes of obesity are covered along with options for obesity screening and prevention. Diagnosis and therapy of acute otitis media and otitis media with effusion are reviewed along with discussion of recent practice guidelines for both entities.

[Etiology of acute otitis media in a children's hospital and antibiotic sensitivity of the bacteria involved]

BACKGROUND

This study provides an update on the bacterial etiology of acute otitis media in our area, the antibiotic sensitivity of the bacteria implicated in this condition, and the prevalence of circulating Streptococcus pneumoniae serotypes.

METHODS

Results from a total of 240 samples obtained by diagnostic tympanocentesis and 167 samples of spontaneous otorrhea processed between 1999 and 2001 were reviewed retrospectively.

RESULTS

The mean age of the patients studied was 17 months and the median was 13 months (range: 1 month-7 years). Among the tympanocentesis samples, S. pneumoniae was recovered from 67 (27.9%), Haemophilus influenzae from 60 (25%), both S. pneumoniae and H. influenzae from 3 (1.3%) and Moraxella catarrhalis from 6 (2.5%). Among the spontaneous otorrhea samples, S. pneumoniae was recovered from 15 (9%), H. influenzae from 25 (15%) and both S. pneumoniae and H. influenzae from 1 (0.6%). The remaining samples showed either no growth or recovery of colonizing flora. The main findings were as follows: 49.3% of S. pneumoniae strains showed intermediate sensitivity to penicillin (MIC: 0.12-1 microg/ml), 16.9% were resistant to penicillin (MIC: > or = 2 microg/ml) and 54% were resistant to macrolides; 24,7% of H. influenzae and 100% of M. catarrhalis strains were beta-lactamase producers; and 64 (84.2%) of 76 S. pneumoniae serotyped strains belonged to pneumococcal heptavalent vaccine serotypes.

CONCLUSIONS

S. pneumoniae and H. influenzae were the main causal agents of acute otitis media. Antibiotic sensitivity of the bacteria involved showed the same characteristics as the general pattern in our country. Spontaneous otorrhea culture was not a useful method for establishing the etiology of acute otitis media. Knowledge of the distribution of S. pneumoniae serotypes is essential for assessing epidemiological changes resulting from the use of heptavalent pneumococcal vaccine.

Oral amoxicillin versus injectable penicillin for severe pneumonia in children aged 3 to 59 months: a randomised multicentre equivalency study

BACKGROUND

Injectable penicillin is the recommended treatment for WHO-defined severe pneumonia (lower chest indrawing). If oral amoxicillin proves equally effective, it could reduce referral, admission, and treatment costs. We aimed to determine whether oral amoxicillin and parenteral penicillin were equivalent in the treatment of severe pneumonia in children aged 3-59 months.

METHODS

This multicentre, randomised, open-label equivalency study was undertaken at tertiary-care centres in eight developing countries in Africa, Asia, and South America. Children aged 3-59 months with severe pneumonia were admitted for 48 h and, if symptoms improved, were discharged with a 5-day course of oral amoxicillin. 1702 children were randomly allocated to receive either oral amoxicillin (n=857) or parenteral penicillin (n=845) for 48 h. Follow-up assessments were done at 5 and 14 days after enrollment. Primary outcome was treatment failure (persistence of lower chest indrawing or new danger signs) at 48 h. Analyses were by intention-to-treat and per protocol.

FINDINGS

Treatment failure was 19% in each group (161 patients, pencillin; 167 amoxillin; risk difference -0.4%; 95% CI -4.2 to 3.3) at 48 h. Infancy (age 3-11 months; odds ratio 2.72, 95% CI 1.95 to 3.79), very fast breathing (1.94, 1.42 to 2.65), and hypoxia (1.95, 1.34 to 2.82) at baseline predicted treatment failure by multivariate analysis.

INTERPRETATION

Injectable penicillin and oral amoxicillin are equivalent for severe pneumonia treatment in controlled settings. Potential benefits of oral treatment include decreases in (1) risk of needle-borne infections; (2) need for referral or admission; (3) administration costs; and (4) costs to the family.

Acute bacterial rhinosinusitis: clinical impact of resistance and susceptibility

Sinusitis is a common disorder associated with notable direct and indirect economic costs. Acute bacterial rhinosinusitis (ABRS) is a relatively poorly defined clinical syndrome characterized by a high spontaneous resolution rate, wide variations in presenting symptoms, and an incomplete understanding of the pathogenesis and clinical course of the disease. Streptococcus pneumoniae and Haemophilus influenzae are the most common causative pathogens in adult ABRS. A relative lack of bacteriological eradication data compared with other respiratory illnesses, uncertainty on the part of many clinicians as to when to treat, and increasing rates of antimicrobial resistance hamper logical treatment strategies. Because it is impossible to know which cases of ABRS will spontaneously resolve and which will not, antimicrobials are recommended. In general, antimicrobial treatment for ABRS should cover both S. pneumoniae and H. influenzae while considering the risk of infection with resistant organisms. Treatment guidelines for ABRS were developed by the Sinus and Allergy Health Partnership in 2000 and were updated in 2004. This article discusses a Sinusitis Therapeutic Outcome Model, a data-driven model used in the development of the treatment guidelines, with respect to different scenarios involving ABRS to illustrate the implications of antimicrobial selection on therapeutic outcome.

Use of oral cephalosporins in the treatment of acute otitis media in children

The selection of the most effective antimicrobial to treat acute otitis media (AOM) has become more difficult in recent years because of increasing antibiotic resistance among all AOM pathogens. Resistance of Streptococcus pneumoniae to penicillin as well as amoxicillin ranges from 30 to 55% in the USA. Currently, 40-55% of Haemophilus influenzae and 90-100% of Moraxella catarrhalis are resistant to penicillin because of the production of Beta-lactamases. This review discusses the availability of oral cephalosporins that can be utilised for the treatment of AOM in children. An evaluation is made regarding their in vitro activity against the pathogens, their middle-ear concentrations, pharmacokinetics and pharmacodynamics (PK/PD). The cephalosporins that will be discussed are cefuroxime-axetil, cefprozil, cefdinir and cefpodoxime-proxetil. The current recommendations for therapy of AOM limit the choices of clinicians to a single cephalosporin (cefuroxime-axetil). However, clinical, bacteriological and PK/PD data shows that several other cephalosporins (cefprozil, cefdinir and cefpodoxime-proxetil) possess similar indices which provide the clinician with wider therapeutic choices that can insure better compliance and ultimately better success in eradication of the infection.

Diagnosis and management of acute otitis media

This evidence-based clinical practice guideline provides recommendations to primary care clinicians for the management of children from 2 months through 12 years of age with uncomplicated acute otitis media (AOM). The American Academy of Pediatrics and American Academy of Family Physicians convened a committee composed of primary care physicians and experts in the fields of otolaryngology, epidemiology, and infectious disease. The subcommittee partnered with the Agency for Healthcare Research and Quality and the Southern California Evidence-Based Practice Center to develop a comprehensive review of the evidence-based literature related to AOM. The resulting evidence report and other sources of data were used to formulate the practice guideline recommendations. The focus of this practice guideline is the appropriate diagnosis and initial treatment of a child presenting with AOM. The guideline provides a specific definition of AOM. It addresses pain management, initial observation versus antibacterial treatment, appropriate choices of antibacterials, and preventive measures. Decisions were made based on a systematic grading of the quality of evidence and strength of recommendations, as well as expert consensus when definitive data were not available. The practice guideline underwent comprehensive peer review before formal approval by the partnering organizations. This clinical practice guideline is not intended as a sole source of guidance in the management of children with AOM. Rather, it is intended to assist primary care clinicians by providing a framework for clinical decision-making. It is not intended to replace clinical judgment or establish a protocol for all children with this condition. These recommendations may not provide the only appropriate approach to the management of this problem.

High-dose azithromycin versus high-dose amoxicillin-clavulanate for treatment of children with recurrent or persistent acute otitis media

Infants and young children, especially those in day care, are at risk for recurrent or persistent acute otitis media (AOM). There are no data on oral alternatives to high-dose amoxicillin-clavulanate for treating AOM in these high-risk patients. In this double-blind, double-dummy multicenter clinical trial, we compared a novel, high-dose azithromycin regimen with high-dose amoxicillin-clavulanate for treatment of children with recurrent or persistent AOM. Three hundred four children were randomized; 300 received either high-dose azithromycin (20 mg/kg of body weight once a day for 3 days) or high-dose amoxicillin-clavulanate (90 mg/kg divided twice a day for 10 days). Tympanocentesis was performed at baseline; clinical response was assessed at day 12 to 16 and day 28 to 32. Two-thirds of patients were aged < or =2 years. A history of recurrent, persistent, or recurrent plus persistent AOM was noted in 67, 18, and 14% of patients, respectively. Pathogens were isolated from 163 of 296 intent-to-treat patients (55%). At day 12 to 16, clinical success rates for azithromycin and amoxicillin-clavulanate were comparable for all patients (86 versus 84%, respectively) and for children aged < or =2 years (85 versus 79%, respectively). At day 28 to 32, clinical success rates for azithromycin were superior to those for amoxicillin-clavulanate for all patients (72 versus 61%, respectively; P = 0.047) and for those aged < or =2 years (68 versus 51%, respectively; P = 0.017). Per-pathogen clinical efficacy against Streptococcus pneumoniae and Haemophilus influenzae was comparable between the two regimens. The rates of treatment-related adverse events for azithromycin and amoxicillin-clavulanate were 32 and 42%, respectively (P = 0.095). Corresponding compliance rates were 99 and 93%, respectively (P = 0.018). These data demonstrate the efficacy and safety of high-dose azithromycin for treating recurrent or persistent AOM.

Optimizing antibacterial therapy for community-acquired respiratory tract infections in children in an era of bacterial resistance

The spread of antibacterial resistance in bacteria that commonly cause childhood community-acquired respiratory tract infections (RTIs), such as acute otitis media, community-acquired pneumonia, and acute pharyngitis, is a major healthcare problem. One of the foremost concerns is the rapid increase in penicillin, macrolide, and multidrug resistance in Streptococcus pneumoniae. There is also a rising prevalence of macrolide resistance in Streptococcus pyogenes in pockets of the United States, and beta-lactamase production in Haemophilus influenzae is widespread. Although data are limited, some evidence suggests that resistance to antibacterials can impair bacteriologic and clinical outcomes in childhood RTIs. Optimizing antibacterial use is important both in the care of individual patients and within strategies to address the wider problem of antibacterial resistance. This involves encouraging judicious antibacterial use (i.e., reducing overuse for viral infection and prophylaxis), and preventing misuse through the wrong choice, dosage, and duration of therapy. Given that initial therapy is usually empiric, antibacterials used to treat community-acquired RTIs in children should ideally have the following properties: an optimal targeted spectrum of activity; high clinical and bacteriologic efficacy against respiratory pathogens, including resistant strains; simple, short-course therapy; and good tolerability and palatability. New antibacterials will continue to have a role in the treatment of RTIs in children, especially where resistance compromises existing therapies.

A mathematical therapeutic outcomes model for sinusitis

The therapeutic outcomes model (TOM) provides a logical and consistent manner in which bacteriologic and clinical efficacy can be predicted and calculated. It not only allows antibiotics to be ranked in efficacy, it gives precise estimates of the magnitude of differences in efficacy, which is typically lacking in older antimicrobial guidelines. The TOM identifies the major variables that need to be considered in accurately estimating outcome and places those variables into the appropriate relationships and formulas so that outcomes will be automatically calculated. In the case of rhinosinusitis, the major variables are (1) likelihood of spontaneously resolving nonbacterial cause, (2) likelihood of nonresolving nonbacterial cause, (3) prevalence of subcauses (eg, different species of bacteria), (4) the spontaneous resolution rates of each subcause, (5) the antibacterial efficacy of the treatment (eg, antibiotic) against each of the subcauses, and (6) the compliance rate of the treatment recommended. Minor variables, such as prior antibiotic use, patient age, or bacterial vaccination status, affect the efficacy of a given agent by modifying the value of one or more of the major variables. The TOM is a superior mechanism for ranking and evaluating relative antibiotic efficacy than previous methodologies.

Antimicrobial resistance among pediatric respiratory tract infections: clinical challenges

Considerable development of antimicrobial resistance has occurred in the major pediatric bacterial pathogens, Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. However, most of the respiratory infections that children suffer are viral and self-limiting, and only a small percentage of them will develop secondary bacterial infections with the pathogens listed. The challenge for rational antibiotic use is to determine which patients can be treated conservatively and which require antimicrobial intervention to avoid prolonged discomfort or development of permanent sequelae. The basis for rational use of antibiotic in the era of resistance in these major pathogens is to avoid overuse of antimicrobial agents, tailor treatment to identified pathogens as much as possible, and base empiric treatment on the disease being treated and the susceptibility of the probable pathogens at breakpoints based on pharmacokinetic and pharmacodynamic parameters. With appropriate dosing regimens based on these parameters and despite development of resistance, amoxicillin is still one of the most active oral agents against S. pneumoniae and non-beta-lactamase producing strains of H. influenzae, whereas amoxicillin-clavulanate is active against beta-lactamase-producing strains of H. influenzae and M. catarrhalis. Parenteral ceftriaxone and oral and parenteral fluoroquinolones are active against all 3 species, but fluoroquinolones should be used with utmost caution when all other options have been considered because of concerns about toxicity and development of resistance. Introduction of a 7-valent conjugate pneumococcal vaccine in the United States in 2000 reduced the prevalence of invasive pneumococcal disease in children younger than 2 years old, but, as of 2001, had not had a major impact on decreasing antimicrobial resistance.