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Staiano A, Bjerrum L, Llor C, Melbye H, Hopstaken R, Gentile I, Plate A, van Hecke O, Verbakel JY. C-reactive protein point-of-care testing and complementary strategies to improve antibiotic stewardship in children with acute respiratory infections in primary care. Front Pediatr 2023; 11:1221007. [PMID: 37900677 PMCID: PMC10602801 DOI: 10.3389/fped.2023.1221007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 09/25/2023] [Indexed: 10/31/2023] Open
Abstract
This paper provides the perspective of an international group of experts on the role of C-reactive protein (CRP) point-of-care testing (POCT) and complementary strategies such as enhanced communication skills training and delayed prescribing to improve antibiotic stewardship in the primary care of children presenting with an acute illness episode due to an acute respiratory tract infection (ARTI). To improve antibiotics prescribing decisions, CRP POCT should be considered to complement the clinical assessment of children (6 months to 14 years) presenting with an ARTI in a primary care setting. CRP POCT can help decide whether a serious infection can be ruled out, before deciding on further treatments or management, when clinical assessment is unconclusive. Based on the evidence currently available, a CRP value can be a valuable support for clinical reasoning and facilitate communication with patients and parents, but the clinical assessment should prevail when making a therapy or referral decision. Nearly half of children tested in the primary care setting can be expected to have a CRP value below 20 mg/l, in which case it is strongly suggested to avoid prescribing antibiotics when the clinical assessment supports ruling out a severe infection. For children with CRP values greater than or equal to 20 mg/l, additional measures such as additional diagnostic tests, observation time, re-assessment by a senior decision-maker, and specialty referrals, should be considered.
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Affiliation(s)
- Annamaria Staiano
- Department of Translational Medical Sciences, University of Naples “Federico II”, Naples, Italy
| | - Lars Bjerrum
- Centre for General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Carl Llor
- Department of Public Health and Primary Care, University of Southern Denmark, Odense, Denmark
| | - Hasse Melbye
- General Practice Research Unit, Department of Community Medicine, The Arctic University of Norway, Tromso, Norway
| | - Rogier Hopstaken
- Department of General Practice, CAPHRI School for Public Health and Primary Care, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Ivan Gentile
- Section of Infectious Diseases, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Andreas Plate
- Institute of Primary Care, University and University Hospital Zurich, Zurich, Switzerland
| | - Oliver van Hecke
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
- NIHR Community Healthcare Medtech and IVD Cooperative, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Jan Y. Verbakel
- NIHR Community Healthcare Medtech and IVD Cooperative, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
- EPI-Centre, Department of Public Health and Primary Care, Academisch Centrum Voor Huisartsgeneeskunde, Leuven & NIHR Community Healthcare Medtech and IVD cooperative, Leuven, Belgium
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Horhat R, Horhat FR, Mocanu V. Is Multidrug Resistance in Acute Otitis Media with Streptococcus pneumoniae Associated with a More Severe Disease? Med Princ Pract 2021; 30:571-578. [PMID: 34348311 PMCID: PMC8739848 DOI: 10.1159/000518720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 07/23/2021] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES Streptococcus pneumoniae is the leading bacterial etiologic agent in acute otitis media (AOM), and it produces a more severe inflammatory response than other otopathogens. Additionally, the presence of multidrug-resistant (MDR) S. pneumoniae is an important issue in the management of AOM. The present pilot study aimed to ascertain whether MDR S. pneumoniae is associated with a higher inflammatory response and/or a more severe disease. METHODS This was a prospective, single-center study on nonpneumococcal conjugate vaccine-immunized pediatric patients with severe AOM. Demographic and clinical characteristics were recorded. Middle ear fluid was obtained and cultured for each patient; antibiotic-resistance profiling was tested for S. pneumoniae isolates. The C-reactive protein (CRP) level and complete blood count were determined. Patients with positive middle ear fluid culture for S. pneumoniae were divided into 2 groups according to antibiotic resistance profile: MDR and non-MDR. RESULTS MDR S. pneumoniae was identified in 15 (35.7%) of the 42 eligible patients. Children in this group had significantly higher CRP levels (72.23 ± 62.92 vs. 14.96 ± 15.57 mg/L, p < 0.001), higher absolute neutrophil count (8.46 ± 3.97 vs. 5.22 ± 4.5 × 103/mm3, p = 0.004), higher percentage of neutrophils (52.85 ± 13.49% vs. 38.34 ± 16.16%, p = 0.004), and were more prone to develop acute mastoiditis (p = 0.01). Receiver operating characteristic analysis identified CRP as the best biomarker to discriminate between the 2 groups of patients (AUC = 0.891). CONCLUSION MDR S. pneumoniae was associated with a more severe inflammatory response and a higher incidence of mastoiditis.
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Affiliation(s)
- Raluca Horhat
- Department of Functional Sciences, Biophysics, “Victor Babeș” University of Medicine and Pharmacy Timișoara, Timisoara, Romania
- Clinic of Paediatric Surgery (Otolaryngology Department), Emergency Children's Hospital Louis Turcanu, Timisoara, Romania
- Center for Modeling Biological Systems and Data Analysis, “Victor Babeş” University of Medicine and Pharmacy, Timisoara, Romania
| | - Florin-Raul Horhat
- Department of Functional Sciences, Medical Informatics and Biostatistics, “Victor Babeș” University of Medicine and Pharmacy, Timisoara, Romania
| | - Valeria Mocanu
- Department of Surgery, Ophthalmology, “Victor Babeș” University of Medicine and Pharmacy, Timisoara, Romania
- Clinic of Paediatric Surgery, Emergency Children's Hospital Louis Turcanu, Timisoara, Romania
- *Valeria Mocanu,
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Management of Pediatric Acute Mastoiditis in Israel: Nationwide Survey Among Otorhinolaryngologists and Emergency Pediatricians. Pediatr Emerg Care 2019; 35:544-547. [PMID: 27977506 DOI: 10.1097/pec.0000000000000964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Acute mastoiditis (AM) is a medical emergency that mandates prompt diagnosis and treatment. Nevertheless, its management often differs between otorhinolaryngologists (ORLs) and pediatricians (PEDs) working in emergency departments. We sought to characterize the similarities and differences between management protocols of these 2 disciplines. METHODS A voluntary electronic questionnaire, including 17 items pertaining to pediatric AM management, was sent to all the 20 otorhinolaryngology and their corresponding pediatric emergency departments nationwide. Each department sent 1 filled out questionnaire. The response rate was 100%. RESULTS Eighteen (90%) ORLs are notified when a child with suspected AM arrives. Medical history collected by both disciplines was similar-previous otologic history (100%), previous antibiotic use (100%), and pneumococcal conjugate vaccination status (60%)-whereas acute otitis media risk factors were more important to PEDs (13 [65%] PEDs, 10 [50%] ORLs). According to 85% to 90% of ORLs and PEDs, imaging was not mandatory upon admission. According to 14 (70%) PEDs and 16 (80%) ORLs, imaging was overall performed in less than 50% of patients during hospitalization. Intravenous ceftriaxone and cefuroxime were the most common first-line antibiotic treatments (8 [40%] ORLs, 10 [50%] PEDs), with a mean treatment duration of 7 to 10 days. Eighteen (90%) of the ORLs, compared with 15 (75%) PEDs, reported that myringotomy (with or without ventilating tube insertion) was performed upon diagnosis (P = 0.05). CONCLUSIONS The management of pediatric AM is generally similar by both disciplines. The use of imaging studies is mild-moderate. We call for a national registry and encourage the publication of guidelines.
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Effect of Vaccination on Pneumococci Isolated from the Nasopharynx of Healthy Children and the Middle Ear of Children with Otitis Media in Iceland. J Clin Microbiol 2018; 56:JCM.01046-18. [PMID: 30257906 PMCID: PMC6258863 DOI: 10.1128/jcm.01046-18] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 09/20/2018] [Indexed: 12/02/2022] Open
Abstract
Vaccination with pneumococcal conjugate vaccines (PCVs) disrupts the pneumococcal population. Our aim was to determine the impact of the 10-valent PCV on the serotypes, genetic lineages, and antimicrobial susceptibility of pneumococci isolated from children in Iceland. Vaccination with pneumococcal conjugate vaccines (PCVs) disrupts the pneumococcal population. Our aim was to determine the impact of the 10-valent PCV on the serotypes, genetic lineages, and antimicrobial susceptibility of pneumococci isolated from children in Iceland. Pneumococci were collected between 2009 and 2017 from the nasopharynges of healthy children attending 15 day care centers and from the middle ears (MEs) of children with acute otitis media from the greater Reykjavik capital area. Isolates were serotyped and tested for antimicrobial susceptibility. Whole-genome sequencing (WGS) was performed on alternate isolates from 2009 to 2014, and serotypes and multilocus sequence types (STs) were extracted from the WGS data. Two study periods were defined: 2009 to 2011 (PreVac) and 2012 to 2017 (PostVac). The overall nasopharyngeal carriage rate was similar between the two periods (67.3% PreVac and 61.5% PostVac, P = 0.090). Vaccine-type (VT) pneumococci decreased and nonvaccine-type (NVT) pneumococci (serotypes 6C, 15A, 15B/C, 21, 22F, 23A, 23B, 35F, and 35B) significantly increased in different age strata post-PCV introduction. The total number of pneumococci recovered from ME samples significantly decreased as did the proportion that were VTs, although NVT pneumococci (6C, 15B/C, 23A, and 23B) increased significantly. Most serotype 6C pneumococci were multidrug resistant (MDR). Serotype 19F was the predominant serotype associated with MEs, and it significantly decreased post-PCV introduction: these isolates were predominantly MDR and of the Taiwan19F-14 PMEN lineage. Overall, the nasopharyngeal carriage rate remained constant and the number of ME-associated pneumococci decreased significantly post-PCV introduction; however, there was a concomitant and statistically significant shift from VTs to NVTs in both collections of pneumococci.
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Bergenfelz C, Hakansson AP. Streptococcus pneumoniae Otitis Media Pathogenesis and How It Informs Our Understanding of Vaccine Strategies. CURRENT OTORHINOLARYNGOLOGY REPORTS 2017; 5:115-124. [PMID: 28616365 PMCID: PMC5446555 DOI: 10.1007/s40136-017-0152-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE OF REVIEW This study aimed to review the literature regarding the mechanisms of transition from asymptomatic colonization to induction of otitis media and how the insight into the pathogenesis of otitis media has the potential to help design future otitis media-directed vaccines. RECENT FINDINGS Respiratory viruses have long been shown to predispose individuals to bacterial respiratory infections, such as otitis media. Recent information suggests that Streptococcus pneumoniae, which colonize the nasopharynx asymptomatically, can sense potentially "threatening" changes in the nasopharyngeal environment caused by virus infection by upregulating specific sets of genes involved in biofilm release, dissemination from the nasopharynx to other sites, and protection against the host immune system. Furthermore, an understanding of the transcriptional and proteomic changes occurring in bacteria during transition to infection has led to identification of novel vaccine targets that are disease-specific and will not affect asymptomatic colonization. This approach will avoid major changes in the delicate balance of microorganisms in the respiratory tract microbiome due to elimination of S. pneumoniae. SUMMARY Our recent findings are reviewed in the context of the current literature on the epidemiology and pathogenesis of otitis media. We also discuss how other otopathogens, such as Haemophilus influenzae and Moraxella catarrhalis, as well as the normal respiratory microbiome, can modulate the ability of pneumococci to cause infection. Furthermore, the unsatisfactory protection offered by the pneumococcal conjugate vaccines is highlighted and we review potential future strategies emerging to confer a more specific protection against otitis media.
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Affiliation(s)
- Caroline Bergenfelz
- Division of Experimental Infection Medicine, Department of Translational Medicine, Wallenberg Laboratory, Lund University, Inga Marie Nilsson's Street 53, 20502 Malmö, SE Sweden
| | - Anders P Hakansson
- Division of Experimental Infection Medicine, Department of Translational Medicine, Wallenberg Laboratory, Lund University, Inga Marie Nilsson's Street 53, 20502 Malmö, SE Sweden
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Tamir SO, Sibbald A, Rupa V, Marchisio P, Homøe P, Daniel SJ, Enoksson F, Marom T. Guidelines for the Treatment of Acute Otitis Media: Why Are There Worldwide Differences? CURRENT OTORHINOLARYNGOLOGY REPORTS 2017. [DOI: 10.1007/s40136-017-0149-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Laaksonen N, Rintamäki L, Korppi M. Pneumococcal vaccinations effectively prevent blood culture-negative infections that resemble occult pneumococcal bacteraemia or bacteraemic pneumococcal pneumonia at one to 36 months of age. Acta Paediatr 2016; 105:1487-1492. [PMID: 27607346 DOI: 10.1111/apa.13580] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Revised: 07/19/2016] [Accepted: 09/05/2016] [Indexed: 12/25/2022]
Abstract
AIM The occurrence of blood culture-positive pneumococcal bacteraemia and bacteraemic pneumonia decreased after large-scale pneumococcal vaccinations were introduced. The aim of this study was to evaluate the effect of pneumococcal vaccinations on hospitalisations due to blood culture-negative infections with fever and leucocytosis, without any other focus than pneumonic infiltration. MATERIAL This was a retrospective hospital chart review covering the prevaccination era of 2008-2009 and postvaccination era of 2012-2013. The number of study subjects with fever and blood leucocytosis of >17.5 × 10E9/L at one to 36 months of age was 202. RESULTS The incidence of hospitalisation for infections associated with fever and leucocytosis, when pneumonic infiltration was present on the chest radiograph, was 4.7/10 000/year, with a 95% confidence interval (95% CI) of 2.2-8.8 in children under 36 months in 2012-2013. When pneumonic infiltration was not present, the respective incidence was 14.6/10 000/year (95% CI: 9.6-21.1). The figure from the 2008-2009 prevaccination era was 11.3 (95% CI: 8.1-15.3) when pneumonic infiltration was present and 24.0/10 000/year (95% CI: 19.2-29.7) when pneumonic infiltration was absent. CONCLUSION This study provides evidence of the effectiveness of pneumococcal vaccinations in preventing blood culture-negative infections that resembled occult pneumococcal bacteraemia (pneumococcaemia) or bacteraemic pneumococcal pneumonia at one to 36 months of age.
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Affiliation(s)
- Neea Laaksonen
- Centre for Child Health Research; Tampere University and University Hospital; Tampere Finland
| | - Lilja Rintamäki
- Centre for Child Health Research; Tampere University and University Hospital; Tampere Finland
| | - Matti Korppi
- Centre for Child Health Research; Tampere University and University Hospital; Tampere Finland
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Influence of Pneumococcal Conjugate Vaccine on Acute Otitis Media with Severe Middle Ear Inflammation: A Retrospective Multicenter Study. PLoS One 2015; 10:e0137546. [PMID: 26348230 PMCID: PMC4562603 DOI: 10.1371/journal.pone.0137546] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Accepted: 08/18/2015] [Indexed: 11/20/2022] Open
Abstract
The Japanese guidelines for acute otitis media in children recommend classifying acute otitis media by age, manifestations and local findings, and also recommend myringotomy for moderate-grade cases with severe local findings, severe-grade cases, and treatment-resistant cases. The heptavalent pneumococcal conjugate vaccine was released in Japan in February 2010. In Hiroshima City, public funding allowing free inoculation with this vaccine was initiated from January 2011, and the number of vaccinated individuals has since increased dramatically. This study investigated changes in the number of myringotomies performed to treat acute otitis media during the 5-year period from January 2008 to December 2012 at two hospitals and five clinics in the Asa Area of Hiroshima City, Japan. A total of 3,165 myringotomies for acute otitis media were performed. The rate of procedures per child-year performed in <5-year-old children decreased by 29.1% in 2011 and by 25.2% in 2012 compared to the mean rate performed in the 3 years prior to the introduction of public funding. A total of 895 myringotomies were performed for 1-year-old infants. The rate of myringotomies per child-year performed for acute otitis media in 1-year-old infants decreased significantly in the 2 years after the introduction of public funding for heptavalent pneumococcal conjugate vaccine compared to all years before introduction (p<0.000001). Our results suggest a benefit of heptavalent pneumococcal conjugate vaccine for acute otitis media in reducing the financial burden of myringotomy. In addition, this vaccine may help prevent acute otitis media with severe middle ear inflammation in 1-year-old infants.
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