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Frost HM, Keith A, Fletcher DR, Sebastian T, Dominguez SR, Kurtz M, Parker SK, Wilson ML, Jenkins TC. Clinical Outcomes Associated with Amoxicillin Treatment for Acute Otitis Media in Children. J Pediatric Infect Dis Soc 2024; 13:203-210. [PMID: 38314853 DOI: 10.1093/jpids/piae010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 02/04/2024] [Indexed: 02/07/2024]
Abstract
BACKGROUND Acute otitis media (AOM) is the most common reason children are prescribed antibiotics. Bacteria that produce beta-lactamase are an increasingly frequent cause of AOM and may be resistant to amoxicillin, the currently recommended treatment for AOM. We aimed to evaluate the clinical outcomes of children treated with amoxicillin for AOM and assessed whether outcomes vary by infecting pathogen or beta-lactamase production. METHODS 205 children 6-35 months old diagnosed with AOM and prescribed amoxicillin were included. Bacterial culture and qualitative multiplex real-time polymerase chain reaction were performed on nasopharyngeal swabs collected at enrollment. Parents completed surveys assessing symptoms, antibiotic adherence, and potential adverse events. The primary outcome was treatment failure with amoxicillin. Secondary outcomes included recurrence, symptom improvement, resolution, and adverse drug events (ADE). RESULTS 8 children (5.4%) experienced treatment failure and 14 (6.8%) had recurrence. By day 5, 152 (74.1%) children had symptom improvement and 97 (47.3%) had resolution. Parents reported ADE for 56 (27.3%) children. Among 149 children who did not take any amoxicillin before enrollment, 98 (65.8%) had one or more beta-lactamase-producing bacteria. Common bacterial otopathogens were Moraxella catarrhalis (79, 53.0%), Streptococcus pneumoniae (51, 34.2%), Haemophilus influenzae (30, 20.1%), and Staphylococcus aureus (21, 14.1%). Treatment failure did not differ between children that did (5, 5.1%) and did not (3, 5.9%) have beta-lactamase-producing otopathogens (p = .05). CONCLUSIONS Among children diagnosed with AOM treated with amoxicillin, treatment failure was uncommon and did not differ by pathogen or beta-lactamase production. These data support guidance recommending amoxicillin despite an increasing prevalence of beta-lactamase-producing bacteria.
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Affiliation(s)
- Holly M Frost
- Department of Pediatrics, Denver Health and Hospital Authority, Denver, CO, USA
- Center for Health Systems Research, Denver Health and Hospital Authority, Denver, CO, USA
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Amy Keith
- Center for Health Systems Research, Denver Health and Hospital Authority, Denver, CO, USA
| | | | - Thresia Sebastian
- Department of Pediatrics, Denver Health and Hospital Authority, Denver, CO, USA
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
- Department of Pediatrics, Alameda Health System, Oakland, CA, USA
| | - Samuel R Dominguez
- Department of Pediatric Infectious Diseases, University of Colorado School of Medicine, Aurora, CO, USA
- Department of Pediatric Infectious Diseases, Children's Hospital Colorado, Aurora, CO, USA
| | - Melanie Kurtz
- Center for Health Systems Research, Denver Health and Hospital Authority, Denver, CO, USA
| | - Sarah K Parker
- Department of Pediatric Infectious Diseases, University of Colorado School of Medicine, Aurora, CO, USA
- Department of Pediatric Infectious Diseases, Children's Hospital Colorado, Aurora, CO, USA
| | - Michael L Wilson
- Department of Pathology and Laboratory Services, Denver Health and Hospital Authority, Denver, CO, USA
- Department of Pathology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Timothy C Jenkins
- Division of Infectious Diseases, Department of Medicine, Denver Health and Hospital Authority, Denver, CO, USA
- Division of Infectious Diseases, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
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Sánchez Arlegui A, Del Arco Rodríguez J, De Velasco Vázquez X, Gallego Rodrigo M, Gangoiti I, Mintegi S. Bacterial pathogens and antimicrobial resistance in acute otitis media. An Pediatr (Barc) 2024; 100:173-179. [PMID: 38350792 DOI: 10.1016/j.anpede.2023.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 12/20/2023] [Indexed: 02/15/2024] Open
Abstract
INTRODUCTION Recent studies show an increase in the prevalence of Haemophilus influenzae and a decrease in Streptococcus pneumoniae among the bacteria that cause acute otitis media (AOM). The objective of our study was to analyse the distribution of pathogens identified in children aged less than 14 years presenting to the emergency department with AOM and their patterns of antimicrobial resistance. PATIENTS AND METHODS Single centre retrospective, analytical study in patients aged less than 14 years with a diagnosis of AOM in whom an ear drainage sample was collected for culture in the paediatric emergency department of a tertiary care hospital between 2013 and 2021. RESULTS During the study period, there were 14 684 documented care episodes corresponding to children with a diagnosis of AOM. An ear drainage culture was performed in 768 of those episodes. The median age of the patients was 2 years, 57% were male and 70% had a previous history of AOM. The most frequently isolated pathogens were: Haemophilus influenzae (n = 188 [24.5%]; 15.5% of them resistant to ampicillin), Streptococcus pyogenes (n = 86 [11.2%]), Staphylococcus aureus (n = 82 [10.7%]), Streptococcus pneumoniae (n = 54 [6.9%]; 9.4% with intermediate resistance to penicillin), Pseudomonas aeruginosa (n = 42 [5.5%]) and Moraxella catarrhalis (n = 11 [1.4%]). No pathogen was isolated in 34.9% of cases. CONCLUSIONS Haemophilus influenzae is the leading cause of AOM in children aged less than 14 years. This, combined with the low frequency of isolation and penicillin resistance of Streptococcus pneumoniae, calls into question the appropriateness of high-dose amoxicillin for empiric treatment of AOM.
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Affiliation(s)
- Amaia Sánchez Arlegui
- Servicio de Urgencias de Pediatría, Hospital Universitario Cruces, Instituto de Investigación Sanitaria Biocruces Bizkaia, Universidad del País Vasco, UPV/EHU, Barakaldo, País Vasco, Spain
| | - Jorge Del Arco Rodríguez
- Servicio de Urgencias de Pediatría, Hospital Universitario Cruces, Instituto de Investigación Sanitaria Biocruces Bizkaia, Universidad del País Vasco, UPV/EHU, Barakaldo, País Vasco, Spain
| | - Xabier De Velasco Vázquez
- Servicio de Urgencias de Pediatría, Hospital Universitario Cruces, Instituto de Investigación Sanitaria Biocruces Bizkaia, Universidad del País Vasco, UPV/EHU, Barakaldo, País Vasco, Spain
| | - Mikel Gallego Rodrigo
- Servicio de Microbiología, Hospital Universitario Cruces, Instituto de Investigación Sanitaria Biocruces Bizkaia, Barakaldo, País Vasco, Spain
| | - Iker Gangoiti
- Servicio de Urgencias de Pediatría, Hospital Universitario Cruces, Instituto de Investigación Sanitaria Biocruces Bizkaia, Universidad del País Vasco, UPV/EHU, Barakaldo, País Vasco, Spain
| | - Santiago Mintegi
- Servicio de Urgencias de Pediatría, Hospital Universitario Cruces, Instituto de Investigación Sanitaria Biocruces Bizkaia, Universidad del País Vasco, UPV/EHU, Barakaldo, País Vasco, Spain.
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Seibert AM, Schenk C, Buckel WR, Patel PK, Fino N, Stanfield V, Hersh AL, Stenehjem E. Beyond antibiotic prescribing rates: first-line antibiotic selection, prescription duration, and associated factors for respiratory encounters in urgent care. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2023; 3:e146. [PMID: 37771738 PMCID: PMC10523551 DOI: 10.1017/ash.2023.416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Revised: 07/03/2023] [Accepted: 07/09/2023] [Indexed: 09/30/2023]
Abstract
Objective Assess urgent care (UC) clinician prescribing practices and factors associated with first-line antibiotic selection and recommended duration of therapy for sinusitis, acute otitis media (AOM), and pharyngitis. Design Retrospective cohort study. Participants All respiratory UC encounters and clinicians in the Intermountain Health (IH) network, July 1st, 2019-June 30th, 2020. Methods Descriptive statistics were used to characterize first-line antibiotic selection rates and the duration of antibiotic prescriptions during pharyngitis, sinusitis, and AOM UC encounters. Patient and clinician characteristics were evaluated. System-specific guidelines recommended 5-10 days of penicillin, amoxicillin, or amoxicillin-clavulanate as first-line. Alternative therapies were recommended for penicillin allergy. Generalized estimating equation modeling was used to assess predictors of first-line antibiotic selection, prescription duration, and first-line antibiotic prescriptions for an appropriate duration. Results Among encounters in which an antibiotic was prescribed, the rate of first-line antibiotic selection was 75%, the recommended duration was 70%, and the rate of first-line antibiotic selection for the recommended duration was 53%. AOM was associated with the highest rate of first-line prescriptions (83%); sinusitis the lowest (69%). Pharyngitis was associated with the highest rate of prescriptions for the recommended duration (91%); AOM the lowest (51%). Penicillin allergy was the strongest predictor of non-first-line selection (OR = 0.02, 95% CI [0.02, 0.02]) and was also associated with extended duration prescriptions (OR = 0.87 [0.80, 0.95]). Conclusions First-line antibiotic selection and duration for respiratory UC encounters varied by diagnosis and patient characteristics. These areas can serve as a focus for ongoing stewardship efforts.
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Affiliation(s)
- Allan M. Seibert
- Division of Infectious Diseases, Intermountain Health, Salt Lake City, UT, USA
| | | | | | - Payal K. Patel
- Division of Infectious Diseases, Intermountain Health, Salt Lake City, UT, USA
| | - Nora Fino
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Valoree Stanfield
- Office of Patient Experience, Intermountain Health, Salt Lake City, UT, USA
| | - Adam L. Hersh
- Department of Pediatrics, Division of Infectious Diseases, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Eddie Stenehjem
- Division of Infectious Diseases, Intermountain Health, Salt Lake City, UT, USA
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El Feghaly RE, Nedved A, Katz SE, Frost HM. New insights into the treatment of acute otitis media. Expert Rev Anti Infect Ther 2023; 21:523-534. [PMID: 37097281 PMCID: PMC10231305 DOI: 10.1080/14787210.2023.2206565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 04/20/2023] [Indexed: 04/26/2023]
Abstract
INTRODUCTION Acute otitis media (AOM) affects most (80%) children by 5 years of age and is the most common reason children are prescribed antibiotics. The epidemiology of AOM has changed considerably since the widespread use of pneumococcal conjugate vaccines, which has broad-reaching implications for management. AREAS COVERED In this narrative review, we cover the epidemiology of AOM, best practices for diagnosis and management, new diagnostic technology, effective stewardship interventions, and future directions of the field. Literature review was performed using PubMed and ClinicalTrials.gov. EXPERT OPINION Inaccurate diagnoses, unnecessary antibiotic use, and increasing antimicrobial resistance remain major challenges in AOM management. Fortunately, effective tools and interventions to improve diagnostic accuracy, de-implement unnecessary antibiotic use, and individualize care are on the horizon. Successful scaling of these tools and interventions will be critical to improving overall care for children.
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Affiliation(s)
- Rana E. El Feghaly
- Department of Pediatrics, Children’s Mercy Kansas City, Kansas City, MO, USA
- Department of Pediatrics, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Amanda Nedved
- Department of Pediatrics, Children’s Mercy Kansas City, Kansas City, MO, USA
- Department of Pediatrics, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Sophie E. Katz
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Holly M. Frost
- Department of Pediatrics, Denver Health and Hospital Authority, Denver, CO, USA
- Center for Health Systems Research, Denver Health and Hospital Authority, Denver, CO, USA
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
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5
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Nasopharyngeal rapid diagnostic testing to reduce unnecessary antibiotic use and individualize management of acute otitis media. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY 2023; 3:e49. [PMID: 36970427 PMCID: PMC10031585 DOI: 10.1017/ash.2023.127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 01/31/2023] [Accepted: 02/01/2023] [Indexed: 03/17/2023]
Abstract
Abstract
Background:
Acute otitis media (AOM) is the most common indication for antibiotics in children. The associated organism can influence the likelihood of antibiotic benefit and optimal treatment. Nasopharyngeal polymerase chain reaction can effectively exclude the presence of organisms in middle-ear fluid. We explored the potential cost-effectiveness and reduction in antibiotics with nasopharyngeal rapid diagnostic testing (RDT) to direct AOM management.
Methods:
We developed 2 algorithms for AOM management based on nasopharyngeal bacterial otopathogens. The algorithms provide recommendations on prescribing strategy (ie, immediate, delayed, or observation) and antimicrobial agent. The primary outcome was the incremental cost-effectiveness ratio (ICER) expressed as cost per quality-adjusted life day (QALD) gained. We used a decision-analytic model to evaluate the cost-effectiveness of the RDT algorithms compared to usual care from a societal perspective and the potential reduction in annual antibiotics used.
Results:
An RDT algorithm that used immediate prescribing, delayed prescribing, and observation based on pathogen (RDT-DP) had an ICER of $1,336.15 per QALD compared with usual care. At an RDT cost of $278.56, the ICER for RDT-DP exceeded the willingness to pay threshold; however, if the RDT cost was <$212.10, the ICER was below the threshold. The use of RDT was estimated to reduced annual antibiotic use, including broad-spectrum antimicrobial use, by 55.7% ($4.7 million for RDT vs $10.5 million for usual care).
Conclusion:
The use of a nasopharyngeal RDT for AOM could be cost-effective and substantially reduce unnecessary antibiotic use. These iterative algorithms could be modified to guide management of AOM as pathogen epidemiology and resistance evolve.
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Abstract
AIM This study aimed to evaluate antibiotic prescriptions for children with otitis media (OM) in a large nationwide network of private clinics between 2014 and 2020. Special focus was paid to amoxicillin and amoxicillin-clavulanic acid prescriptions, which the national guidelines recommend for first-line drugs. We also focused on macrolides, which are commonly prescribed for respiratory tract infections in children but are not appropriate for OM cases. METHODS The data were obtained from the electronic health records of about 250,000 annual visits in <18 years old children. The collected variables were all diagnoses, age, visit year, doctor's specialty, and prescribed antibiotics. Children with OM and upper respiratory tract infections were included, but those with lower respiratory tract infections were excluded. RESULTS The number of children with OM was 357,390 (55.2% boys). Antibiotics were prescribed in 44.8% of cases, with the lowest proportion (44.1%) being in <2 years old children. The overall prescription rate decreased from 48.3% in 2014 to 41.4% in 2020. The rates were 19.3% and 18.1% for amoxicillin and 12.6% and 13.2% for amoxicillin-clavulanic acid, respectively. Macrolide prescriptions were reduced from 7.5% to 3.5%. Pediatricians prescribed antibiotics for 38.8%, general practitioners for 54.0% and ear, nose and throat physicians for 39.8% of children with OM. CONCLUSION The selection of antibiotics for OM, when prescribed, was according to the recommendations (amoxicillin or amoxicillin-clavulanic acid) in 80.1% of pediatricians, 67.0% of general practitioners and 55.1% of ear, nose and throat physicians.
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Frost HM, Bizune D, Gerber JS, Hersh AL, Hicks LA, Tsay SV. Amoxicillin Versus Other Antibiotic Agents for the Treatment of Acute Otitis Media in Children. J Pediatr 2022; 251:98-104.e5. [PMID: 35944719 PMCID: PMC10122571 DOI: 10.1016/j.jpeds.2022.07.053] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 06/17/2022] [Accepted: 07/22/2022] [Indexed: 01/04/2023]
Abstract
OBJECTIVES The objective of the study was to compare the antibiotic treatment failure and recurrence rates between antibiotic agents (amoxicillin, amoxicillin-clavulanate, cefdinir, and azithromycin) for children with uncomplicated acute otitis media (AOM). STUDY DESIGN We completed a retrospective cohort study of children 6 months-12 years of age with uncomplicated AOM identified in a nationwide claims database. The primary exposure was the antibiotic agent, and the primary outcomes were treatment failure and recurrence. Logistic regression was used to estimate ORs, and analyses were stratified by primary exposure, patient age, and antibiotic duration. RESULTS Among the 1 051 007 children included in the analysis, 56.6% were prescribed amoxicillin, 13.5% were prescribed amoxicillin-clavulanate, 20.6% were prescribed cefdinir, and 9.3% were prescribed azithromycin. Most prescriptions (93%) were for 10 days, and 98% were filled within 1 day of the medical encounter. Treatment failure and recurrence occurred in 2.2% (95% CI: 2.1, 2.2) and 3.3% (3.2, 3.3) of children, respectively. Combined failure and recurrence rates were low for all agents including amoxicillin (1.7%; 1.7, 1.8), amoxicillin-clavulanate (11.3%; 11.1, 11.5), cefdinir (10.0%; 9.8, 10.1), and azithromycin (9.8%; 9.6, 10.0). CONCLUSIONS Despite microbiologic changes in AOM etiology, treatment failure and recurrence were uncommon for all antibiotic agents and were lower for amoxicillin than for other agents. These findings support the continued use of amoxicillin as a first-line agent for AOM when antibiotics are prescribed.
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Affiliation(s)
- Holly M Frost
- Department of Pediatrics, Denver Health and Hospital Authority, Denver, CO; Center for Health Systems Research, Denver Health and Hospital Authority, Denver, CO; Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO.
| | - Destani Bizune
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - Jeffrey S Gerber
- Division of Infectious Diseases, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Adam L Hersh
- Division of Pediatric Infectious Diseases, University of Utah, Salt Lake City, UT
| | - Lauri A Hicks
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - Sharon V Tsay
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
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8
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Park BL, Trehan I. Amoxicillin Dose and Duration of Treatment and Need for Antibiotic Re-treatment in Children With Community-Acquired Pneumonia. JAMA 2022; 327:1089-1090. [PMID: 35289887 DOI: 10.1001/jama.2022.1022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Brian L Park
- Department of Pediatrics, University of Washington, Seattle
| | - Indi Trehan
- Department of Pediatrics, University of Washington, Seattle
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9
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Two Co(II) coordination polymers: Crystal structures and treatment activity on bacterial acute sinusitis. J INDIAN CHEM SOC 2021. [DOI: 10.1016/j.jics.2021.100252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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10
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Fuji N, Pichichero M, Kaur R. Haemophilus influenzae Prevalence, Proportion of Capsulated Strains and Antibiotic Susceptibility During Colonization and Acute Otitis Media in Children, 2019-2020. Pediatr Infect Dis J 2021; 40:792-796. [PMID: 34321442 DOI: 10.1097/inf.0000000000003171] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The objective of this study was to determine the prevalence, proportion of encapsulated strains and antibiotic susceptibility of Haemophilus influenzae isolated from young children. METHODS Children, 6 months to 30 months old, were prospectively enrolled from September 2019 to September 2020 at Rochester, NY, pediatric clinics. H. influenzae isolates from nasopharynx (NP) at healthy visits and disease isolates from NP and middle ear fluid (MEF) at onset of acute otitis media (AOM) were characterized by capsular typing, β-lactamase production and antibiotic susceptibility. RESULTS Samples from 565 healthy visits and 130 AOM visits were collected. H. influenzae was detected 5.9% and 27% in the NP from healthy and AOM visits, respectively. In the MEF, H. influenzae was isolated in 43% of samples. Eight percent of H. influenzae isolates were encapsulated, 88% type f. Overall 39.7% of isolates were β-lactamase producing; 43% for MEF isolates. Ampicillin, trimethoprim/sulfamethoxazole, erythromycin and clarithromycin nonsusceptibility were found in more than 25% of isolates. None of the encapsulated H. influenzae isolates were positive for β-lactamase production or ampicillin nonsusceptibility. 9.2% of isolates were β-lactamase negative, ampicillin resistant (β-lactamase negative, ampicillin resistant + β-lactamase negative, ampicillin intermediate). CONCLUSIONS The prevalence of H. influenzae in the NP of young children is very low at times of health, but H. influenzae is highly prevalent in MEF at onset of AOM. Nontypeable H. influenzae accounts for >90% of all H. influenzae isolates. Type f predominated among encapsulated strains. β-lactamase production and antibiotic nonsusceptibility among H. influenzae strains isolated from the NP and MEF are common.
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Affiliation(s)
- Naoko Fuji
- From the Center for Infectious Diseases and Immunology, Rochester General Hospital Research Institute, Rochester, New York
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Ooi SZY, Sichimba D, Dalle DU, Higginbotham G, Takoutsing BD, Bankole NDA, Egiz A, Kotecha J, de Koning R, Nguembu S, Zolo Y, Dokponou YCH, Chilawa S, Bandyopadhyay S, Kanmounye US. Management and Outcomes of Paediatric Intracranial Suppurations in Low- and Middle-Income Countries: A Scoping Review. Front Surg 2021; 8:690895. [PMID: 34466410 PMCID: PMC8403063 DOI: 10.3389/fsurg.2021.690895] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 07/12/2021] [Indexed: 12/02/2022] Open
Abstract
Introduction: Intracranial suppurations account for a significant proportion of intracranial masses in low- and middle-income countries (LMICs), particularly among children. The development of better imaging equipment, antibiotics, and surgical techniques has enabled significant progress in detecting and treating intracranial abscesses. However, it is unclear whether these advances are accessible and utilised by LMICs. In this review, we aimed to describe the landscape of paediatric intracranial suppurations in LMICs. Methods: This scoping review was conducted using the Arksey and O'Malley framework. MEDLINE, EMBASE, WHO Global Index Medicus, AJOL and Google scholar were searched for relevant articles from database inception to January 18th, 2021. Publications in English and French were included. Results: Of the 1,011 records identified, 75 were included. The studies, on average, included 18.8 (95% CI = 8.4-29.1) children (mean age: 8.2 years). Most children were male (62.2%, 95% CI = 28.7-95.7%). Intracranial suppurations were most commonly (46.5%) located in the supratentorial brain parenchyma. The most prevalent causative mechanism was otitis (37.4%) with streptococcus species being the most common causative organism (19.4%). CT scan (71.2%) was most commonly used as a diagnostic tool and antibiotics were given to all patients. Symptoms resolved in 23.7% and improved in 15.3% of patients. The morbidity rate was 6.9%, 18.8% of patients were readmitted, and the mortality rate was 11.0%. Conclusion: Most intracranial suppurations were complications of preventable infections and despite MRI being the gold standard for detecting intracranial suppurations, CT scans were mostly used in LMICs. These differences are likely a consequence of inequities in healthcare and have resulted in a high mortality rate in LMICs.
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12
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周 慧, 许 昱. [Reasonable application of antibiotics in pediatric acute rhinosinusitis]. LIN CHUANG ER BI YAN HOU TOU JING WAI KE ZA ZHI = JOURNAL OF CLINICAL OTORHINOLARYNGOLOGY, HEAD, AND NECK SURGERY 2021; 35:752-755. [PMID: 34304540 PMCID: PMC10127806 DOI: 10.13201/j.issn.2096-7993.2021.08.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Indexed: 11/12/2022]
Abstract
The incidence of upper respiratory tract infection in children is extremely high, and some of them are prone to develop to acute rhinosinusitis. Antibiotics are the first-line medication to alleviate bacterial infections. However, due to the lack of practical and accurate objective indicators for the diagnosis of acute rhinosinusitis, it is difficult to distinguish the acute bacterial rhinosinusitis subgroup, leading to the overuse of antibiotics. In recent years, the form of antibiotic resistance has become more severe, and the application conditions of antibiotics have become more stringent. In addition, the physiological conditions of children are different from adults. Chinese and foreign studies are controversial about the rational application of antibiotics in children with acute rhinosinusitis. The relevant researches of antibiotic treatment in children with acute rhinosinusitis are now reviewed, with a view to providing clinical reference for the rational use of antibiotics in this group of people.
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Affiliation(s)
- 慧琴 周
- 武汉大学人民医院耳鼻咽喉头颈外科(武汉,430060)
| | - 昱 许
- 武汉大学人民医院耳鼻咽喉头颈外科(武汉,430060)
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13
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Yang N, Xu DH, Lin FF, Pan ZH, Zou YH. Application values of two Co(II) coordination polymers on bacterial acute sinusitis by reducing the Streptococcus pneumoniae viability. INORG NANO-MET CHEM 2021. [DOI: 10.1080/24701556.2021.1956962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Neng Yang
- E.N.T. Department, Zhejiang Taizhou Hospital Affiliated to Wenzhou Medical University, Taizhou, Zhejiang, China
| | - Dan-Hui Xu
- E.N.T. Department, Zhejiang Taizhou Hospital Affiliated to Wenzhou Medical University, Taizhou, Zhejiang, China
| | - Fen-Fen Lin
- Operation Room, Zhejiang Taizhou Hospital Affiliated to Wenzhou Medical University, Taizhou, Zhejiang, China
| | - Zhao-Hu Pan
- E.N.T. Department, Zhejiang Taizhou Hospital Affiliated to Wenzhou Medical University, Taizhou, Zhejiang, China
| | - Yu-Hua Zou
- E.N.T. Department, Taizhou First people's Hospital, Taizhou, Zhejiang, China
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Patel S, Olympia RP. School Nurses on the Front Lines of Healthcare: Getting aHEAD of EmergENT Eye, Ear, Nose, and Throat Infections. NASN Sch Nurse 2021; 37:25-30. [PMID: 34060930 DOI: 10.1177/1942602x211019109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
School nurses may deal with various common infectious eye, ear, nose, and throat-related chief complaints in regular practice. Recognizing the signs and symptoms of severe infection is paramount to preventing life-threatening complications that can have both acute and long-term implications. Distinguishing urgent and emergent eye, ear, nose, and throat conditions to send to the emergency department is integral to reducing the morbidity associated with these conditions. This article discusses three different students presenting with various chief complaints, from the initial assessment by the school nurse to the appropriate disposition and follow-up.
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Affiliation(s)
| | - Robert P Olympia
- Professor, Departments of Emergency Medicine and Pediatrics, Penn State College of Medicine, Attending Pediatric Emergency Medicine physician, Penn State Hershey Medical Center, Hershey, PA
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Fu BF, Xiong J, Ma LX, Liu EL, Li D. Two Co(Ⅱ) coordination polymers: Application values on newborn bacterial acute sinusitis by reducing the Streptococcus pneumoniae viability. Inorganica Chim Acta 2021. [DOI: 10.1016/j.ica.2021.120270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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16
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Tuoheti A, Gu X, Cheng X, Zhang H. Silencing Nrf2 attenuates chronic suppurative otitis media by inhibiting pro-inflammatory cytokine secretion through up-regulating TLR4. Innate Immun 2021; 27:70-80. [PMID: 32579053 PMCID: PMC7780353 DOI: 10.1177/1753425920933661] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 05/15/2020] [Accepted: 05/20/2020] [Indexed: 01/27/2023] Open
Abstract
Compromised TLR-mediated chronic inflammation contributes to bacterial infection-caused chronic suppurative otitis media, but the mechanisms are unclear. The present study examined the expression status of nuclear erythroid 2-related factor 2 (Nrf2) and TLRs in human middle-ear mucosae tissues collected from patients with chronic suppurative otitis media, chronic otitis media and non-otitis media, and found that Nrf2 was high-expressed, whereas TLR4, instead of other TLRs, was low expressed in chronic suppurative otitis media compared to chronic otitis media and non-chronic otitis media groups. Consistently, inflammatory cytokines were significantly up-regulated in the chronic suppurative otitis media group, instead of the chronic otitis media and non-chronic otitis media groups. Next, LPS-induced acute otitis media and chronic suppurative otitis media models in mice were established, and high levels of inflammatory cytokines were sustained in the mucosae tissues of chronic suppurative otitis media mice compared to the non-otitis media and acute otitis media groups. Interestingly, continuous low-dose LPS stimulation promoted Nrf2 expression, but decreased TLR4 levels in chronic suppurative otitis media mice mucosae. In addition, knock-down of Nrf2 increased TLR4 expression levels in chronic suppurative otitis media mice, and both Nrf2 ablation and TLR4 overexpression inhibited the pro-inflammatory cytokine expression in chronic suppurative otitis media. Finally, we found that both Nrf2 overexpression and TLR4 deficiency promoted chronic inflammation in LPS-induced acute otitis media mice models. Taken together, knock-down of Nrf2 reversed chronic inflammation to attenuate chronic suppurative otitis media by up-regulating TLR4.
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Affiliation(s)
- Abulajiang Tuoheti
- Department of Otorhinolarygology, The First Affiliated Hospital of Xinjiang Medical University, China
| | - Xingzhi Gu
- Department of Otorhinolaryngology Head and Neck Surgery, Sanya Central Hospital (Third People’s Hospital of Hainan Province), China
| | - Xiuqin Cheng
- Department of Otorhinolarygology, People's Hospital of Xinjiang Uygur Autonomous Region, China
| | - Hua Zhang
- Department of Otorhinolarygology, The First Affiliated Hospital of Xinjiang Medical University, China
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Leung AK, Hon KL, Chu WC. Acute bacterial sinusitis in children: an updated review. Drugs Context 2020; 9:dic-2020-9-3. [PMID: 33281908 PMCID: PMC7685231 DOI: 10.7573/dic.2020-9-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 10/29/2020] [Accepted: 10/29/2020] [Indexed: 12/02/2022] Open
Abstract
Background In the pediatric age group, approximately 7.5% of upper respiratory tract infections (URIs) are complicated by acute bacterial sinusitis (ABS). Despite its prevalence, ABS is often overlooked in young children. The diagnosis and management present unique challenges in primary care. This is an updated narrative review on the evaluation, diagnosis, and management of ABS. Methods A PubMed search was performed using the key term ‘acute sinusitis’. The search strategy included clinical trials, meta-analyses, randomized controlled trials, observational studies, and reviews. The search was restricted to the English literature and children. Results Haemophilus influenzae (non-typeable), Streptococcus pneumoniae, and Moraxella catarrhalis are the major pathogens in uncomplicated ABS in otherwise healthy children. In complicated ABS, polymicrobial infections are common. The diagnosis of acute sinusitis is mainly clinical and based on stringent criteria, including persistent symptoms and signs of a URI beyond 10 days, without appreciable improvement; a URI with high fever and purulent nasal discharge at onset lasting for at least 3 consecutive days; and biphasic or worsening symptoms. Conclusion Data from high-quality studies on the management of ABS are limited. The present consensus is that amoxicillin-clavulanate, at a standard dose of 45 mg/kg/day orally, is the drug of choice for most cases of uncomplicated ABS in children in whom antibacterial resistance is not suspected. Alternatively, oral amoxicillin 90 mg/kg/day can be administered. For those with severe ABS or uncomplicated acute sinusitis who are at risk for severe disease or antibiotic resistance, oral high-dose amoxicillin-clavulanate (90 mg/kg/day) is the drug of choice.
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Affiliation(s)
- Alexander Kc Leung
- Department of Pediatrics, The University of Calgary, and The Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Kam Lun Hon
- Department of Paediatrics, The Chinese University of Hong Kong, Shatin, Hong Kong.,Department of Paediatrics and Adolescent Medicine, The Hong Kong Children's Hospital, Hong Kong
| | - Winnie Cw Chu
- Department of Imaging & Interventional Radiology, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong
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18
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Mokrzan EM, Ahearn CP, Buzzo JR, Novotny LA, Zhang Y, Goodman SD, Bakaletz LO. Nontypeable Haemophilus influenzae newly released (NRel) from biofilms by antibody-mediated dispersal versus antibody-mediated disruption are phenotypically distinct. Biofilm 2020; 2:100039. [PMID: 33447823 PMCID: PMC7798465 DOI: 10.1016/j.bioflm.2020.100039] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 11/02/2020] [Accepted: 11/12/2020] [Indexed: 02/08/2023] Open
Abstract
Biofilms contribute significantly to the chronicity and recurrence of bacterial diseases due to the fact that biofilm-resident bacteria are highly recalcitrant to killing by host immune effectors and antibiotics. Thus, antibody-mediated release of bacteria from biofilm residence into the surrounding milieu supports a powerful strategy to resolve otherwise difficult-to-treat biofilm-associated diseases. In our prior work, we revealed that antibodies directed against two unique determinants of nontypeable Haemophilus influenzae (NTHI) [e.g. the Type IV pilus (T4P) or a bacterial DNABII DNA-binding protein, a species-independent target that provides structural integrity to bacterial biofilms] release biofilm-resident bacteria via discrete mechanisms. Herein, we now show that the phenotype of the resultant newly released (or NRel) NTHI is dependent upon the specific mechanism of release. We used flow cytometry, proteomic profiles, and targeted transcriptomics to demonstrate that the two NRel populations were significantly different not only from planktonically grown NTHI, but importantly, from each other despite genetic identity. Moreover, each NRel population had a distinct, significantly increased susceptibility to killing by either a sulfonamide or β-lactam antibiotic compared to planktonic NTHI, an observation consistent with their individual proteomes and further supported by relative differences in targeted gene expression. The distinct phenotypes of NTHI released from biofilms by antibodies directed against specific epitopes of T4P or DNABII binding proteins provide new opportunities to develop targeted therapeutic strategies for biofilm eradication and disease resolution.
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Affiliation(s)
- Elaine M Mokrzan
- Center for Microbial Pathogenesis, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - Christian P Ahearn
- Center for Microbial Pathogenesis, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - John R Buzzo
- Center for Microbial Pathogenesis, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - Laura A Novotny
- Center for Microbial Pathogenesis, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - Yan Zhang
- Department of Biomedical Informatics, The Ohio State University College of Medicine, Columbus, OH, USA.,The Ohio State University Comprehensive Cancer Center (OSUCCC - James), Columbus, OH, USA
| | - Steven D Goodman
- Center for Microbial Pathogenesis, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Lauren O Bakaletz
- Center for Microbial Pathogenesis, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
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Molloy L, Barron S, Khan N, Abrass E, Ang J, Abdel-Haq N. Oral β-Lactam Antibiotics for Pediatric Otitis Media, Rhinosinusitis, and Pneumonia. J Pediatr Health Care 2020; 34:291-300. [PMID: 32334748 DOI: 10.1016/j.pedhc.2019.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 10/29/2019] [Accepted: 11/06/2019] [Indexed: 12/14/2022]
Abstract
Acute otitis media, acute bacterial rhinosinusitis, and community-acquired pneumonia are major drivers of pediatric antibiotic consumption. With many available options and the added challenges of navigating antibiotic allergies and de-escalating from intravenous treatment for children requiring hospitalization, prescribing for these relatively simple infections can be a source of confusion and error. The purpose of this article is to evaluate the pharmacokinetic and pharmacodynamic properties of antibiotics commonly prescribed for these disease states, and to specifically compare antipneumococcal activity between oral beta-lactams.
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20
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Immunization with a Biofilm-Disrupting Nontypeable Haemophilus influenzae Vaccine Antigen Did Not Alter the Gut Microbiome in Chinchillas, Unlike Oral Delivery of a Broad-Spectrum Antibiotic Commonly Used for Otitis Media. mSphere 2020; 5:5/2/e00296-20. [PMID: 32295873 PMCID: PMC7160684 DOI: 10.1128/msphere.00296-20] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The prevalence of chronic and recurrent diseases, combined with the overuse/abuse of antibiotics that has led to the sobering emergence of bacteria resistant to multiple antibiotics, has mandated that we develop novel approaches to better manage these diseases or, ideally, prevent them. Biofilms play a key role in the pathogenesis of chronic and recurrent bacterial diseases but are difficult, if not impossible, to eradicate with antibiotics. We developed a vaccine antigen designed to mediate biofilm disruption; however, it is also important that delivery of this vaccine does not induce collateral damage to the microbiome. The studies described here validated a vaccine approach that targets biofilms without the consequences of an altered gut microbiome. While delivery of the antibiotic most commonly given to children with ear infections did indeed alter the gut microbiome, as expected, immunization via traditional injection or by noninvasive delivery to the skin did not result in changes to the chinchilla gut microbiome. The use of broad-spectrum antibiotics to treat diseases, such as the highly prevalent pediatric disease otitis media (OM), contributes significantly to the worldwide emergence of multiple-antibiotic-resistant microbes, and gut dysbiosis with diarrhea is a common adverse sequela. Moreover, for many diseases, like OM, biofilms contribute significantly to chronicity and recurrence, yet biofilm-resident bacteria are characteristically highly resistant to antibiotics. The most cost-effective way to both prevent and resolve diseases like OM, as well as begin to address the problem of growing antibiotic resistance, would be via the development of novel approaches to eradicate bacterial biofilms. Toward this goal, we designed a vaccine antigen that induces the formation of antibodies that prevent biofilm formation and, thereby, experimental OM in the middle ears of chinchillas by the predominant Gram-negative pathogen responsible for this disease, nontypeable Haemophilus influenzae. These antibodies also significantly disrupt preexisting biofilms formed by diverse pathogens. Whereas preclinical data strongly support the continued development of this vaccine antigen, which targets an essential structural element of bacterial biofilms, a concern has been whether active immunization would also lead to unintended collateral damage in the form of an altered gut microbiome. To address this concern, we assessed changes in the microbiome of the chinchilla gut over time after the delivery of either amoxicillin-clavulanate, the standard of care for OM, or after immunization with our biofilm-targeted vaccine antigen either via a traditional subcutaneous route or via a novel noninvasive transcutaneous route. We show that differences in the abundance of specific taxa were found only in the stools of antibiotic-treated animals. IMPORTANCE The prevalence of chronic and recurrent diseases, combined with the overuse/abuse of antibiotics that has led to the sobering emergence of bacteria resistant to multiple antibiotics, has mandated that we develop novel approaches to better manage these diseases or, ideally, prevent them. Biofilms play a key role in the pathogenesis of chronic and recurrent bacterial diseases but are difficult, if not impossible, to eradicate with antibiotics. We developed a vaccine antigen designed to mediate biofilm disruption; however, it is also important that delivery of this vaccine does not induce collateral damage to the microbiome. The studies described here validated a vaccine approach that targets biofilms without the consequences of an altered gut microbiome. While delivery of the antibiotic most commonly given to children with ear infections did indeed alter the gut microbiome, as expected, immunization via traditional injection or by noninvasive delivery to the skin did not result in changes to the chinchilla gut microbiome.
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21
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Akers JA, Johnson TM, Hill RB, Kawaguchi S. Rational Prophylactic Antibiotic Selection for Sinus Elevation Surgery. Clin Adv Periodontics 2019; 10:42-55. [PMID: 31609504 DOI: 10.1002/cap.10080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 06/03/2019] [Indexed: 01/26/2023]
Abstract
FOCUSED CLINICAL QUESTION For a generally healthy patient with no risk indicators for postoperative infection, what is the most appropriate perioperative antibiotic regimen for sinus elevation surgery in terms of reducing postoperative infection risk and minimizing untoward effects? CLINICAL SCENARIO A 38-year-old female patient in good general and periodontal health presents missing tooth #14 (Fig. ). She reports no systemic conditions, no history of sinusitis, and no allergies. Medications include acetaminophen and ibuprofen as needed for pain. The patient's dentition is minimally restored, with no active caries. Cone-beam computed tomography reveals a clear, pneumatized left maxillary sinus and inadequate bone volume to support dental implant placement (Fig. ). No septa or pathologic lesions are present, the ostium appears patent, and no thickening of the Schneiderian membrane is appreciable. The patient states that she wants to replace her missing molar without restoring adjacent teeth (Figs. and ). [Figure: see text] [Figure: see text] [Figure: see text] [Figure: see text].
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Affiliation(s)
- Joshua A Akers
- Department of Periodontics, Army Postgraduate Dental School, Uniformed Services University of the Health Sciences, Fort Gordon, GA
| | - Thomas M Johnson
- Department of Periodontics, Army Postgraduate Dental School, Uniformed Services University of the Health Sciences, Fort Gordon, GA
| | - Richard B Hill
- Department of Periodontics, Army Postgraduate Dental School, Uniformed Services University of the Health Sciences, Fort Gordon, GA
| | - Sachiyo Kawaguchi
- Department of Periodontics, US Army Dental Health Activity, Joint Base San Antonio, San Antonio, TX
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Torretta S, Drago L, Marchisio P, Gaini L, Guastella C, Moffa A, Rinaldi V, Casale M, Pignataro L. Review of Systemic Antibiotic Treatments in Children with Rhinosinusitis. J Clin Med 2019; 8:E1162. [PMID: 31382570 PMCID: PMC6723210 DOI: 10.3390/jcm8081162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 07/31/2019] [Accepted: 08/01/2019] [Indexed: 01/02/2023] Open
Abstract
Antibiotic treatment in paediatric rhinosinusitis is still a matter of debate, as the current guidelines have been drafted mainly based on clinical studies published before 2013. Recent modifications in the epidemiological basis of the disease might mean that current treatments are not completely adequate considering the evolving microbiological profile of the disease. The present paper reviews the role of systemic antibiotics in children with acute (ARS), chronic (CRS), recurrent (RARS), and complicated acute (CoARS) rhinosinusitis. A total of 14 studies (including 3 prospective non-randomised studies, 8 retrospective studies, and 3 prospective randomised studies) of the 115 initially identified papers were included in this review, corresponding to 13,425 patients. Five papers dealt with ARS, four papers with RARS or CRS, and five papers with CoARS; the remaining papers included patients with either ARS or CRS. Data about the effectiveness of antibiotic treatment in children with ARC, CRS, and CoARS is scarce, as only three randomised controlled trials have been published in the last decade, with contrasting results. There is an urgent need for dedicated controlled trials not only to test the actual clinical benefits deriving from the routine use of systemic antibiotics in different categories of patients but also to compare the effectiveness of various therapeutic protocols in terms of the type of antibacterial molecules and the duration of treatment.
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Affiliation(s)
- Sara Torretta
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan 20100, Italy.
- Department of Clinical Sciences and Community Health, University of Milan, Milan 20100, Italy.
| | - Lorenzo Drago
- Department of Biomedical Sciences for Health, University of Milan, Milan 20100, Italy
| | - Paola Marchisio
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan 20100, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan 20100, Italy
| | - Lorenzo Gaini
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan 20100, Italy
| | - Claudio Guastella
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan 20100, Italy
| | - Antonio Moffa
- Unit of Otolaryngology, University of Foggia, Foggia 71121, Italy
| | - Vittorio Rinaldi
- Unit of Otolaryngology, UOS ORL TI, Campus Bio-medico University, Rome 00128, Italy
| | - Manuel Casale
- Unit of Otolaryngology, UOS ORL TI, Campus Bio-medico University, Rome 00128, Italy
| | - Lorenzo Pignataro
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan 20100, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan 20100, Italy
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