Diagnostic accuracy of nasopharyngeal swabs in detecting biofilm-producing bacteria in chronic adenoiditis: a preliminary study

Topical administration of S. salivarius 24SMB-S. oralis 89a in children with adenoidal disease: a double-blind controlled trial

Chronic adenoiditis (CA) is generally sustained by some infectious foci mainly located within the nasopharynx or in the deep adenoidal pads and it is characterized by a complex interplay between bacterial species. The aim of this study was to assess the efficacy and safety of the topical nasal administration of a probiotic compound based on S. salivarius 24SMB and S. oralis 89a in children with CA in terms of reduction in: the number of acute adenoidal infections (primary outcome), and in the blockage of the nasopharynx space by hypertrophic adenoids (secondary outcome). A prospective, double-blind, 1:1 randomized controlled study was performed to test the effectiveness of a 90-day treatment with Rinogermina spray (DMD ITALIA s.r.l, Rome), 1 puff each nostril twice a day for 90 days, to nasal spray placebo in children with CA (in terms of number of acute exacerbations and blockage of nasopharynx space assessed after 90 days of treatment- T1, and 90 days later- T2). The final analysis was based on 152 children (males = 48.0%; mean age = 49.2 ± 14.1 months). Compared to the baseline, no significant differences in terms of number of acute exacerbations at T1 and T2 follow-up visits were detected in both groups. After treatment, a significant reduction in the blockage of nasopharynx space by hypertrophic adenoids (0.002 < p-value < 0.007) compared to the baseline was attested in the study group at T1 and T2, but not in the control group.

CONCLUSIONS

Our findings document a positive effect of Rinogermina spray in achieving reduction in the blockage of nasopharynx space by hypertrophic adenoids, thus suggesting that its use into the integrated therapeutic management of children with CA could be of a certain utility.

WHAT IS KNOWN

• Chronic adenoiditis in children results from an imablance in baterial homeostasis at the nasophaynx, with impairment in respiratory microbiota. • The modulatory effect of target transnasal bacteriotheray by means of S. salivarius has been considered in children with chronic adenoiditis in children with recurrent acute otitis media with preliminary positive results.

WHAT IS NEW

• This randomized controlled study, specifically designed on a cohrt of children with chronic adenoiditis, documents a certain effectiveness of the probiotic treatment in achieving a reduction in the grade of adenoidal hypertropy, compared to placebo.

Biofilm formation and molecular analysis of intercellular adhesion gene cluster (icaABCD) among Staphylococcus aureus strains isolated from children with adenoiditis

Background and Objectives:

It is well known that Staphylococcus aureus biofilm plays an important role in adenoiditis and biofilm resistance frequently results in failure of therapy. The goal of this study was to evaluate the biofilm production of S. aureus isolates obtained from adenoid specimens and assess the relationship between biofilm formation ability and ica operon genes.

Materials and Methods:

A total of 112 adenoid samples were obtained from patients under 15 years old with adenoid hypertrophy. All S. aureus isolates were initially identified by standard microbiological tests and amplification of nuc by polymerase chain reaction (PCR) technique. Biofilm formation of S. aureus isolates was evaluated and icaADBC genes were detected by PCR technique.

Results:

There were 46 isolates (41%) identified as S. aureus. The ability to produce biofilm was detected among total S. aureus isolates. Molecular study of ica operon revealed that 2 (6.3%) and 19 (59.4%) isolates carried icaA and icaD, respectively. The prevalence of icaA + icaD was seen among 11 (34.4%) S. aureus isolates, while icaC and icaB were not detected.

Conclusion:

Our findings indicated that icaABCD operon are associated with biofilm formation in S. aureus isolates, however the absence of these genes may not necessarily exclude this property.

Nasopharyngeal Microbiota Analysis in Healthy and Otitis-prone Children: Focus on History of Spontaneous Tympanic Membrane Perforation

BACKGROUND

Recurrent acute otitis media (RAOM) is common in children, and it may result in spontaneous tympanic membrane perforation (STMP), management of which is often challenging. In the upper respiratory tract (URT), resident microorganisms play a pivotal role in otitis media pathogenesis and prevention, as they are able to inhibit the colonization process and otopathogens growth. In particular, Dolosigranulum spp. and Corynebacterium spp. have been associated with respiratory health in several studies. This study aims at comparing both nasopharyngeal microbiota of children with RAOM versus matched controls and nasopharyngeal microbiota of children with a history of RAOM with STMP.

METHOD

Nasopharyngeal swabs were collected from 132 children, median age 3.51 (2.13-4.72), including 36 healthy children, 50 with RAOM without STMP, and 46 with RAOM with STMP. Bacterial DNA was subsequently extracted and 16S rRNA gene V3-V4 regions were polymerase chain reaction amplified and sequenced using Illumina MiSeq technology.

RESULTS

A higher relative abundance of Dolosigranulum and Corynebacterium genera was detected in the nasopharynx of healthy children (16.5% and 9.3%, respectively) in comparison with RAOM without STMP (8.9% and 4.3%, respectively) and RAOM with STMP (5.2% and 2.8%, respectively). A decreasing pattern in relative abundance of these 2 pivotal genera through disease severity was detected. In all groups, the most abundant genera were Moraxella, Streptococcus and Haemophilus, followed by Dolosigranulum and Corynebacterium.

CONCLUSIONS

Our study provides a characterization of the URT microbiota in otitis-prone children with and without history of recurrent STMP, suggesting that the role of Dolosigranulum and Corynebacterium in regulating the healthy URT microbiota should be further studied.

Surgical Treatment of Paediatric Chronic Rhinosinusitis

Rhinosinusitis (RS) is a common disease in children, significantly affecting their quality of life. Chronic rhinosinusitis (CRS) is frequently linked to other respiratory diseases, including asthma. Children affected by CRS may be candidates for surgery in the case of failure of maximal medical therapy comprising three to six weeks of broad-spectrum systemic antibiotics with adjunctive therapies. Although endoscopic sinus surgery (ESS) is the surgical treatment of choice in adult patients with CRS, different surgical procedures are scheduled for refractory paediatric CRS and include adenoidectomy, paediatric ESS (PESS), and balloon catheter sinuplasty (BCS). The present paper discusses the indications and limitations of each treatment option in children with CRS. Given the amount of current evidence, it is reasonable to suggest that, in young and otherwise healthy children with refractory CRS, an adenoidectomy (eventually combined with BCS) should be offered as the first-line surgical treatment. Nevertheless, this approach may be considered ineffective in some patients who should be candidates for traditional ESS. In older children, those with asthma, or in the case of peculiar conditions, traditional ESS should be considered as the primary treatment.

Role of Biofilms in Children with Chronic Adenoiditis and Middle Ear Disease

Chronic adenoiditis occurs frequently in children, and it is complicated by the subsequent development of recurrent or chronic middle ear diseases, such as recurrent acute otitis media, persistent otitis media with effusion and chronic otitis media, which may predispose a child to long-term functional sequalae and auditory impairment. Children with chronic adenoidal disease who fail to respond to traditional antibiotic therapy are usually candidates for surgery under general anaesthesia. It has been suggested that the ineffectiveness of antibiotic therapy in children with chronic adenoiditis is partially related to nasopharyngeal bacterial biofilms, which play a role in the development of chronic nasopharyngeal inflammation due to chronic adenoiditis, which is possibly associated with chronic or recurrent middle ear disease. This paper reviews the current evidence concerning the involvement of bacterial biofilms in the development of chronic adenoiditis and related middle ear infections in children.

Microbiological Aspects of Acute and Chronic Pediatric Rhinosinusitis

The microbiology of acute and chronic rhinosinusitis has been extensively studied, but there are still some differences of view concerning the etiology of the former, and many disagreements regarding the microbiology of the latter. Establishing the concomitant distribution of the causative micro-organisms in cases that involve multiple sinuses is scientifically and practically important. The main problems are the variety of aerobes and anaerobes that may be involved, and the fact that different tracts of the sinuses of the same patient may be simultaneously affected. Rhinosinusitis may also involve the formation of biofilm, which may play a significant role in its pathogenesis and persistence. Biofilms have a number of advantages in terms of bacterial survival, and their perpetuation can create a certain degree of instability in host-bacteria interactions. Sinonasal microflora may further complicate pathogenesis and the identification of the pathogen(s) involved. Furthermore, the concentration, uniformity, and type/number of strains of nasal microbiota may vary from one site to another. The relative and total micro-organism counts can also be affected by various factors, and microbiota can modulate the course of both acute and chronic rhinosinusitis.

In reply to "Commentary to: Endoscopic and clinical benefits of hyaluronic acid in children with chronic adenoiditis and middle ear disease", by Zhengcai Lou

Some considerations will be expressed in consideration of the commentary previously published. In particular, we underline that no other medications were administered to the patients during the study period and any clinical evaluation was postponed in case of acute upper respiratory tract infection in the previous 14 days. We strongly advocate antibiotic treatment during any acute otitis media episode, and we agree that topically administered hyaluronic acid should be considered as a supporting treatment, "complementary to traditional therapies" in children with recurrent disease.

Adenoid bacterial colonization in a paediatric population

Adenoids play a key role in both respiratory and ear infection in children. It has also been shown that adenoidectomy improves these symptoms in this population. The main goal of the present study was to evaluate adenoid bacterial colonization and document a possible relation with infectious respiratory disease. A prospective observational study was designed to evaluate the proposed hypothesis in a paediatric population submitted to adenoidectomy by either infectious or non-infectious indications and compare these two cohorts. A total of 62 patients with ages ranging from 1 to 12 years old were enrolled in the study. Adenoid surface, adenoid core and middle meatus microbiota were compared. A close association between adenoid colonization and nasal infection was found, supporting that adenoids may function as bacterial reservoir for upper airway infection. The obtained results also contribute to explain the success of adenoidectomy in patients with infectious indications.

The presence of biofilm-producing bacteria on tonsils is associated with increased exhaled nitric oxide levels: preliminary data in children who experience recurrent exacerbations of chronic tonsillitis

BACKGROUND

It has been suggested that bacterial biofilms may be a causative factor in the aetiopathogenesis of chronic tonsillitis. Involvement of exhaled nitric oxide has been previously considered, with conflicting findings.

OBJECTIVE

A pilot study was performed to investigate the relationship between exhaled nitric oxide levels and the presence of tonsillar biofilm-producing bacteria in children with chronic tonsillitis.

METHOD

Tonsillar biofilm-producing bacteria on bioptic specimens taken during tonsillectomy were assessed by means of spectrophotometry.

RESULTS

Analysis was based on 24 children aged 5-10 years (median, 7.5 years). Biofilm-producing bacteria were found in 40.9 per cent of specimens. The median exhaled nitric oxide level was 11.6 ppb (range, 3.2-22.3 ppb). There was a significant relationship between the presence of biofilm-producing bacteria and increased exhaled nitric oxide levels (p = 0.03). Children with exhaled nitric oxide levels of more than 8 ppb were at three times greater risk of developing tonsillar biofilm-producing bacteria than those with lower levels.

CONCLUSION

Our findings suggest the possibility of discriminating children with chronic biofilm-sustained tonsillar infections on the basis of exhaled nitric oxide levels.

Role of biofilm in children with recurrent upper respiratory tract infections

Recurrent respiratory tract infections (RRTIs) are very common in children and a major challenge for pediatricians. In the last few years, bacterial biofilms have been linked to RRTIs and antibiotic resistance, and have raised serious concerns regarding the therapeutic management of recurrent middle ear diseases, chronic rhinosinusitis, and recurrent pharyngotonsillitis. This paper aims to review the new insights into biofilm-related upper respiratory tract infections in children and possible therapeutic strategies. It focuses on the clinical implications for recurrent disease and on studies in pediatric patients. Analysis of the literature showed that the involvement of bacterial biofilm in recurrent upper airway tract infections is an emerging problem that may lead to serious concerns about infection control. Despite the large amount of research within this field, detailed insight into the complex structure of bacterial biofilms and the ultrastructural and biochemical mechanisms responsible for its evasion of the immune system and resistance to treatments is currently lacking. In the future, additional emphasis should be placed on biofilm management as a component of therapeutic strategies. This goal can be attained by finding feasible methods for detecting biofilms in vivo and identifying effective methods for administering treatments that eradicate preexisting bacterial biofilms or hinder bacterial adhesion to respiratory cells.

Topographic distribution of biofilm-producing bacteria in adenoid subsites of children with chronic or recurrent middle ear infections

OBJECTIVES

Bacterial biofilms have been found in the adenoids of children with recurrent acute otitis media (AOM) and persistent otitis media with effusion (OME). However, the possible difference in biofilm-producing bacteria (BPBs) between the adenoid surface at the nasopharyngeal dome (ND) and near the ostium of the eustachian tube (ET) has not been investigated. This study aimed to assess the difference in BPBs between adenoid biopsy specimens of the ND and those taken near the pharyngeal ostium of the ET in children with chronic adenoiditis with recurrent AOM and/or persistent OME.

METHODS

We collected adenoid biopsy specimens from the ND and ET during transoral endoscopic adenoidectomy to assess BPB by means of spectrophotometric analysis.

RESULTS

We collected 135 adenoid biopsy specimens from 45 children. BPBs were detected significantly (p = 0.04) more frequently in the ET samples than in the ND samples, mainly Staphylococcus aureus. Although the prevalence of S aureus was slightly greater in the ND samples, and that of Streptococcus pneumoniae and Moraxella catarrhalis was slightly greater in the ET samples, these differences were not statistically significant.

CONCLUSIONS

The fact that BPBs were significantly more frequently located near the ostium of the ET suggests that the adenoids are a reservoir for bacteria and indicates that hypertrophic adenoids (particularly hypertrophy near the ostium of the ET) play a role in recurrent AOM and/or OME.

Recurrences in chronic tonsillitis substained by tonsillar biofilm-producing bacteria in children. Relationship with the grade of tonsillar hyperplasy

OBJECTIVES

It has been suggested that bacterial biofilms are involved in chronic tonsillar disease, but there is a lack of strong evidence concerning their etiopathogenic role in childhood chronic tonsillar infections. The aim of this study was to assess the presence of biofilm-producing bacteria (BPB) in tonsillar bioptic specimens taken from children with recurrent exacerbations of chronic hyperplastic tonsillitis, and to evaluate the possible relationship between them and the patients' demographic and clinical characteristics.

METHODS

22 children (68.2% males; median age 6.5 years, range 3-13) with recurrent exacerbations of chronic hyperplastic tonsillitis were included. The presence of tonsillar BPB was assessed by means of the spectrophotometric analysis of tonsillar bioptic specimens taken during tonsillectomy between episodes of tonsillar infection.

RESULTS

BPB were found in 50.0% of the 44 tonsillar specimens, and Staphylococcus aureus was the most frequent pathogen (81.8%). There was a significant relationship (p=0.02) between the grade of tonsillar hyperplasy (GTH) and the presence of tonsillar BPB, with an increased relative risk (RR=4.27, standard error=2.57, p<0.01) of tonsillar BPB development in children with GTH scores of >2.

CONCLUSIONS

The findings of this study: (1) confirm the presence of tonsillar BPB in children with recurrent exacerbations of chronic tonsillar infections; (2) suggest that GTH is an important indicator of the presence of tonsillar BPB; and (3) raise the question as to whether tonsillar biofilm is a causative factor or just a consequence of recurrent exacerbations of chronic hyperplastic tonsillitis.

The utility of nasopharyngeal culture in the management of chronic adenoiditis

OBJECTIVES

To examine the utility of nasopharyngeal culture in the management of children with chronic adenoiditis to determine if it results in a change in antibiotic therapy.

METHODS

Retrospective chart review of pediatric patients managed for chronic adenoiditis, being defined as cough, postnasal drip, and congestion for over three months with endoscopic evidence of nasopharyngeal purulence with normal anterior rhinoscopy and middle meati. Standard treatment was defined as amoxicillin clavulanate or amoxicillin clavulanate ES-600 in non-penicillin allergic patients, and cefuroxime or clarithromycin for penicillin allergic patients. Nasopharyngeal culture results and antibiotic prescriptions were reviewed to look for a change from the standard.

RESULTS

Of 207 patients diagnosed with chronic adenoiditis, 198 had nasopharyngeal cultures (119 male, 79 female, mean age 3.7 years). The most common organisms isolated were Streptococcus pneumoniae sensitive to penicillin in 40 cultures (20.2%), S. pneumoniae intermediate or resistant to penicillin in 26 (13.1%), Moraxella catarrhalis in 27 (13.6%), Haemophilus influenzae in 57 (28.8%), and Staphylococcus aureus intermediate or resistant to penicillin in 26 (13.1%). 13.3% of S. aureus isolated was methicillin resistant. 103 (52.0%) children required different antibiotics from the standard, and 26 (13.1%) had no antibiotics prescribed based on a negative culture. Of the 87 children suspected to have upper airway reflux, 25 (28.7%) had negative cultures. Of the 135 patients with follow-up, 50 (37.0%) reported resolution and 50 (37.0%) reported improvement of their symptoms.

CONCLUSION

Nasopharyngeal culture has significant utility in the choice of antibiotics for children with chronic adenoiditis.

Nasopharyngeal biofilm-producing otopathogens in children with nonsevere recurrent acute otitis media

OBJECTIVE

Bacterial biofilms have been detected in biopsies of the adenoid and middle ear mucosa of otitis-prone children and children with chronic middle otitis media. However, the invasiveness of biopsy makes it unsuitable for routine clinical practice, especially in pediatrics. This study aimed to investigate nasopharyngeal biofilm-producing otopathogens (BPOs) of nasopharyngeal swabs (NPS) in children with a history of nonsevere recurrent acute otitis media (RAOM) and healthy controls.

STUDY DESIGN

A cross-sectional study with planned data collection.

SETTING

University of Milan.

SUBJECTS AND METHODS

Transoral NPS were taken from infants and children aged 10 months to 11 years with nonsevere RAOM or healthy controls without adenoid hypertrophy. Nasopharyngeal colonization by otopathogens was assessed by means of microbiological cultures and standard bacterial identification, as well as nasopharyngeal BPOs by means of spectrophotometric analysis.

RESULTS

The study involved 113 children (56.6% males; median age 40 months; range, 10-132 months): 58 with a history of nonsevere RAOM (51.3%) and 55 controls (48.7%). Otopathogens were significantly more frequently detected in the RAOM group (24/58, 41.4%) than in controls (8/55, 14.5%; P = .003); the main pathogens were respectively Haemophilus influenzae (12/24, 50.0%) and Streptococcus pyogenes (3/8, 37.5%). Nasopharyngeal BPOs were more frequently isolated in the RAOM group (17/58, 29.3%) than in controls (6/55, 10.9%; P = .02). H influenzae (12/17, 70.6%) was confirmed as the main pathogen in the RAOM group.

CONCLUSION

The presence of nasopharyngeal BPOs is an important factor favoring RAOM; it is therefore useful investigating biofilms even in children with nonsevere recurrences of AOM without adenoid hypertrophy.