Updated Guidelines for the Management of Acute Otitis Media in Children by the Italian Society of Pediatrics: Prevention

A Systematic Review and Meta-Analysis of the Efficacy of Antimicrobial Chemoprophylaxis for Recurrent Acute Otitis Media in Children

OBJECTIVES

Acute otitis media (AOM) is a common childhood infection. Recurrent AOM affects a subset of children, resulting in an adverse impact on quality of life, socioeconomic disadvantage, and risk of long-term sequelae. Antimicrobial chemoprophylaxis is used in some settings but is increasingly controversial due to an awareness of adverse long-term effects and contribution to global antibiotic resistance.

DESIGN AND SETTING

A comprehensive literature search was undertaken using Medline (1946-October 2023) and Embase (1974-October 2023). The primary aim was to assess the efficacy of antimicrobial chemoprophylaxis on AOM episodes in children < 18 years of age. Bias and quality assessment was performed. Dichotomous data were analysed using risk ratio with 95% confidence intervals. Meta-analysis was carried out using random-effects models for pooled analysis, independent of heterogeneity. Heterogeneity was assessed using the I2 statistic.

MAIN OUTCOME MEASURES

The effect of antimicrobial chemoprophylaxis in children with rAOM on the number of individual AOM episodes.

SECONDARY OUTCOMES

assessment of antimicrobial agents and outcomes in children with risk factors.

RESULTS

Assessment of qualitative data was performed on 20 studies (n = 2210). No controlled trials were identified post-multivalent pneumococcal conjugate vaccine (PCV) introduction, restricting current generalisability. Quantitative meta-analysis on nine pre-PCV studies (n = 1087) demonstrated antimicrobial chemoprophylaxis reduced any episode of AOM with a risk ratio 0.59 (95% CI 0.45-0.77).

CONCLUSION

Families and clinicians must balance marginal short-medium term benefit (based on pre-PCV data), and the potential for adverse effects to that individual, and the societal risk of antimicrobial resistance with prolonged antibiotic use.

What can be done to protect toddlers from air pollution: Current evidence

PROBLEM

Toddlers are more prone to exposure to widely distributed air pollution and to health damage from it. However, systematic summaries of evidence on protective behaviors against air pollution for toddlers are lacking.

OBJECTIVE

To identify currently available evidence on protective behaviors against air pollution for toddlers.

METHODS

The literature retrieval was performed in selected databases, limited from 2002 to 2022. Studies meeting the following criteria were included and praised: 1) clinical practice guideline, systematic review, expert consensus, recommended practice, randomized control test (RCT) or cohort study published in Chinese or English; 2) studies reporting effects of protective behaviors against air pollution on toddlers' health outcomes or providing recommendation on these behaviors. The evidence in the included studies was extracted, synthesized and graded for evidence summary.

RESULTS

Studies (N = 19) were used for evidence summary development and 35 pieces of best evidence were synthesized, which were divided into three categories, including "avoiding or reducing air pollution generation", "removing existing air pollution", and "avoiding or reducing exposure to existing air pollution".

CONCLUSIONS

More evidence is needed to identify protective measures against outdoor air pollution and tobacco smoke. Research in the future should focus on the safety, effectiveness and feasibility of universal measures implemented in toddlers, and try to develop protective measures specific to toddlers which highlight their special nature.

IMPLICATIONS

The results of this study can help pediatric nurses provide individualized advice and assistance for toddlers and their families, and conduct research on the effectiveness of toddler-targeting protective behaviors more efficiently.

Leading reasons for antibiotic prescriptions in pediatric respiratory infections: influence of fever in a primary care setting

BACKGROUND

Antibiotic overuse in children is a significant public health concern, as it can lead to the emergence and spread of antibiotic-resistant bacteria. Although respiratory infections account for most antibiotic prescriptions in children, many of these infections are viral and do not require antibiotics. In this study, we aimed to investigate the use of antibiotics in children with respiratory infections in a primary care setting and to explore the possible role of fever on antibiotic prescription.

METHODS

We conducted a prospective observational study that evaluated preschool children aged 0-5 years who were assessed by their primary care pediatricians for respiratory infectious diseases between October 2019 and March 2021. The study involved 69 public primary care pediatricians and a total of 678 pediatric episodes for respiratory infections.

RESULTS

Amoxicillin/clavulanate was the most frequently prescribed drug. Bronchitis accounted for most of inappropriate antibiotic prescriptions (73%). Furthermore, the presence of fever was associated with a ~ 300% increase in the likelihood of prescribing antibiotics for respiratory infections that do not typically require antibiotics.

CONCLUSION

Our findings emphasize the need for adherence to international guidelines and recommendations in the primary care of children to reduce unnecessary antibiotic use and prevent the development of antibiotic resistance. This study also underscores the potential relevance of new studies to evaluate antibiotic prescription attitudes in other clinical settings and geographical areas.

Short-term antibiotic therapy for the most common bacterial respiratory infections in infants and children

Overuse and misuse of antibiotics have strongly accelerated the progressive increase in bacterial antimicrobial resistance (AMR). The evidence that antimicrobial selective pressure was greater the longer the antibiotic therapy was continued has led some experts to reconsider duration of antibiotic therapy testing the use of short-term drug administration. If as effective as long-term therapy, short-term therapy could have been an easy measure to limit AMR emergence. In the present narrative review, whether present knowledge on short-term therapy of acute streptococcal pharyngitis (ASF), acute otitis media (AOM) and mild to moderate community-acquired pneumonia (CAP) allows systematic use of short-term therapy in infants and children with these diseases is discussed. Literature analysis showed that reducing the duration of antibiotic therapy for some of the most common pediatric respiratory infections could be a valid measure to contain the antibiotic abuse and the consequent impact on the emergence of AMR. Several data seem to indicate that this type of intervention is possible, as short-term therapy has been found as effective as the traditionally recommended long-term therapy in some cases of ASF, AOM and mild to moderate CAP. However, further studies are needed to better characterize infants and children who can have benefit with short-term antibiotic therapy in common bacterial respiratory infections.

Does social distancing impact pediatric upper airway infections? An observational controlled study and a brief literature review

PURPOSE

SARS-CoV-2 pandemic has reduced social interaction even among children. The objective of the study was to assess the role of social distancing in the course of common pediatric upper airway recurrent diseases.

MATERIALS AND METHODS

Patients aged ≤14 years with at least one ENT-related clinical condition were retrospectively recruited. All patients had two outpatient evaluations in the same period (April - September): the control group had the first evaluation in 2018 and second in 2019, whereas the case group had the first evaluation in 2019 and second in 2020. Patients of each group were individually compared between their two visits and deemed improved/unchanged/worsened for each specific ENT condition. The percentage of children improved/unchanged/worsened were then collectively compared between the two groups for each condition.

RESULTS

Patients who experienced social distancing presented a significantly higher improvement rate than controls for recurrent acute otitis media episodes (35.1 % vs. 10.8 %; Fisher's exact test p = 0.033) and for tympanogram type (54.5 % vs. 11.1 %, Fisher's exact test p = 0.009).

CONCLUSIONS

The anti-contagion social restrictions decreased the prevalence of middle ear infections and effusion in children. Further studies on larger cohorts are required to better elucidate these findings.

Immunological profiles of children with recurrent otitis media with or without spontaneous tympanic membrane perforation and of children with recurrent respiratory infections

OBJECTIVES

The primary aim of this study was to compare the immunological profiles of children affected by recurrent acute otitis media (rAOM) with and without spontaneous tympanic membrane perforation (STMP). The secondary aim was to compare immunological features of children without parameters outside the normal range and affected by either rAOM or recurrent respiratory tract infections (rRTI).

METHODS

In this study, otherwise healthy children (<10 years of age) with rAOM or rRTI were included. Data on perinatal history, vaccination status, presence of risk factors for rAOM or rRTI (including personal or family history of allergy) and number of infectious episodes in the previous 12 months were retrospectively obtained. Furthermore, data on immunological profile (blood cell count, circulating IgA, IgG, IgM and total IgE, IgG subclasses and lymphocyte subpopulations) were collected. The immune profile of children affected by rAOM with and without STMP were compared. Among children with parameters within normal range, we compared the levels of the immunological parameters of children affected by rAOM (with and without STMP) and rRTI.

RESULTS

The study involved a total of 751 children: 566 (75.3%) with rAOM and 185 (24.7%) with rRTI. Among the 566 children with rAOM, 39.7% had uncomplicated rAOM and 60.3% had rAOM with STMP. The mean age of the study population was 34.9 (SD 20.5) months. The frequency of children with parameters outside the normal range was similar among children with rAOM with (4.9%) and without STMP (6.1%). Among subjects without parameters outside the normal range, children with uncomplicated rAOM had significantly lower serum IgG, lymphocyte CD8⁺ and CD19⁺ and significantly higher IgG2 levels than children affected by rAOM with STMP. Finally, children with rAOM had lower levels of IgA, IgM and IgG2 and higher levels of IgG, lymphocyte CD19⁺ and CD16/56+ compared to children with rRTI.

CONCLUSIONS

A low (<6.5%) percentage of children with rAOM with or without STMP present parameters outside the normal range. Among subjects without parameters outside the normal range, children with uncomplicated rAOM have a different immune profile as compared to those with STMP and rRTI. New prospective studies are needed to further explore the immune features of children affected by rAOM with and without STMP.

Recurrent Acute Otitis Media Environmental Risk Factors: A Literature Review from the Microbiota Point of View

Acute otitis media (AOM) constitutes a multifactorial disease, as several host and environmental factors contribute to its occurrence. Prevention of AOM represents one of the most important goals in pediatrics, both in developing countries, in which complications, mortality, and deafness remain possible consequences of the disease, compared to in developed countries, in which this condition has an important burden in terms of medical, social, and economical implications. The strategies for AOM prevention are based on reducing the burden of risk factors, through the application of behavioral, environmental, and therapeutic interventions. The introduction of culture-independent techniques has allowed high-throughput investigation of entire bacterial communities, providing novel insights into the pathogenesis of middle ear diseases through the identification of potential protective bacteria. The upper respiratory tract (URT) is a pivotal region in AOM pathogenesis, as it could act as a source of pathogens than of protective microorganisms for the middle ear (ME). Due to its direct connection with the external ambient, the URT is particularly exposed to the influence of environmental agents. The aim of this review was to evaluate AOM environmental risk factors and their impact on URT microbial communities, and to investigate AOM pathogenesis from the microbiota perspective.

Has Otitis Media Disappeared during COVID-19 Pandemic? A Fortuitus Effect of Domestic Confinement

Background: To measure patient flow at our Pediatric Emergency Department (PED) during the Italian lockdown, with particular care in terms of otolaryngological (ENT)-related diagnoses. Methods: A retrospective evaluation of electronic charts of children admitted to our PED in the City Center of Milan (Italy) for any disease. The outcome was to compare distribution of diagnoses performed at our PED during 21 February–3 May 2019 (period 1) to 21 February–3 May 2020 (period 2). Results: A total of 4538 children were evaluated during period 1 compared to 1310 during period 2. A statistically significant overall effect on diagnosis between the study periods was attested (p-value < 0.001; pseudo R2 = 0.010), ENT-related diagnoses being more frequently documented in period 1 (80.4% vs. 19.5%; p-value < 0.001), as well as those related to middle ear infections (92.8% vs. 7.2%; p-value < 0.001). Non-complicated acute otitis media more frequently occurred in period 1 (92.0% vs. 8.0%; p-value < 0.001); no significant difference in the number of complicated middle ear infections occurred (95.8% vs. 4.2%). Conclusions: The exceptional circumstances of the Italian lockdown resulted in a significant decrease in patients’ attendance to our PED, especially when considering diagnoses related to any ENT disorder, middle ear disease, and non-complicated middle ear infection.

Improvement in the appropriate antimicrobial usage for treating pediatric acute otitis media in Japan: A descriptive study using nation-wide electronic medical record data

OBJECTIVES

We investigated changes in prescriptions for antimicrobial agents to treat children with acute otitis media (AOM).

METHODS

A descriptive study using an electronic medical record database. Of 199,896 patients enrolled between 2001 and 2019, a total of 10,797 were aged <16 years and had AOM as their first and primary disease (overall pediatric AOM cohort). In addition, 4786 patients with AOM without other comorbidities (pediatric AOM cohort) were included.

RESULTS

In the overall pediatric AOM cohort, the age distribution ranged from 11% to 23% for those younger than 2 years and from 66% to 77% for those younger than 6 years, with no change over time. In the pediatric AOM cohort, the antimicrobial prescription rate was 91% in 2001 but declined to 40% by 2019. Antimicrobial use increased from 0% to 75% for penicillins, whereas use of cephalosporins decreased from 84% to 10%. The prescription rate for acetaminophen alone increased from 33% to 58%. There were no differences in the incidence of adverse reactions among the prescribed antimicrobials.

CONCLUSIONS

Due to education efforts and promotion of the proper use of antimicrobials through means such as the Clinical practice guidelines for the diagnosis and management of acute otitis media in children (2006) and the Manual of Antimicrobial Stewardship (2016), a change in the use of antimicrobials occurred, leading to a trend to more proper use of these agents.

Incidental lowering of otitis-media complaints in otitis-prone children during COVID-19 pandemic: not all evil comes to hurt

Given COVID-19 pandemic periodic outpatient assessment of otitis-prone children regularly followed at our tertiary outpatient clinic of upper respiratory tract infections was discontinued since 9 March. In order to avoid leaving the patients to themselves just during the winter months, which are the most critical ones for these children, we kept in touch with the families of 102 children (mean age 41.4 ± 14.0 months) who had had a follow-up visit scheduled during the lockdown, and compensated with telemedicine assessment. This incidentally leads to the unexpected but not at all negative finding that a consistent clinical improvement had been occurred in most (82.3%) of children. A statistically significant reduction in the mean number of documented acute otitis media episodes, otorrhea episodes, and systemic antibiotic treatments during the February-April 2020 period compared with February-April 2019 was attested. Clinical evaluation performed in 27.4% cases revealed normal middle ear findings in all but three (89.3%) children.Conclusion: Our data document a global improvement of otitis-prone children in Milan during the Italian lockdown, as a fortuitous and incidental positive effect of the national lockdown. What is Know: • During COVID-19 pandemic in Italy any non-urgent medical activity including periodic outpatient assessment of otitis-prone children was discontinued. • Otitis-prone children experience acute infectious exacerbations mainly in winter. What is New: • Most of children reached by means of a telemedicine assessment during lockdown experienced a subjective clinical improvement; clinical assessment at the end of the lockdown revealed normal otoscopic findings in most cases. • Exceptional circumstances during COVID-19 pandemic had a fortuitous positive effect on otitis-prone children's clinical conditions.

Allergy and Otitis Media in Clinical Practice

PURPOSE OF REVIEW

Otitis media (OM) is a disease with very high prevalence in infancy, substantial burden on healthcare resources, and relevant impact on the quality of life of families. The link between OM and allergy is controversial and still debated. However, a fundamental premise has to be placed before introducing this topic: there is the need to use clear and unambiguous terms. Literature abounds with misleading terms that significantly affect the methodology and consequently the outcomes. Moreover, it is essential to differentiate patients according to the OM type (i.e., acute OM, OM with effusion, and chronic suppurative OM), the allergic disease, and mainly the age.

RECENT FINDINGS

There are some recent studies exploring this issue through different approaches, such as epidemiological, mechanistic, and therapeutic. To identify allergy as a pathogenic factor for OM could improve the management of OM patients. Vice versa, to suspect allergy in OM patients could be reasonable in selected patients. The current narrative review provides an overview of the evidence concerning the potential role of allergy in OM. As there are conflicting findings, a possible interpretation of pathophysiological events and a pragmatic approach are proposed.