Acute otitis media guidelines in selected developed and developing countries: uniformity and diversity

Factors affecting the antimicrobial changes during treatment for acute otitis media in Japan: A retrospective cohort study using classification and regression trees (CART) analysis

OBJECTIVES

Factors that affect the change of first-line antimicrobial agents were investigated to further promote their appropriate use.

METHODS

This descriptive study used an electronic medical records database. Total 16,353 of the 199,896 patients enrolled between 1996 and 2019 met the inclusion criteria and formed the overall pediatric acute otitis media (AOM) cohort. The factors leading to the change in first-line antimicrobial agents within 14 days were analyzed using classification and regression trees (CART) analysis.

RESULTS

This antimicrobial treatment cohort, involved 4860 cases of AOM alone and 9567 cases of AOM with other diseases. The size of the medical facility based on number of beds and historical duration of patient registration impacted on antimicrobial changes.

CONCLUSIONS

The current results show that hospital-wide or nation-wide antimicrobial stewardship promotion could be the most influencing factor for antimicrobial changes. Particularly in cases of AOM where other diseases coexist, a more accurate diagnosis and definition of treatment failure of first-line drug are suggested to be important while establishing future treatment strategies. The current study is important to promote appropriate antimicrobial use for AOM treatment.

Parental experiences and opinions regarding the management of acute otitis media in Finland-a comparative questionnaire between 2006 and 2019

BACKGROUND

Treatment guidelines for acute otitis media (AOM) have changed over the past 20 years. Watchful waiting is often recommended as an option for antibiotic treatment and the use of proper pain medication is emphasised.

OBJECTIVE

To study parental experiences and opinions regarding the management of AOM and compare our findings with our previous questionnaire submitted in 2006.

METHODS

We sent an online survey link through day-care centres and Facebook parental groups in Turku area. Children <4 years of age attending day care were included in the analysis. We asked about the child's history of AOM, parental opinions about AOM treatment, and antibiotic resistance. Results of 2019 were compared with those of 2006.

RESULTS

Altogether 84% (320/381) and 83% (568/681) of children had had at least 1 episode of AOM in 2019 and 2006, respectively. In 2019, more children had been treated without antibiotics (30% vs. 13%, P < 0.001) and fewer parents thought that antibiotics are necessary for the treatment of AOM (70% vs. 85%, P < 0.001) compared with 2006. The use and knowledge of painkillers had increased over the past 13 years. Painkillers had been given at least once to 93% (296/320) of children in 2019 and 80% (441/552) of children in 2006 (P < 0.001).

CONCLUSIONS

Today, more parents accept watchful waiting as a treatment option for AOM and give painkillers to their children, which indicates that the education about optimal management of AOM has reached parents.

Global, Regional, and National Burdens of Otitis Media From 1990 to 2019: A Population Based Study

OBJECTIVES

Otitis media is one of the most important causes of hearing loss at an early age. Effective vaccination with the routine 7-valent pneumococcal conjugate vaccine (PCV-7) was introduced in 2000. It has been gradually replaced by the pneumococcal nontypeable Haemophilus influenzae protein D conjugate vaccine or the higher-valent 13-valent PCV (PCV-13) since 2010. Data on the change in otitis media burden in recent years are sparse at the global, regional, and national levels.

DESIGN

The Global Burden of Disease 2019 study was used to evaluate the prevalence, incidence, mortality, disability-adjusted life year (DALY) rates, and the average annual percentage changes (AAPCs) in otitis media in geographic populations worldwide from 1990 to 2019. These global trends were further analyzed by subgroup (age, sex, and sociodemographic index [SDI]).

RESULTS

Globally, the all-age rate of prevalence (AAPC = -0.7, 95% confidence interval [CI] = -0.7 to -0.8), DALYs (AAPC = -1.0, 95% CI = -1.1 to -1.0), and mortality (AAPC = -6.8, 95% CI = -7.3 to -6.4) from otitis media decreased constantly between 1990 and 2019. The all-age rate of incidence decreased sharply between 2000 and 2009 with an AAPC of -1.2 (95% CI = -1.4 to -0.9) and continued the downward trend between 2010 and 2019 (AAPC = -0.2, 95% CI = -0.3 to -0.1). In 2019, children aged 1 to 4 years old had the highest incidence at 29,127.3 per 100,000 population, while young adults under 30 years old accounted for 91.3% of the incident cases. Individuals living in middle-SDI countries had the largest increase in the incidence of otitis media, with an AAPC of 0.3 (95% CI = 0.3 to 0.3) between 1990 and 2019. The incidence and DALYs from otitis media decreased with increasing SDI. Regionally, the largest increase in incidence was observed in high-income Asia Pacific, Eastern Europe, and Western Sub-Saharan Africa between 1990 and 2019. Nationally, the largest increase in the incidence of otitis media was observed in the Republic of Korea, with an AAPC of 0.8 (95% CI = 0.6 to 1.1) in the same time period.

CONCLUSIONS

There have been successful previous endeavors to reduce DALYs and mortality attributed to otitis media on a global scale. The worldwide incidence of otitis media experienced a sharp decline following the introduction of PCV-7 in 2000, and this downward trend persisted in subsequent years with the adoption of PCV-13/pneumococcal nontypeable Haemophilus influenzae protein D conjugate vaccine. Continual epidemiological surveillance of otitis media's global trends, pathogen distribution, and resistance patterns remains imperative.

Comparative efficacy and optimal duration of first-line antibiotic regimens for acute otitis media in children and adolescents: a systematic review and network meta-analysis of 89 randomized clinical trials

INTRODUCTION

Antibiotic use for acute otitis media (AOM) is one of the major sources of antimicrobial resistance. However, the effective minimal antibiotic duration for AOM remains unclear. Moreover, guidelines often recommend broad ranges (5-10 days) of antibiotic use, yet the clinical impact of such a wide window has not been assessed.

METHODS

We systematically searched PubMed/MEDLINE, Embase, Scopus, Web of Science, and Cochrane Library from database inception to 6 October 2021. Network meta-analysis was conducted on randomized controlled trials that assessed antibiotic treatment for AOM in children (PROSPERO CRD42020196107).

RESULTS

For amoxicillin and amoxicillin-clavulanate, 7-day regimens were noninferior to 10-day regimens in clinical responses [amoxicillin: risk ratio (RR) 0.919 (95% CI 0.820-1.031), amoxicillin-clavulanate: RR 1.108 (0.957-1.282)], except for ≤ 2 years. For the third-generation cephalosporins, 7-day and 10-day regimens had similar clinical responses compared to placebo [7-day: RR 1.420 (1.190-1.694), 10-day: RR 1.238 (1.125-1.362) compared to placebo]. However, 5-day regimens of amoxicillin-clavulanate and third-generation cephalosporins were inferior to 10-day regimens. Compared to amoxicillin, a shorter treatment duration was tolerable with amoxicillin-clavulanate.

CONCLUSIONS

Our findings indicated that 10 days of antibiotic use may be unnecessarily long, while the treatment duration should be longer than 5 days. Otherwise, 5-day regimens would be sufficient for a modest treatment goal. Our findings revealed that the current wide range of recommended antibiotic durations may have influenced the clinical outcome of AOM, and a narrower antibiotic duration window should be re-established.

Impact of ventilation tube insertion on long-term language outcomes at 6 and 10 years of age: A prospective pregnancy cohort study

OBJECTIVE

Investigating the impact of early childhood ventilation tube insertion (VTI) on long-term language outcomes.

DESIGN

Longitudinal cohort study.

SETTING

A total of 2900 pregnant women participated in the Raine Study between 1989 and 1991 in Western Australia, and 2868 children have been followed up.

PARTICIPANTS

Based on parental reports, 314 children had a history of recurrent otitis media but did not undergo VTI (rOM group); another 94 received VTI (VTI group); while 1735 had no history of rOM (reference group) in the first 3 years of childhood. Children with data on outcomes and confounders were included in analyses of PPVT-R at ages 6 (n = 1567) and 10 years (n = 1313) and CELF-III at 10 years (n = 1410) (approximately 5% in the VTI group and 15% in the rOM group).

MAIN OUTCOME MEASURES

Peabody Picture Vocabulary Test-Revised edition and Clinical Evaluation of Language Fundamentals® Preschool-3.

RESULTS

At 6 years, mean PPVT-R scores were significantly lower in the VTI group than the reference group (β = -3.3; 95% CI [-6.5 to -0.04], p = .047). At 10 years, while the difference between the VTI and reference groups was less pronounced for PPVT-R scores, there was a small but consistent trend of lower measures, on average, across CELF-III scores (expressive: β = -3.4 [-7.1 to 0.27], p = .069; receptive: β = -4.1 [-7.9 to -0.34], p = .033; total: β = -3.9 [-7.5 to -0.21], p = .038). There was no evidence to suggest that language outcomes in the rOM group differed from the reference group.

CONCLUSION

Lower scores of language outcomes in school-aged children who received VTI in early childhood may suggest a long-term risk which should be considered alongside the potential benefits of VTI.

Can ChatGPT help patients answer their otolaryngology questions?

Background

Over the past year, the world has been captivated by the potential of artificial intelligence (AI). The appetite for AI in science, specifically healthcare is huge. It is imperative to understand the credibility of large language models in assisting the public in medical queries.

Objective

To evaluate the ability of ChatGPT to provide reasonably accurate answers to public queries within the domain of Otolaryngology.

Methods

Two board-certified otolaryngologists (HZ, RS) inputted 30 text-based patient queries into the ChatGPT-3.5 model. ChatGPT responses were rated by physicians on a scale (accurate, partially accurate, incorrect), while a similar 3-point scale involving confidence was given to layperson reviewers. Demographic data involving gender and education level was recorded for the public reviewers. Inter-rater agreement percentage was based on binomial distribution for calculating the 95% confidence intervals and performing significance tests. Statistical significance was defined as p < .05 for two-sided tests.

Results

In testing patient queries, both Otolaryngology physicians found that ChatGPT answered 98.3% of questions correctly, but only 79.8% (range 51.7%-100%) of patients were confident that the AI model was accurate in its responses (corrected agreement = 0.682; p < .001). Among the layperson responses, the corrected coefficient was of moderate agreement (0.571; p < .001). No correlation was noted among age, gender, or education level for the layperson responses.

Conclusion

ChatGPT is highly accurate in responding to questions posed by the public with regards to Otolaryngology from a physician standpoint. Public reviewers were not fully confident in believing the AI model, with subjective concerns related to less trust in AI answers compared to physician explanation. Larger evaluations with a representative public sample and broader medical questions should immediately be conducted by appropriate organizations, governing bodies, and/or governmental agencies to instill public confidence in AI and ChatGPT as a medical resource.

Level of Evidence

4.

Acute otitis media diagnosis in childhood: still a problem in 2023?

BACKGROUND

Diagnosis of acute otitis media (AOM) in children can be challenging, given that symptoms are often non-specific or absent, and that the direct observation of the tympanic membrane in its entirety through otoscopy can sometimes be difficult. The aim of this study is to assess the diagnostic concordance in detection of AOM episodes between primary care paediatricians and physicians especially trained in paediatric otoscopy, and to characterize the most misleading elements in diagnostic failure.

METHODS

Consecutive clinical charts of children regularly followed for recurrent AOM (RAOM, i.e.: >3 episodes in 6 months or > 4 episodes in 1 year) at our Otitis Media paediatric outpatient clinic were retrospectively screened, in order to collect any diagnosis of AOM episode (and the related clinical findings/middle ear complaints) performed by primary care paediatricians/emergency room paediatricians. Diagnosis of AOM episode was validated by the same experienced physician (FF) in case of otoscopic relief of a bulging eardrum with at least one of the following: hyperaemia or yellow-like colour. The diagnostic concordance in detection of AOM episodes between primary care/emergency room paediatricians and our internal validator was expressed as the percentage of matching diagnosis.

RESULTS

One hundred and thirty-four single AOM episodes occurring in 87 children (mean age: 26.9 +/- 18.9 months) were included in the analysis. Diagnostic concordance in detection of AOM episodes between primary care/emergency room paediatricians and our internal validator was reported in 72.4% of cases. The most common pitfall found in our study was the misleading diagnosis of AOM in case of hyperaemic tympanic membrane without bulging (32/37 out of non-validated diagnoses).

CONCLUSIONS

AOM diagnosis still represents a relevant issue among paediatricians in our country, and the presence of tympanic membrane hyperaemia without concomitant bulging can be confusing.

Effectiveness of analgesic ear drops as add-on treatment to oral analgesics in children with acute otitis media: study protocol of the OPTIMA pragmatic randomised controlled trial

INTRODUCTION

Ear pain is the most prominent symptom of childhood acute otitis media (AOM). To control the pain and reduce reliance on antibiotics, evidence of effectiveness for alternative interventions is urgently needed. This trial aims to investigate whether analgesic ear drops added to usual care provide superior ear pain relief over usual care alone in children presenting to primary care with AOM.

METHODS AND ANALYSIS

This is a pragmatic, two-arm, individually randomised, open, superiority trial with cost-effectiveness analysis and nested mixed-methods process evaluation in general practices in the Netherlands. We aim to recruit 300 children aged 1-6 years with a general practitioner (GP) diagnosis of AOM and ear pain. Children will be randomly allocated (ratio 1:1) to either (1) lidocaine hydrochloride 5 mg/g ear drops (Otalgan) one to two drops up to six times daily for a maximum of 7 days in addition to usual care (oral analgesics, with/without antibiotics); or (2) usual care. Parents will complete a symptom diary for 4 weeks as well as generic and disease-specific quality of life questionnaires at baseline and 4 weeks. The primary outcome is the parent-reported ear pain score (0-10) over the first 3 days. Secondary outcomes include proportion of children consuming antibiotics, oral analgesic use and overall symptom burden in the first 7 days; number of days with ear pain, number of GP reconsultations and subsequent antibiotic prescribing, adverse events, complications of AOM and cost-effectiveness during 4-week follow-up; generic and disease-specific quality of life at 4 weeks; parents' and GPs' views and experiences with treatment acceptability, usability and satisfaction.

ETHICS AND DISSEMINATION

The Medical Research Ethics Committee Utrecht, the Netherlands, has approved the protocol (21-447/G-D). All parents/guardians of participants will provide written informed consent. Study results will be submitted for publication in peer-reviewed medical journals and presented at relevant (inter)national scientific meetings.

TRIAL REGISTRATION

The Netherlands Trial Register: NL9500; date of registration: 28 May 2021. At the time of publication of the study protocol paper, we were unable to make any amendments to the trial registration record in the Netherlands Trial Register. The addition of a data sharing plan was required to adhere to the International Committee of Medical Journal Editors guidelines. The trial was therefore reregistered in ClinicalTrials.gov (NCT05651633; date of registration: 15 December 2022). This second registration is for modification purposes only and the Netherlands Trial Register record (NL9500) should be regarded as the primary trial registration.

Long-term follow-up after recurrent otitis media and ventilation tube insertion: Hearing outcomes and middle-ear health at six years of age

OBJECTIVES

To investigate the long-term impact of recurrent otitis media (rOM) and ventilation tube insertion (VTI) in early childhood on hearing outcomes and middle-ear health three to five years later, in a prospective pregnancy cohort study.

METHODS

Children were classified into rOM (n = 314), VTI (n = 94), and reference (n = 1735) groups, according to their otitis media (OM) history in their first three years of life. Audiometry at frequencies 500 Hz, 1000 Hz, 2000 Hz, and 4000 Hz, and tympanometry were performed when children were approximately six years of age.

RESULTS

A binary logistic regression incorporating a range of potential confounding variables showed that hearing outcomes and middle-ear health status in children who had early childhood rOM with or without undergoing VTI were not significantly different to those in the reference group. The only significant difference was found in the VTI group for both tympanometry (OR = 2.190; 95% CI = 1.123, 4.270) and audiometry outcomes at 4000 Hz (OR = 3.202; 95% CI 1.341, 6.717), in the left ear only. The median score of the better ear 4FA was 20 dB in children in all groups.

CONCLUSION

Children with rOM with or without undergoing VTI in the first three years of childhood had comparable hearing outcomes and middle-ear health status to those with no history of the disease, at around the age of six years. Although children who underwent VTI had an increased risk of abnormal middle-ear status and some elevation in hearing levels in their left ear only, their audiometry results were still within normal limits, indicating that the impact of VTI in early childhood is unlikely to have clinically significant adverse impact on later hearing outcomes.

Relevance of the Consensus Principles for Appropriate Antibiotic Prescribing in 2022

BACKGROUND

In the late 1990s, as a response to rising antimicrobial resistance (AMR), an independent multinational, interdisciplinary group was formed specifically targeting primary care antibiotic prescribing for community-acquired respiratory tract infections (CA-RTIs). The group comprised senior clinicians from Canada, Israel, Spain, Sweden, UK and USA. The group's objectives were to provide recommendations for antibiotic stewardship in the community because, whilst it was widely accepted that inappropriate antibiotic use was contributing to AMR, it remained difficult to change prescribing behaviour. The group aimed to identify principles underlying appropriate antibiotic prescribing and guideline formulation to reduce morbidity from CA-RTIs, limit therapeutic failure and, importantly, curb AMR emergence. The group published a report in 2002, which has become known as the Consensus Principles.

OBJECTIVES

(i) To consider the relevance of the Consensus Principles in 2022 by reviewing current global approaches to rising AMR. A wide range of factors, such as antibiotic overuse, most recently seen in COVID-19 patients, are still driving rising AMR even though there has been a high-level international response to the AMR threat; and (ii) as an introduction to this Supplement, which reports the findings of analyses of how AMR is being addressed in nine disparate countries (Brazil, India, Kuwait, Mexico, Pakistan, Russia, Saudi Arabia, Türkiye and Vietnam). Understanding how these initiatives are being pursued in different countries helps identify areas where more information is needed.

CONCLUSIONS

Adherence to the Consensus Principles remains as important now as it was in 2002. Achieving appropriate antibiotic prescribing is a vital objective in order that the right patient receives the right antibiotics at the right time to ensure optimal clinical outcomes while at the same time helping to limit further increases in AMR.

The Use of PCR for Respiratory Virus Detection on the Diagnosis and Treatment Decision of Respiratory Tract Infections in Iraq

Diseases of the respiratory system are a common cause of antibiotic prescription in Iraq and worldwide. Technology has been recently used for its diagnosis, such as the Film Array Respiratory Panel. This study aims to identify the correlation between the diagnosis and treatment of respiratory tract infections with the result of polymerase chain reaction (PCR) for respiratory viruses. A descriptive, cross-sectional, retrospective study included 134 patients treated at Alkharama Hospital and the Private Hospital in Baghdad, Iraq, in the period from January 2020 to March 2020 For all cases, the results of the panel and the treatment received by the patients were analysed. 58% received antibiotic treatment upon admission, 13% combined treatment (antibiotic + antiviral), 27% received symptomatic treatment, and 2% were treated with the first-instance antiviral. After the result, 38% continued with antibiotics, 30% with antibiotics and antivirals, 13.8% with antivirals and 18.2% with symptomatic treatment. Despite the worldwide alarm over antimicrobial resistance, patients continue to be treated with antibiotics due to a situation that is influenced by several factors.

Treatment failure in pediatric acute otitis media: How do you define?

INTRODUCTION

Reaching the point of treatment failure in the management of pediatric acute otitis media (AOM) is decision-changing, and is often associated with switching to a broader coverage antibiotic with/without middle ear surgical drainage. Yet, still there is no consensus on the definition of what is treatment failure, which may lead to confusion for clinical decision-making purposes. We sought to review the heterogeneity of treatment failure definitions in AOM.

METHODS

We searched for relevant English language manuscripts using the following key-words: ['otitis media' (OM) or (AOM)] AND ['treatment failure' or 'failure' or 'response failure' or 'response'] AND 'human' in various electronic databases from 1/1/2005 through 10/31/2020.

RESULTS

In the 60 retrieved papers, treatment failure was considered only when antibiotics had been prescribed beforehand, but not when watchful waiting had been adopted. We categorized the manuscripts into 5 major treatment failure definition subgroups, which occasionally overlapped: unimprovement or worsening of symptoms or signs of failure in otoscopy (n = 36), specialist(s) referral or hospital admission (n = 12), changing or adding antibiotic treatment (n = 22), failure to eradicate causative bacteria (n = 7) and failure as perceived by parents (n = 4).

CONCLUSIONS

We suggest a broader definition of AOM treatment failure including physical examination findings and degree of initial treatment response, which will enable an unbiased, uniform comparison of treatments for pediatric AOM.

Pneumococcal Conjugated Vaccines Decreased Acute Otitis Media Burden: A Population-Based Study in Israel

OBJECTIVE

To study time trends in all-cause acute otitis media (AOM) burden by calculating incidence rates of AOM episodes and recurrent acute otitis media (rAOM) cases in highly immunized pediatric population during the pre- and post-pneumococcal conjugated vaccine (PCV) years.

STUDY DESIGN

In this population-based study, AOM episodes and rAOM cases were identified in Clalit Health Services-insured Israeli children aged 0-10 years between 2005 and 2018 by using a data-sharing platform. Because a near-sequential implementation of PCV-7/PCV-13 occurred within a 1-year period (2009/2010), we compared AOM visits before (2005-July 2009) and after (August 2009-2018) the introduction of PCVs. We focused on children younger than 2 years of age, who are the target population of PCVs and are at AOM peak age.

RESULTS

We identified 805 389 AOM episodes contributed by 270 137 children. The median number of AOM episodes was 2 (IQR 1-4). A downward trend of incidence rates of AOM episodes was observed during the post-PCV years in children younger than age 9 years (P < .001). The largest decrease (21%) was observed in children younger than 1 year, from 807/1000 children during the pre-PCV years to 640/1000 during the post-PCV years (P < .001). An average annual decrease of ∼14/1000 AOM episodes was calculated in children younger than 1 year old (β = -13.39, 95% CI -16.25 to -10.53, P < .001). Of rAOM cases, documented in 84 237 (31.2%) children, 74% were in children younger than 2 years, and 55% were in boys. The risk to develop rAOM significantly decreased during the post-PCV years in children younger than 2 years (hazard ratio 0.893, 95% CI 0.878-0.908; P < .001).

CONCLUSIONS

AOM burden significantly decreased following PCVs introduction in highly immunized children.

Antibiotic prescription policy for acute otitis media: do we follow the guidelines?

BACKGROUND

Acute otitis media (AOM) is a common cause for antibiotic prescription. Most guidelines endorse abstaining from immediate antibiotic treatment ('watchful waiting', WW) in mild-moderate episodes. We studied adherence rates to the latest AOM guidelines (2013), in terms of antibiotic type and prescription options.

METHODS

In this population-based study, AOM episodes were identified in Clalit Health Services-insured children aged 0-10 years between 2011 and 2018, using a data-sharing platform. After identifying the index, prescription and issuing dates for antibiotics for each AOM episode, treatment was categorized as immediate (≤2 days after diagnosis) or WW (antibiotic not prescribed/issued; prescribed ≤2 days after diagnosis but issued on Days 2-7; or prescribed/issued on Days 2-7). Guideline adherence was measured according to age.

RESULTS

Of the 491 106 episodes, 361 518 (73.6%) were treated with antibiotics. Following the 2013 guidelines, the ratio of episodes in children aged ≤6 months that were adherent (immediate treatment) was higher (OR = 1.22; 95% CI 1.15-1.29; P < 0.001), whereas the adherent episode ratio for children aged 6-24 months and 2-10 years (WW) was lower (OR = 0.87; 95% CI 0.85-0.88 and OR = 0.94; 95% CI 0.92-0.96, respectively; P < 0.001). Antibiotic prescription rates after 2013 for children aged ≤6 months were not different (OR = 1.03; 95% CI 0.96-1.1; P = 0.4), but were higher in children aged 6-24 months and 2-10 years (OR = 1.07; 95% CI 1.05-1.09; P < 0.001 and OR = 1.02; 95% CI 1.01-1.04; P = 0.015, respectively). Amoxicillin was the most common antibiotic, administered in 75.6% of episodes. Azithromycin was most commonly associated with treatment failure (6.6%).

CONCLUSIONS

Improved adherence to the 2013 guidelines was observed only in children aged ≤6 months and over-treatment with antibiotics was still high.

First-line antibiotic prescription patterns for acute otitis media in children: A descriptive study using Japanese claims data (2014-2018)

INTRODUCTION

Acute otitis media is a highly prevalent disease in children. Although guidelines in many countries recommend amoxicillin as the first-line treatment for acute otitis media, the prescribing pattern in Japan is not clear. Our objective was to clarify the amoxicillin prescriptions as first-line antibiotics for acute otitis media and factors associated with amoxicillin prescriptions. Also, changes in amoxicillin prescriptions during the study period by medical facilities were investigated.

METHODS

Using an administrative claims database, we included new episodes of acute otitis media prescribed antibiotics in children under seven years of age between 2014 and 2018. The proportion of amoxicillin prescription was described. Using multivariate logistic regression analysis, factors associated with amoxicillin prescription were evaluated. Rate differences were calculated to describe changes in amoxicillin prescription by medical facilities.

RESULTS

207,213 episodes in 149,929 patients were identified. Amoxicillin prescription was 24.0% and increased over the study period (P for trend <0.001). Characteristics of medical facilities were associated with amoxicillin prescriptions, and hospitals were more likely to prescribe amoxicillin (adjusted odds ratio: 1.71, 95% confidence intervals: 1.63 to 1.79). Compared to 2014, the range of increase in amoxicillin prescription in 2018 was greater in hospitals (14.9%) and pediatric clinics (10.5%) than in otolaryngology clinics (5.9%) and other specialty clinics (6.0%).

CONCLUSIONS

During the study period, amoxicillin prescriptions had increased compared to 2014, but the proportion was still low. Clinics prescribed less amoxicillin than hospitals, and the range of increase was small. Our results suggested that some interventions focused on clinics are needed.

Allergy is not a risk factor for recurrent acute otitis media: a real-life clinical experience

Background

Acute otitis media (AOM) is the most common bacterial infection in children. Some children with AOM tend to be otitis-prone, such as to have frequent recurrence of AOM (RAOM). The possible RAOM risk factors are widely debated.

Objective

The aim was to identify predictive factors, including clinical data and endoscopic findings, for RAOM in children.

Methods

The current study was performed in a real-life setting, such as an otorhinolaryngologic (ORL) clinic. In this study, 1,002 children (550 males, 452 females; mean age, 5.77 ± 1.84 years), complaining upper airway symptoms, were consecutively visited. Detailed clinical history and nasal endoscopy were performed.

Results

Throughout the ORL visit, it was possible to define some factors involved in the recurrence of AOM, including female sex, artificial feeding, tonsillar and adenoid hypertrophy, whereas male sex and recurrent respiratory infections could protect from RAOM.

Conclusion

Allergy was not associated with RAOM. In addition, this real-life study identified some predictive factors of RAOM, thus also in a primary care setting it is possible to achieve important information that is relevant in clinical practice.

From Evidence to Clinical Guidelines in Antibiotic Treatment in Acute Otitis Media in Children

Acute otitis media (AOM) in children represents a public health concern, being one of the leading causes of health care visits and antibiotic prescriptions worldwide. The overall aim of this paper is to unravel the major current insights into the antibiotic treatment of AOM in children. Our approach is three-fold: 1. a preclinical evaluation of antibiotics in animal models of AOM stressing on the advantages of different species when testing for different schemes of antibiotics; 2. an overview on the new antimicrobial agents whose efficacy has been demonstrated in refractory cases of AOM in children; and 3. an analysis of the different guidelines stressing on the differences and similarities between the various schemes of antibiotic treatment. The preferred therapeutic agents remain amoxicillin and the amoxicillin-clavulanate combination for AOM caused by Streptococcus pneumoniae, whereas oral cephalosporin is preferred in AOM due to Moraxella catarrhalis and Haemophilus influenzae. As for the second and third line antimicrobial treatments, there is a wide variety of suggested antibiotic classes with variations in duration and posology. The decision to prescribe antimicrobial treatment as a first-line choice is based on the severity of the symptoms in 16 of the guidelines included in this review.

Pneumococcal conjugate vaccines for preventing acute otitis media in children

BACKGROUND

Prior to introducing pneumococcal conjugate vaccines (PCVs), Streptococcus pneumoniae was most commonly isolated from the middle ear fluid of children with acute otitis media (AOM). Reducing nasopharyngeal colonisation of this bacterium by PCVs may lead to a decline in AOM. The effects of PCVs deserve ongoing monitoring since studies from the post-PCV era report a shift in causative otopathogens towards non-vaccine serotypes and other bacteria. This updated Cochrane Review was first published in 2002 and updated in 2004, 2009, 2014, and 2019.

OBJECTIVES

To assess the effect of PCVs in preventing AOM in children up to 12 years of age.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, LILACS, Web of Science, and two trials registers, ClinicalTrials.gov and WHO ICTRP, to 11 June 2020.

SELECTION CRITERIA

Randomised controlled trials of PCV versus placebo or control vaccine.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane. The primary outcomes were frequency of all-cause AOM and adverse effects. Secondary outcomes included frequency of pneumococcal AOM and frequency of recurrent AOM (defined as three or more AOM episodes in six months or four or more in one year). We used GRADE to assess the certainty of the evidence.

MAIN RESULTS

We included 15 publications of 11 trials (60,733 children, range 74 to 37,868 per trial) of 7- to 11-valent PCVs versus control vaccines (meningococcus type C vaccine in three trials, and hepatitis A or B vaccine in eight trials). We included one additional publication of a previously included trial for this 2020 update. We did not find any relevant trials with the newer 13-valent PCV. Most studies were funded by pharmaceutical companies. Overall, risk of bias was low. In seven trials (59,415 children), PCVs were administered in early infancy, whilst four trials (1318 children) included children aged one year and over who were either healthy or had a history of respiratory illness. There was considerable clinical heterogeneity across studies, therefore we reported results from individual studies. PCV administered in early infancy PCV7 The licenced 7-valent PCV with CRM197 as carrier protein (CRM197-PCV7) was associated with a 6% (95% confidence interval (CI) -4% to 16%; 1 trial; 1662 children) and 6% (95% CI 4% to 9%; 1 trial; 37,868 children) relative risk reduction (RRR) in low-risk infants (moderate-certainty evidence), but was not associated with a reduction in all-cause AOM in high-risk infants (RRR -5%, 95% CI -25% to 12%). PCV7 with the outer membrane protein complex of Neisseria meningitidis serogroup B as carrier protein (OMPC-PCV7) was not associated with a reduction in all-cause AOM (RRR -1%, 95% CI -12% to 10%; 1 trial; 1666 children; low-certainty evidence). CRM197-PCV7 and OMPC-PCV7 were associated with 20% (95% CI 7% to 31%) and 25% (95% CI 11% to 37%) RRR in pneumococcal AOM, respectively (2 trials; 3328 children; high-certainty evidence), and CRM197-PCV7 with 9% (95% CI -12% to 27%) and 10% (95% CI 7% to 13%) RRR in recurrent AOM (2 trials; 39,530 children; moderate-certainty evidence). PHiD-CV10/11 The effect of a licenced 10-valent PCV conjugated to protein D, a surface lipoprotein of Haemophilus influenzae, (PHiD-CV10) on all-cause AOM in healthy infants varied from 6% (95% CI -6% to 17%; 1 trial; 5095 children) to 15% (95% CI -1% to 28%; 1 trial; 7359 children) RRR (low-certainty evidence). PHiD-CV11 was associated with 34% (95% CI 21% to 44%) RRR in all-cause AOM (1 trial; 4968 children; moderate-certainty evidence). PHiD-CV10 and PHiD-CV11 were associated with 53% (95% CI 16% to 74%) and 52% (95% CI 37% to 63%) RRR in pneumococcal AOM (2 trials; 12,327 children; high-certainty evidence), and PHiD-CV11 with 56% (95% CI -2% to 80%) RRR in recurrent AOM (1 trial; 4968 children; low-certainty evidence). PCV administered at a later age PCV7 We found no evidence of a beneficial effect on all-cause AOM of administering CRM197-PCV7 in children aged 1 to 7 years with a history of respiratory illness or frequent AOM (2 trials; 457 children; moderate-certainty evidence) and CRM197-PCV7 combined with a trivalent influenza vaccine in children aged 18 to 72 months with a history of respiratory tract infections (1 trial; 597 children; moderate-certainty evidence). CRM197-PCV9 In 1 trial including 264 healthy daycare attendees aged 1 to 3 years, CRM197-PCV9 was associated with 17% (95% CI -2% to 33%) RRR in parent-reported all-cause otitis media (very low-certainty evidence). Adverse events Nine trials reported on adverse effects (77,389 children; high-certainty evidence). Mild local reactions and fever were common in both groups, and occurred more frequently in PCV than in control vaccine groups: redness (< 2.5 cm): 5% to 20% versus 0% to 16%; swelling (< 2.5 cm): 5% to 12% versus 0% to 8%; and fever (< 39 °C): 15% to 44% versus 8% to 25%. More severe redness (> 2.5 cm), swelling (> 2.5 cm), and fever (> 39 °C) occurred less frequently (0% to 0.9%, 0.1% to 1.3%, and 0.4% to 2.5%, respectively) in children receiving PCV, and did not differ significantly between PCV and control vaccine groups. Pain or tenderness, or both, was reported more frequently in PCV than in control vaccine groups: 3% to 38% versus 0% to 8%. Serious adverse events judged to be causally related to vaccination were rare and did not differ significantly between groups, and no fatal serious adverse event judged causally related to vaccination was reported.

AUTHORS' CONCLUSIONS

Administration of the licenced CRM197-PCV7 and PHiD-CV10 during early infancy is associated with large relative risk reductions in pneumococcal AOM. However, the effects of these vaccines on all-cause AOM is far more uncertain based on low- to moderate-certainty evidence. We found no evidence of a beneficial effect on all-cause AOM of administering PCVs in high-risk infants, after early infancy, and in older children with a history of respiratory illness. Compared to control vaccines, PCVs were associated with an increase in mild local reactions (redness, swelling), fever, and pain and/or tenderness. There was no evidence of a difference in more severe local reactions, fever, or serious adverse events judged to be causally related to vaccination.

Clinical practice guidelines for the diagnosis and management of acute otitis media in children-2018 update

OBJECTIVE

"Clinical Practice Guidelines for the Diagnosis and Management of Acute Otitis Media in Children-2018 update (2018 Guidelines)" aim to provide appropriate recommendations about the diagnosis and management of children with acute otitis media (AOM), including recurrent acute otitis media (recurrent AOM), in children under 15 years of age. These evidence-based recommendations were created with the consensus of the subcommittee members, taking into consideration unique characteristics of bacteriology and antimicrobial susceptibilities of AOM pathogens in Japan, as well as global advances in vaccines.

METHODS

The subcommittee re-evaluated key clinical issues based on SCOPE (a master plan of the guidelines) and created clinical questions (CQ) about the diagnosis and management of AOM patients. A literature search of the publications from 2013 to 2016 were added to the Guidelines 2013, not only to assess the evidence on the effectiveness of vaccines, but also to provide up to date information of the bacteriology and antimicrobial susceptibilities of AOM causative pathogens in Japan.

RESULTS

We have proposed guidelines for disease severity-based management of AOM patients, after classifying AOM severity into mild, moderate, and severe, based on age, clinical manifestations, and otoscopic findings.

CONCLUSIONS

Precise otoscopic findings are essential for judging AOM severity, which can lead to appropriate management of AOM patients.

Clinical practice guidelines for acute otitis media in children: a systematic review and appraisal of European national guidelines

OBJECTIVES

To appraise European guidelines for acute otitis media (AOM) in children, including methodological quality, level of evidence (LoE), astrength of recommendations (SoR), and consideration of antibiotic stewardship.

DESIGN

Systematic review of the literature.

DATA SOURCES

Three-pronged search of (1) databases: Medline, Embase, Cochrane library, Guidelines International Network and Trip Medical Database; (2) websites of European national paediatric associations and (3) contact of European experts. Data were collected between January 2017 and February 2018.

ELIGIBILITY CRITERIA

National guidelines of European countries for the clinical management of AOM in children aged <16 years.

DATA EXTRACTION AND SYNTHESIS

Data were extracted using tables constructed by the research team. Guidelines were graded using AGREE II criteria. LoE and SoR were compared. Guidelines were assessed for principles of antibiotic stewardship.

RESULTS

AOM guidelines were obtained from 17 or the 32 countries in the European Union or European Free Trade Area. The mean AGREE II score was ≤41% across most domains. Diagnosis of AOM was based on similar signs and symptoms. The most common indication for antibiotics was tympanic membrane perforation/otorrhoea (14/15; 93%). The majority (15/17; 88%) recommended a watchful waiting approach to antibiotics. Amoxicillin was the most common first-line antibiotic (14/17; 82%). Recommended treatment duration varied from 5 to 10 days. Seven countries advocated high-dose (75-90 mg/kg/day) and five low-dose (30-60 mg/kg/day) amoxicillin. Less than 60% of guidelines used a national or international scale system to rate level of evidence to support recommendations. Under half of the guidelines (7/17; 41%) referred to country-specific microbiological and antibiotic resistance data.

CONCLUSIONS

Guidelines for managing AOM were similar across European countries. Guideline quality was mostly weak, and it often did not refer to country-specific antibiotic resistance patterns. Coordinating efforts to produce a core guideline which can then be adapted by each country may help improve overall quality and contribute to tackling antibiotic resistance.

Role of Biofilms in Post-Tympanostomy Tube Otorrhea

OBJECTIVE

Nearly half of children who undergo tympanostomy tube (TT) insertion may experience otorrhea following surgery. We sought to review the evidence for the role of bacterial biofilms in post-tympanostomy tube otorrhea (PTTO) and the accumulated experience regarding the preventive measures for biofilm formation/adhesion on TTs.

METHODS

English literature search for relevant MeSH keywords was conducted in the following databases: MEDLINE (via PubMed), Ovid Medline, Google Scholar, and Clinical Evidence (BMJ Publishing) between January 1, 1995, and December 31, 2019. Subsequently, articles were reviewed and included if biofilm was evident in PTTO.

RESULTS

There is an increased evidence supporting the role of biofilms in PTTO. Studies on TT design and material suggest that nitinol and/or silicone TTs had a lower risk for PTTO and that biofilms appeared in specific areas, such as the perpendicular junction of the T-tubes and the round rims of the Paparella-type tubes. Biofilm-component DNAB-II protein family was present in half of children with PTTO, and targeting this protein may lead to biofilm collapse and serve as a potential strategy for PTTO treatment. Novel approaches for the prevention of biofilm-associated PTTO include changing the inherent tube composition; tube coating with antibiotics, polymers, plant extracts, or other biofilm-resistant materials; impregnation with antimicrobial compounds; and surface alterations by ion-bombardment or surface ionization, which are still under laboratory investigation.

CONCLUSIONS

Currently, there is no type of TT on which bacteria will not adhere. The challenges of treating PTTO indicate the need for further research in optimization of TT design, composition, and coating.

Panel 6: Otitis media and associated hearing loss among disadvantaged populations and low to middle-income countries

OBJECTIVE:

Summarise the published evidence on otitis media and associated hearing loss in low to middle-income countries (LMIC) and disadvantaged populations.

DATA SOURCES:

PubMed and other databases.

REVIEW METHODS:

Firstly, sensitive search strategy using ‘otitis media’, combined with specific key words for each topic of the review, from January 2015 to June 2019. Then, restriction to LMIC and disadvantaged populations. Topics covered included prevention, epidemiology, risk factors, microbiology, prognosis, diagnosis, and treatment.

CONCLUSIONS:

There was a high degree of methodological heterogeneity and high risk of bias. The majority of studies were school-based. In Africa, Asia and Oceania (e.g., Australian Aboriginal populations) the prevalence of OM was respectively 8% (range 3–16%), 14% (range 7–22%) and 50% (4–95%). Prevalence of any hearing loss in these regions was 12% (range 8–17%), 12% (range 3–24%), and 26% (range 25–28%) respectively. Risk factors in LMIC and disadvantaged populations included age, gender, exposure to smoke and pollution. Microbiology was reported for otitis media with effusion at time of surgery or ear discharge (acute otitis media with perforation or chronic suppurative otitis media). Specimen handling and processing in hospital laboratories was associated with low detection of S. pneumoniae and H. influenzae. Case series described complicated cases of OM due to M. tuberculosis, multidrug resistance and HIV. QOL studies identified discrimination of persons with OM and hearing loss. Diagnostic methods varied greatly, from naked eye to tympanometry. Treatment interventions were reported from four RCTs. Non-RCTs included evaluations of guidelines, surgery outcomes, access to ENTs.

IMPLICATIONS FOR CLINICAL PRACTICE:

Chronic suppurative otitis media, otitis media with effusion and conductive hearing loss are common in LMIC and disadvantaged populations. Paucity of research, poor regional representation, non-standardised methods and low-quality reporting preclude accurate assessment of disease burden in LMIC and disadvantaged populations. Awareness and adherence to reporting Guidelines should be promoted.

Panel 1: Biotechnology, biomedical engineering and new models of otitis media

OBJECTIVE

To summarize recently published key articles on the topics of biomedical engineering, biotechnology and new models in relation to otitis media (OM).

DATA SOURCES

Electronic databases: PubMed, Ovid Medline, Cochrane Library and Clinical Evidence (BMJ Publishing).

REVIEW METHODS

Articles on biomedical engineering, biotechnology, material science, mechanical and animal models in OM published between May 2015 and May 2019 were identified and subjected to review. A total of 132 articles were ultimately included.

RESULTS

New imaging technologies for the tympanic membrane (TM) and the middle ear cavity are being developed to assess TM thickness, identify biofilms and differentiate types of middle ear effusions. Artificial intelligence (AI) has been applied to train software programs to diagnose OM with a high degree of certainty. Genetically modified mice models for OM have further investigated what predisposes some individuals to OM and consequent hearing loss. New vaccine candidates protecting against major otopathogens are being explored and developed, especially combined vaccines, targeting more than one pathogen. Transcutaneous vaccination against non-typeable Haemophilus influenzae has been successfully tried in a chinchilla model. In terms of treatment, novel technologies for trans-tympanic drug delivery are entering the clinical domain. Various growth factors and grafting materials aimed at improving healing of TM perforations show promising results in animal models.

CONCLUSION

New technologies and AI applications to improve the diagnosis of OM have shown promise in pre-clinical models and are gradually entering the clinical domain. So are novel vaccines and drug delivery approaches that may allow local treatment of OM.

IMPLICATIONS FOR PRACTICE

New diagnostic methods, potential vaccine candidates and the novel trans-tympanic drug delivery show promising results, but are not yet adapted to clinical use.

Inflammation, infection, and allergy of upper airways: new insights from national and real-world studies

The upper airways (UA) should be considered as a functional unit. Current functional anatomy divides URT in three, mutually dependent, "junction boxes": i) the ostio-meatal complex (OMC), ii) the spheno-ethmoidal recess (SER), and iii) the rhinopharynx (RP). Correct ventilation and effective mucociliary clearance of these sites significantly affect the healthy physiology of the entire respiratory system. The OMC, SER, and RP obstruction is the first pathogenic step in the inflammatory/infectious cascade of UA disorders. The inflammation of the respiratory mucosa is the main pathogenic factor for airway obstruction. Moreover, bacterial biofilm (a strategy modality of bacterial survival) is an important local cause of systemic antibiotic ineffectiveness, recurrent infections, and antibiotic resistance. Health microbiota guarantees UA wellness; on the contrary, dysbiosis promotes and worsens UA infections. Allergy, namely type 2 inflammation, is a common cause of UA obstruction such as promoting in turn infections. Fiberoptic endoscopy is a mandatory diagnostic tool in clinical practice. Nasal cytology, mainly concerning flow cytometry, allows defining rhinitis phenotypes so allowing a precision medicine approach. Several conventional therapeutic approaches are available, but efficacy and safety should be ever properly considered before the prescription. Also, complementary medicine plays a fruitful role in the management of UA diseases. National and real-world studies are reported and discussed as they may be useful in daily clinical practice.

Assessing the appropriateness of the management of otitis media in Australia: A population-based sample survey

AIM

Acute otitis media (AOM) is the most common infectious disease for which antibiotics are prescribed; its management is costly and has the potential to increase the antimicrobial resistance of this infection. This study measured the levels of adherence to the clinical practice guidelines (CPGs) of AOM and otitis media with effusion (OME) management in Australian children.

METHODS

We searched for national and international CPGs relating to AOM and OME in children and created 37 indicators for assessment. We reviewed medical records for adherence to these indicators in 120 locations, across one inpatient and three ambulatory health-care settings. Our review sample was obtained from three Australian states that contain 60% of the nation's children.

RESULTS

We reviewed the records of 1063 children with one or more assessments of CPG adherence for otitis media. Of 22 indicators with sufficient data, estimated adherence ranged from 7.4 to 99.1%. Overuse of treatment, particularly overprescribing of antibiotics, was more common than underuse. A frequent lack of adherence with recommended care was observed for children aged between 1 and 2 years with AOM. Adherence varied by health-care setting, with emergency departments and inpatient settings more adherent to CPGs than general practices.

CONCLUSIONS

Our assessment of a number of indicators in the common settings in which otitis media is treated found that guideline adherence varied widely between individual indicators. Internationally agreed standards for diagnosis and treatment, coupled with clinician education on the existence and content of CPGs and clinical decision support, are needed to improve the management of children presenting with AOM and OME.

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

BACKGROUND

New insights into the diagnosis, treatment and prevention of acute otitis media (AOM) have been gained in recent years. For this reason, the Italian Paediatric Society has updated its 2010 guidelines.

METHODS

A literature search was carried out on PubMed. Only pediatric studies published between January 1, 2010 and December 31, 2018 in English or Italian were included. Each included study was assessed according to the GRADE methodology. The quality of the systematic reviews was assessed using AMSTAR 2. The recommendations were formulated by a multidisciplinary panel of experts.

RESULTS

Prompt antibiotic treatment is recommended for children with otorrhea, intracranial complications and/or a history of recurrence and for children under the age of 6 months. For children 6 months to 2 years of age, prompt antibiotic treatment is recommended for all forms of unilateral and bilateral AOM, whether mild or severe. Prompt antibiotic treatment is also recommended for children over 2 years with severe bilateral AOM. A watchful-waiting approach can be applied to children over 2 years with mild or severe unilateral AOM or mild bilateral AOM. High doses of amoxicillin, or amoxicillin-clavulanic acid for patients with a high risk of infection by Beta-lactamase producing strains, remain the first-line antibiotics.

CONCLUSIONS

AOM should be managed on a case-by-case basis that takes account of the child's age, the severity of the episode and whether it is unilateral or bilateral. In patients under 2 years, prompt antibiotic treatment is always recommended.

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

BACKGROUND

In recent years, new progress has been made regarding the diagnosis, treatment and prevention of acute otitis media (AOM). The Italian Pediatric Society therefore decided to issue an update to the previous guidelines published in 2010.

METHODS

Literature searches were conducted on MEDLINE by Pubmed, including studies in children, in English or Italian, published between January 1, 2010, and December 31, 2018. The quality of the included studies was assessed using the grading of recommendations, assessment, development and evaluations (GRADE) methodology. In particular, the quality of the systematic reviews was evaluated using the AMSTAR 2 appraisal tool. The guidelines were formulated using the GRADE methodology by a multidisciplinary panel of experts.

RESULTS

The diagnosis of AOM is based on acute clinical symptoms and otoscopic evidence; alternatively, the presence of otorrhea associated with spontaneous tympanic membrane perforation allows the AOM diagnosis. The diagnosis of AOM must be certain and the use of a pneumatic otoscope is of fundamental importance. As an alternative to the pneumatic otoscope, pediatricians can use a static otoscope and a tympanometer. To objectively establish the severity of the episode for the formulation of a correct treatment program, an AOM severity scoring system taking into account clinical signs and otoscopic findings was developed.

CONCLUSIONS

The diagnosis of AOM is clinical and requires the introduction of specific medical training programs. The use of pneumatic otoscopes must be promoted, as they are not sufficiently commonly used in routine practice in Italy.

Impact of Antimicrobial Treatment for Acute Otitis Media on Carriage Dynamics of Penicillin-Susceptible and Penicillin-Nonsusceptible Streptococcus pneumoniae

Background

Despite concerns that antimicrobial treatment of prevalent infections may select for drug-resistant bacteria, the effects of antimicrobial treatment on colonization dynamics have not been well quantified.

Methods

We measured impacts of antimicrobial treatment on nasopharyngeal carriage of penicillin-susceptible Streptococcus pneumoniae (PSSP) and penicillin-nonsusceptible (PNSP) lineages at the end of treatment and 15, 30, and 60 days after treatment in a previously conducted randomized, double-blinded, placebo-controlled trial of amoxicillin-clavulanate for stringently defined acute otitis media.

Results

In intention-to-treat analyses, immediate treatment with amoxicillin-clavulanate reduced PSSP carriage prevalence by 88% (95% confidence interval [CI], 76%-96%) at the end of treatment and by 27% (-3%-49%) after 60 days but did not alter PNSP carriage prevalence. By the end of treatment, 7% of children who carried PSSP at enrollment remained colonized in the amoxicillin-clavulanate arm, compared with 61% of PSSP carriers who received placebo; impacts of amoxicillin-clavulanate persisted at least 60 days after treatment among children who carried PSSP at enrollment. Amoxicillin-clavulanate therapy reduced PSSP acquisition by >80% over 15 days. Among children who carried PNSP at enrollment, no impacts on carriage prevalence of S. pneumoniae, PSSP, or PNSP were evident at follow-up visits.

Conclusions

Although the absolute risk of carrying PNSP was unaffected by treatment, antimicrobial therapy conferred a selective impact on colonizing pneumococci by accelerating clearance and delaying acquisition of PSSP.

Pneumococcal conjugate vaccines for preventing acute otitis media in children

BACKGROUND

Prior to introducing pneumococcal conjugate vaccines (PCVs), Streptococcus pneumoniae was most commonly isolated from middle ear fluid of children with acute otitis media (AOM). Reducing nasopharyngeal colonisation of this bacterium by PCVs may lead to a decline in AOM. The effects of PCVs deserve ongoing monitoring since studies from the post-PCV era report a shift in causative otopathogens towards non-vaccine serotypes and other bacteria. This updated Cochrane Review was first published in 2002 and updated in 2004, 2009, and 2014. The review title was changed (to include the population, i.e. children) for this update.

OBJECTIVES

To assess the effect of PCVs in preventing AOM in children up to 12 years of age.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, LILACS, Web of Science, and trials registers (ClinicalTrials.gov and WHO ICTRP) to 29 March 2019.

SELECTION CRITERIA

Randomised controlled trials of PCV versus placebo or control vaccine.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane. The primary outcomes were frequency of all-cause AOM and adverse effects. Secondary outcomes included frequency of pneumococcal AOM and frequency of recurrent AOM (defined as three or more AOM episodes in six months or four or more in one year). We used GRADE to assess the quality of the evidence.

MAIN RESULTS

We included 14 publications of 11 trials (60,733 children, range 74 to 37,868 per trial) of 7- to 11-valent PCVs versus control vaccines (meningococcus type C vaccine in three trials, and hepatitis A or B vaccine in eight trials). We included two additional trials for this update. We did not find any relevant trials with the newer 13-valent PCV. Most studies were funded by pharmaceutical companies. Overall, risk of bias was low. In seven trials (59,415 children) PCVs were administered in early infancy, while four trials (1318 children) included children aged one year and over who were either healthy or had a history of respiratory illness. There was considerable clinical heterogeneity across studies, therefore we did not perform meta-analyses.Adverse eventsNine trials reported on adverse effects (77,389 children; high-quality evidence). Mild local reactions and fever were common in both groups, and occurred more frequently in PCV than in control vaccine groups: redness (< 2.5 cm): 5% to 20% versus 0% to 16%; swelling (< 2.5 cm): 5% to 12% versus 0% to 8%; and fever (< 39 °C): 15% to 44% versus 8% to 25%. More severe redness (> 2.5 cm), swelling (> 2.5 cm), and fever (> 39 °C) occurred less frequently (0% to 0.9%, 0.1% to 1.3%, and 0.4% to 2.5%, respectively in children receiving PCV) and did not differ significantly between PCV and control vaccine groups. Pain or tenderness, or both was reported more frequently in PCV than in control vaccine groups: 3% to 38% versus 0% to 8%. Serious adverse events judged causally related to vaccination were rare and did not differ significantly between groups, and no fatal serious adverse event judged causally related to vaccination was reported.PCV administered in early infancyPCV7The effect of a licenced 7-valent PCV with CRM197 as carrier protein (CRM197-PCV7) on all-cause AOM varied from -5% (95% confidence interval (CI) -25% to 12%) relative risk reduction (RRR) in high-risk infants (1 trial; 944 children; moderate-quality evidence) to 6% (95% CI -4% to 16%; 1 trial; 1662 children) and 6% (95% CI 4% to 9%; 1 trial; 37,868 children) RRR in low-risk infants (high-quality evidence). PCV7 with the outer membrane protein complex of Neisseria meningitidis serogroup B as carrier protein (OMPC-PCV7), was not associated with a reduction in all-cause AOM (RRR -1%, 95% CI -12% to 10%; 1 trial; 1666 children; high-quality evidence).CRM197-PCV7 and OMPC-PCV7 were associated with 20% (95% CI 7% to 31%) and 25% (95% CI 11% to 37%) RRR in pneumococcal AOM, respectively (2 trials; 3328 children; high-quality evidence) and CRM197-PCV7 with 9% (95% CI -12% to 27%) to 10% (95% CI 7% to 13%) RRR in recurrent AOM (2 trials; 39,530 children; high-quality evidence).PHiD-CV10/11The effect of a licenced 10-valent PCV conjugated to protein D, a surface lipoprotein of Haemophilus influenzae, (PHiD-CV10) on all-cause AOM varied from 6% (95% CI -6% to 17%; 1 trial; 5095 children) to 15% (95% CI -1% to 28%; 1 trial; 7359 children) RRR in healthy infants (moderate-quality evidence). PHiD-CV11 was associated with 34% (95% CI 21% to 44%) RRR in all-cause AOM (1 trial; 4968 children; high-quality evidence).PHiD-CV10 and PHiD-CV11 were associated with 53% (95% CI 16% to 74%) and 52% (95% CI 37% to 63%) RRR in pneumococcal AOM (2 trials; 12,327 children; high-quality evidence) and PHiD-CV11 with 56% (95% CI -2% to 80%) RRR in recurrent AOM (1 trial; 4968 children; moderate-quality evidence).PCV administered at later agePCV7We found no evidence of a beneficial effect on all-cause AOM of administering CRM197-PCV7 in children aged 1 to 7 years with a history of respiratory illness or frequent AOM (2 trials; 457 children; high-quality evidence) and CRM197-PCV7 combined with a trivalent influenza vaccine in children aged 18 to 72 months with a history of respiratory tract infections (1 trial; 597 children; high-quality evidence).CRM197-PCV9In 1 trial including 264 healthy day-care attendees aged 1 to 3 years, CRM197-PCV9 was associated with 17% (95% CI -2% to 33%) RRR in parent-reported all-cause OM (low-quality evidence).

AUTHORS' CONCLUSIONS

Administration of the licenced CRM197-PCV7 and PHiD-CV10 during early infancy is associated with large relative risk reductions in pneumococcal AOM. However, the effects of these vaccines on all-cause AOM is far more uncertain. We found no evidence of a beneficial effect on all-cause AOM of administering PCVs in high-risk infants, after early infancy (i.e. in children one year and above), and in older children with a history of respiratory illness. Compared to control vaccines, PCVs were associated with an increase in mild local reactions (redness, swelling), fever, and pain and/or tenderness. We found no evidence of a difference in more severe local reactions, fever, or serious adverse events judged causally related to vaccination.

Antibiotic prescription for febrile children in European emergency departments: a cross-sectional, observational study

BACKGROUND

Prevalence of serious bacterial infections in children in countries in western Europe and the USA is low. Antibiotic stewardship aims at a more rational use of antibiotics but information on the frequency of antibiotic prescription to children in emergency departments is scarce. We aimed to quantify and explain variability in antibiotic prescription in children attending European paediatric emergency departments.

METHODS

We did a cross-sectional, observational study of children aged between 1 month and 16 years who presented with fever to one of 28 European emergency departments on one random sampling day per month between Nov 1, 2014, and Feb 28, 2016. The surveyed sites were spread across 11 countries and included 17 academic hospitals with 3000 to up to 80 000 annual visits to their paediatric emergency departments. We determined the proportion of children without comorbidities who received antibiotic prescriptions by country, focus of infection, and type of antibiotic. We then did a detailed analysis of the same population, using a multilevel logistic regression analysis, into the variability in prescriptions across hospitals, focusing particularly on respiratory tract infections and correcting for a combination of result-dependent factors. Random group assignment was done by computer randomisation.

FINDINGS

Of 5177 children in total, 617 children had comorbidities. Of the 4560 children without comorbidities, 1454 (32%) received antibiotics. This percentage varied from 19% to 64% across countries. Of these 1454 prescriptions issued, 893 (61%) were second-line antibiotics. Antibiotic prescription for respiratory tract infections, the most common infection type, in children without comorbidities was most variable across countries (15-67% for upper respiratory tract infections and 24-87% for lower respiratory tract infections) and was associated with age (odds ratio [OR] 1·51, 95% CI 1·08-2·13), fever duration (OR 1·45, 1·01-2·07), blood concentrations of C-reactive protein (OR 2·31, 1·67-3·19), and chest x-ray results (OR 10·62, 5·65-19·94, for focal abnormalities; OR 3·49, 1·59-7·64, for diffuse abnormalities). After correcting for patient characteristics, diagnostic assessment, and hospital characteristics, antibiotic prescription for respiratory tract infections remained highly variable across emergency departments (standardised antibiotic prescription ratio 0·49-2·04).

INTERPRETATION

Antibiotic prescription in European emergency departments is highly variable, with frequent use of second-line antibiotics. To ensure successful antibiotic stewardship initiatives in Europe aimed at reducing unnecessary prescription of antibiotics, variability of prescription across hospitals should be considered, drivers of suboptimal antibiotic prescription at the local level need to be identified, and European guidelines need to be devised.

FUNDING

None.

Emerging Technologies for the Diagnosis of Otitis Media

OBJECTIVE

To review new experimental techniques for the diagnosis of otitis media (OM).

DATA SOURCES

Literature search in English in the following databases: MEDLINE (via PubMed), Ovid Medline, Google Scholar, and Clinical Evidence (BMJ Publishing) between January 1, 2005, and April 30, 2018. Subsequently, articles were reviewed and included only if relevant.

REVIEW METHODS

MeSH terms: ["diagnosis"] AND [all forms of OM] AND ["human"] AND ["ear"] and ["tympanic membrane"]. The retrieved innovative diagnostic techniques rely on and take advantage of the physical properties of the tympanomastoid cavity components: tympanic membrane (TM) thickness, its translucency and compliance; middle ear fluid characteristics; biofilm presence; increased tissue metabolic activity in OM states; and fluid presence in the mastoid cavity. These parameters are taken into account to establish OM diagnosis objectively. We review spectral gradient acoustic reflectometry, digital otoscopy, TM image analysis, multicolor reflectance imaging, anticonfocal middle ear assessment, optical coherence tomography, quantitative pneumatic otoscopy, transmastoid ultrasound, wideband measurements, TM thickness mapping, shortwave infrared imaging, and wideband acoustic transfer functions.

CONCLUSIONS

New experimental techniques are gradually introduced to overcome the limitations of standard otoscopy. The aforementioned techniques are still under investigation and are pending widespread clinical use. The implementation of these techniques in the market is dependent on their success in clinical trials, as well as on their future cost.

IMPLICATION FOR PRACTICE

New techniques for the diagnosis of OM can objectively evaluate the morphology of the TM, determine the presence of middle ear fluid and evaluate its content, and thus potentially replace standard otoscopy.

Influenza vaccination and prevention of antimicrobial resistance

INTRODUCTION

Abuse and misuse of available antimicrobial drugs have increased antimicrobial resistance (AMR), with relevant adverse health and economic impacts. Several factors suggest that the influenza vaccine is a possible effective measure to control AMR through a significant reduction in antibiotic consumption. In this paper, aspects related will be discussed.

AREAS COVERED

Although the effectiveness of influenza immunization can significantly vary according to the study design, the circulating influenza viruses, the type of vaccine, the age of the enrolled subjects, the outcome measured and the season of the study, all experts agree that the influenza vaccine can significantly reduce the risk of contracting influenza in subjects of any age. Consequently, influenza vaccination may reduce the number of bacterial superimposed infections that can complicate influenza and require antibiotic prescriptions

EXPERT COMMENTARY

Several indirect and direct observations seem to indicate that influenza vaccines can play an important role in reducing influenza-related antibiotic prescriptions. This finding can lead to at least two undeniable advantages, reductions in drug expenditure and limitations of the risk of favoring AMR development. However, only when universal vaccination is accepted and implemented will the true advantages of the influenza vaccine in reducing AMR development be completely known and exploited.

Effectiveness of amoxicillin alone in the treatment of uncomplicated acute otitis media: a systematic review protocol

INTRODUCTION

Amoxicillin is the first-line antibiotic recommended by most scientific societies for the treatment of uncomplicated acute otitis media (AOM) in children and adults. In low-income and middle-income countries however, absence of setting-specific recommendations and antibiotic resistance, promoted by higher population density and over-the-counter antibiotic availability, could hamper the effectiveness of amoxicillin. We aim to provide updated information to enable evidence-based decisions for first-line therapy of uncomplicated AOM in our setting.

METHODS AND ANALYSIS

We will conduct a systematic review of all randomised controlled trials on the clinical effectiveness of amoxicillin for the treatment of uncomplicated AOM in children above 6 months and adults. The search will include studies published from the generation of the included databases to 31 December 2017. Study selection will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and study quality will be assessed by the Risk of Bias Assessment Tool from the Cochrane Handbook for randomised trials. A meta-analysis will be conducted for homogeneous studies, eventually, using the fixed-effect model. Subgroup analysis will include age groups, amoxicillin dosage, treatment duration, effectiveness criteria, time of trial realisation, study quality and region of the world involved.

ETHICS AND DISSEMINATION

Formal ethical approval is not required, as primary data will not be collected. The results will be disseminated through a peer-reviewed publication and presented at scientific meetings.

PROSPERO REGISTRATION NUMBER

CRD42017080029.

Treatment of Acute Otitis Media in the Pediatric Emergency Department

BACKGROUND

Over-treatment of acute otitis media (AOM) with antibiotics is common, and poses a high burden on health-care systems.

METHODS

Records of children 6-36 months of age with AOM visiting a university-affiliated pediatric emergency department between 2014 and 2016 were reviewed for the treatment given: watchful waiting versus antibiotics. If antibiotics were prescribed, the type and duration were recorded. We evaluated appropriate and inappropriate treatment rates of eligible AOM cases, in respect to the local guidelines, which encourage watchful waiting in most mild-moderate cases.

RESULTS

Out of 1493 AOM visits, 863 (57.8%) were boys, with a median age of 14.9 months (interquartile range, 9-19). The overall pre-visit antibiotic rate was 24.1%, but among those children examined by a physician, this rate was 95.2%. Amoxicillin was the most common antibiotic, administered in 66.3% of the cases. Only 21 children (5.8%) had been treated with antibiotics for ≥7 days before their visit, and were considered as treatment failure. Antibiotic therapy upon discharge was recorded in 1394/1449 visits (96.2%), again with amoxicillin as the most common antibiotic therapy, in 80.8% of the cases. In these visits, the average duration of antibiotic treatment was 8.29 days. Appropriateness of treatment (watchful waiting or antibiotics) could be analyzed in 1134 visits; 20.9% were considered as inappropriate. Of them, 98.3% were prescribed with the wrong antibiotic type and duration.

CONCLUSIONS

Adherence rate to the local guidelines treatment recommendations for uncomplicated AOM was high, as measured by whether appropriate treatment was given and type and duration of antibiotics.

Impact of acute otitis media clinical practice guidelines on antibiotic and analgesic prescriptions: a systematic review

BACKGROUND

Clinical practice guidelines focusing on judicious use of antibiotics for childhood acute otitis media (AOM) have been introduced in many countries around the world.

OBJECTIVE

To systematically review the effects of these guidelines on the prescription of antibiotics and analgesics for children with AOM.

METHODS

Systematic searches of PubMed, Embase and Cochrane Library from inception to 6 June 2017 using broad search terms. Studies specifically aimed at evaluating the effects of introduction of national AOM practice guidelines on type of antibiotic and/or analgesic prescriptions were included, irrespective of design, setting or language. The Risk Of Bias In Non-randomized Studies of Interventions tool was used to assess risk of bias.

RESULTS

Of 411 unique records retrieved, seven studies conducted in six different countries (France, Italy, Spain, Sweden, UK and USA (twice)) compared data before and after guideline introduction. All studies had an observational design, using longitudinal data of children aged under 15 years (n=200-4.6 million) from either routine care, insurance databases or electronic surveys. Risk of bias of all studies was judged serious to critical.Of the five studies reporting on antibiotic prescription rates, three showed a decline of 5%-12% up to 3 years after guideline introduction and two found no or negligible effect. In one US study, the initial 9% decline decreased to 5% after 4-6 years. The recommended first choice antibiotic was prescribed more frequently (9%-58% increase) after guideline introduction in four out of five studies reporting on this outcome. Analgesic prescription rates for AOM were reported in one US study and increased from 14% to 24% after guideline introduction.

CONCLUSION

Based upon what is published, the effects of introduction of national clinical practice guidelines on antibiotic and analgesic prescribing for children with AOM seem modest at the most.

REGISTRATION

PROSPERO: CRD42016050976.

How to avoid the inappropriate use of antibiotics in upper respiratory tract infections? A position statement from an expert panel

INTRODUCTION

Bacterial resistance burden has increased in the past years, mainly due to inappropriate antibiotic use. Recently it has become an urgent public health concern due to its impact on the prolongation of hospitalization, an increase of total cost of treatment and mortality associated with infectious disease. Almost half of the antimicrobial prescriptions in outpatient care visits are prescribed for acute upper respiratory infections, especially rhinosinusitis, otitis media, and pharyngotonsillitis. In this context, otorhinolaryngologists play an important role in orienting patients and non-specialists in the utilization of antibiotics rationally and properly in these infections.

OBJECTIVES

To review the most recent recommendations and guidelines for the use of antibiotics in acute otitis media, acute rhinosinusitis, and pharyngotonsillitis, adapted to our national reality.

METHODS

A literature review on PubMed database including the medical management in acute otitis media, acute rhinosinusitis, and pharyngotonsillitis, followed by a discussion with a panel of specialists.

RESULTS

Antibiotics must be judiciously prescribed in uncomplicated acute upper respiratory tract infections. The severity of clinical presentation and the potential risks for evolution to suppurative and non-suppurative complications must be taken into 'consideration'.

CONCLUSIONS

Periodic revisions on guidelines and recommendations for treatment of the main acute infections are necessary to orient rationale and appropriate use of antibiotics. Continuous medical education and changes in physicians' and patients' behavior are required to modify the paradigm that all upper respiratory infection needs antibiotic therapy, minimizing the consequences of its inadequate and inappropriate use.

Bacteriotherapy with Streptococcus salivarius 24SMB and Streptococcus oralis 89a nasal spray for preventing recurrent acute otitis media in children: a real-life clinical experience

Recurrence of acute otitis media (RAOM) is a relevant issue in the clinical practice. “Bacteriotherapy” has been proposed as an option in children with RAOM. Streptococcus salivarius 24SMB nasal spray has been previously demonstrated to reduce the risk of acute otitis media (AOM) in otitis-prone children. The current retrospective and observational study aimed to confirm this outcome in a real-life setting, such as the common pediatric practice. Group A (108 children) served as control; group B (159 children) was treated with S. salivarius 24SMB and Streptococcus oralis 89a nasal spray after the first AOM episode. Active treatment consisted of 3 monthly courses: 2 puffs per nostril twice/day for a week. Group B showed a significant reduction of AOM episodes in comparison with group A (p<0.0001). Notably, all actively treated children with the highest AOM recurrence had a reduction of recurrence, whereas only 50% of the control group children had reduced RAOM (p<0.0001). Also, severity grade of AOM significantly diminished after the preventive bacteriotherapy (p<0.0001). In conclusion, the current retrospective and observational study demonstrated that S. salivarius 24SMB and S. oralis 89a nasal spray could be effective in the prevention of RAOM in a real-life setting.