American Academy of Pediatrics Subcommittee on Management of Acute Otitis Media. Diagnosis and management of acute otitis media

Effects of Bifidobacterium animalis subsp. lactis BB-12 and yogurt on mice during oral antibiotic administration

Probiotics have the potential to prevent disruptions to normal gastrointestinal function caused by oral antibiotic use. In this study, we examined the capacity of Bifidobacterium animalis subspecies lactis BB-12 (BB-12) and yogurt, separately and combined, to mitigate the effects of the antibiotic amoxicillin-clavulanate (AMC) on the gut microbiota and metabolomes of C57BL/6 J mice. Male and female mice were administered either BB-12, yogurt, BB-12 in yogurt, or saline for 10 days concurrent with the inclusion of AMC in the drinking water. Male mice exposed to AMC exhibited significant reductions (p<0.05) in body weight over the course of the study compared to sham (no AMC) controls whereas no such effects were observed for female mice. AMC administration resulted in rapid alterations to the intestinal microbiota in both sexes irrespective of BB-12 or yogurt treatment, including significant (p<0.05) losses in bacterial cell numbers and changes in microbial alpha-diversity and beta-diversity in the feces and cecal contents. The effects of AMC on the gut microbiota were observed within one day of administration and the bacterial contents continued to change over time, showing a succession marked by rapid reductions in Muribaculaceae and Lachnospiraceae and temporal increases in proportions of Acholeplasmataceae (day 1) and Streptococcaceae and Leuconostocaceae (day 5). By day 10 of AMC intake, high proportions of Gammaproteobacteria assigned as Erwiniaceae or Enterobacteriaceae (average of 63 %), were contained in the stools and were similarly enriched in the cecum. The cecal contents of mice given AMC harbored significantly reduced concentrations of (branched) short-chain fatty acids (SCFA), aspartate, and other compounds, whereas numerous metabolites, including formate, lactate, and several amino acids and amino acid derivatives were significantly enriched. Despite the extensive impact of AMC, starting at day 7 of the study, the body weights of male mice given yogurt or BB-12 (in saline) with AMC were similar to the healthy controls. BB-12 (in saline) and yogurt intake was associated with increased Streptococcaceae and both yogurt and BB-12 resulted in lower proportions of Erwiniaceae in the fecal and cecal contents. The cecal contents of mice fed BB-12 in yogurt contained levels of formate, glycine, and glutamine that were equivalent to the sham controls. These findings highlight the potential of BB-12 and yogurt to mitigate antibiotic-induced gut dysbiosis.

[Increasing incidence of mastoidectomies in children : Result of reduced antibiotic therapy or late COVID-19 sequela?]

BACKGROUND

An increasing number of pediatric patients with mastoiditis and a consequent increase in mastoidectomy rates was noted in 2022 and 2023.

OBJECTIVE

This study aimed to analyze the increase in the number of children presenting with mastoiditis and subsequent mastoidectomy, to assess correlations with prior antibiotic treatment or COVID-19 infection, and to provide an overview of involved pathogens, treatment, and disease course.

MATERIALS AND METHODS

A retrospective analysis of all patients with mastoidectomy since 2012 was conducted. Data collected comprised type and duration symptoms, prior antibiotic therapy, diagnostic tests and disease course, causal pathogens, length of hospitalization, and complications.

RESULTS

A highly significant increase in mastoidectomies in children could be demonstrated from 2022. Neither the pathogens involved nor the course of disease or complications showed differences. An increase in the number of patients with prior outpatient antibiotic therapy could be shown. About a half of the patients becoming ill after fall 2022 had a positive history of COVID. Hyperplasia of adenoid tissue was a far less frequent causal mechanism than in the years before COVID.

CONCLUSION

No clear correlation with reduced outpatient antibiotic therapy could be found. Whether there exists an association with prior COVID infection cannot be judged at this time, due to the high number of asymptomatic and therefore unknown COVID infections.

Comparison of amoxicillin administered twice and three times daily in children with acute otitis media

To compare the effectiveness of amoxicillin administered in regimens of two or three daily doses in children with acute otitis media (AOM). As a secondary aim, we measured and compared treatment adherence between the two groups.A prospective observational study was conducted in the emergency department of a children's hospital.We recruited a total of 353 patients having a median age of 1.58 years. Twice-daily dosing was prescribed to 58%, while 42% received three doses per day. The clinical course of AOM was favourable in 92% of the patients who received two doses of amoxicillin and in 95% of those who received three doses (p = 0.25). Four patients (1%) had persistent symptoms beyond day 7. None developed intracranial complications. In the group receiving three doses daily, 31% reported difficulties with the dosing schedule, and 9.6% faced challenges when administering the medication at the specified volume, compared with 5.8% and 25% of those who received the two-dose regimen, respectively.  Conclusion: Twice-daily amoxicillin has similar efficacy to a three-dose daily regimen and can offer advantages for caregivers in terms of administration schedule. What is Known: • Amoxicillin given in two daily doses is as effective as a three doses regimen in the treatment of acute otitis media in children. • The lower the number of daily doses, the higher the adherence to a drug treatment. What is New: • Administration of amoxicillin in twice-daily doses may improve adherence, as it is less frequently associated with family-perceived problems with dosing schedules.

Immediate versus delayed versus no antibiotics for respiratory infections

BACKGROUND

Concerns exist regarding antibiotic prescribing for respiratory tract infections (RTIs) owing to adverse reactions, cost and antibacterial resistance. One proposed strategy to reduce antibiotic prescribing is to provide prescriptions, but to advise delay in antibiotic use with the expectation that symptoms will resolve first. This is an update of a Cochrane Review originally published in 2007, and updated in 2010, 2013 and 2017.

OBJECTIVES

To evaluate the effects on duration and/or severity of clinical outcomes (pain, malaise, fever, cough and rhinorrhoea), antibiotic use, antibiotic resistance and patient satisfaction of advising a delayed prescription of antibiotics in respiratory tract infections.

SEARCH METHODS

From May 2017 until 20 August 2022, this was a living systematic review with monthly searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL and Web of Science. We also searched the WHO International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov on 20 August 2022. Due to the abundance of evidence supporting the review's key findings, it ceased being a living systematic review on 21 August 2022.

SELECTION CRITERIA

Randomised controlled trials involving participants of all ages with an RTI, where delayed antibiotics were compared to immediate or no antibiotics. We defined a delayed antibiotic as advice to delay the filling of an antibiotic prescription by at least 48 hours. We considered all RTIs regardless of whether antibiotics were recommended or not.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures.

MAIN RESULTS

For this 2022 update, we added one new trial enrolling 448 children (436 analysed) with uncomplicated acute RTIs. Overall, this review includes 12 studies with a total of 3968 participants, of which data from 3750 are available for analysis. These 12 studies involved acute RTIs including acute otitis media (three studies), streptococcal pharyngitis (three studies), cough (two studies), sore throat (one study), common cold (one study) and a variety of RTIs (two studies). Six studies involved only children, two only adults and four included both adults and children. Six studies were conducted in primary care, four in paediatric clinics and two in emergency departments. Studies were well reported and appeared to provide moderate-certainty evidence. Randomisation was not adequately described in two trials. Four trials blinded the outcome assessor, and three included blinding of participants and doctors. We conducted meta-analyses for pain, malaise, fever, adverse effects, antibiotic use and patient satisfaction. Cough (four studies): we found no differences amongst delayed, immediate and no prescribed antibiotics for clinical outcomes in any of the four studies. Sore throat (six studies): for the outcome of fever with sore throat, four of the six studies favoured immediate antibiotics, and two found no difference. For the outcome of pain related to sore throat, two studies favoured immediate antibiotics, and four found no difference. Two studies compared delayed antibiotics with no antibiotic for sore throat, and found no difference in clinical outcomes. Acute otitis media (four studies): two studies compared immediate with delayed antibiotics - one found no difference for fever, and the other favoured immediate antibiotics for pain and malaise severity on Day 3. Two studies compared delayed with no antibiotics: one found no difference for pain and fever severity on Day 3, and the other found no difference for the number of children with fever on Day 3. Common cold (two studies): neither study found differences for clinical outcomes between delayed and immediate antibiotic groups. One study found delayed antibiotics were probably favoured over no antibiotics for pain, fever and cough duration (moderate-certainty evidence).

ADVERSE EFFECTS

there were either no differences for adverse effects or results may have favoured delayed over immediate antibiotics with no significant differences in complication rates (low-certainty evidence). Antibiotic use: delayed antibiotics probably resulted in a reduction in antibiotic use compared to immediate antibiotics (odds ratio (OR) 0.03, 95% confidence interval (CI) 0.01 to 0.07; 8 studies, 2257 participants; moderate-certainty evidence). However, a delayed antibiotic was probably more likely to result in reported antibiotic use than no antibiotics (OR 2.52, 95% CI 1.69 to 3.75; 5 studies, 1529 participants; moderate-certainty evidence). Patient satisfaction: patient satisfaction probably favoured delayed over no antibiotics (OR 1.45, 1.08 to 1.96; 5 studies, 1523 participants; moderate-certainty evidence). There was probably no difference in patient satisfaction between delayed and immediate antibiotics (OR 0.77, 95% CI 0.45 to 1.29; 7 studies, 1927 participants; moderate-certainty evidence). No studies evaluated antibiotic resistance. Reconsultation rates and use of alternative medicines were similar for delayed, immediate and no antibiotic strategies. In one of the four studies reporting use of alternative medicines, less paracetamol was used in the immediate group compared to the delayed group.

AUTHORS' CONCLUSIONS

For many clinical outcomes, there were no differences between prescribing strategies. Symptoms for acute otitis media and sore throat were modestly improved by immediate antibiotics compared with delayed antibiotics. There were no differences in complication rates. Delaying prescribing did not result in significantly different levels of patient satisfaction compared with immediate provision of antibiotics (86% versus 91%; moderate-certainty evidence). However, delay was favoured over no antibiotics (87% versus 82%). Delayed antibiotics achieved lower rates of antibiotic use compared to immediate antibiotics (30% versus 93%). The strategy of no antibiotics further reduced antibiotic use compared to delaying prescription for antibiotics (13% versus 27%). Delayed antibiotics for people with acute respiratory infection reduced antibiotic use compared to immediate antibiotics, but was not shown to be different to no antibiotics in terms of symptom control and disease complications. Where clinicians feel it is safe not to prescribe antibiotics immediately for people with RTIs, no antibiotics with advice to return if symptoms do not resolve is likely to result in the least antibiotic use while maintaining similar patient satisfaction and clinical outcomes to delayed antibiotics. Where clinicians are not confident in not prescribing antibiotics, delayed antibiotics may be an acceptable compromise in place of immediate prescribing to significantly reduce unnecessary antibiotic use for RTIs, while maintaining patient safety and satisfaction levels. Further research into antibiotic prescribing strategies for RTIs may best be focused on identifying patient groups at high risk of disease complications, enhancing doctors' communication with patients to maintain satisfaction, ways of increasing doctors' confidence to not prescribe antibiotics for RTIs, and policy measures to reduce unnecessary antibiotic prescribing for RTIs.

A trial-based cost-effectiveness analysis of antibiotic prescription strategies for non-complicated respiratory tract infections in children

BACKGROUND

Antibiotic prescription for respiratory tract infections (RTIs) in children attending primary care centres is almost double that predicted according to bacterial prevalence. Delayed antibiotic prescription (DAP) is designed to deploy a more rational use of antibiotics. While studies have evaluated DAP efficacy and safety for children with RTIs, little research has been conducted on the economic implications.

METHODS

Our trial compared cost-effectiveness for DAP, immediate antibiotic prescription (IAP), and no antibiotic prescription (NAP) for children aged 2-14 years with acute uncomplicated RTIs attended to in 39 primary care centres in Spain. The main outcome was the incremental cost-effectiveness ratio (ICER), measured in euros per gained quality-adjusted life days (QALDs). Net monetary benefit (NMB) was also calculated as a tool for decision making. The analysis was performed from a societal perspective for a time horizon of 30 days, and included healthcare direct costs, non-healthcare direct and indirect costs, and the antimicrobial resistance (AMR) cost.

RESULTS

DAP was the most cost-effective strategy, even when the cost of AMR was included. QALD values for the three strategies were very similar. IAP compared to DAP was more costly (109.68 vs 100.90 euros) and similarly effective (27.88 vs 27.94 QALDs). DAP compared to NAP was more costly (100.90 vs 97.48 euros) and more effective (27.94 vs. 27.82 QALDs). The ICER for DAP compared to NAP was 28.84 euros per QALD. The deterministic sensitivity analysis indicated that non-healthcare indirect costs had the greatest impact on the ICER. The cost-effectiveness acceptability curve showed that DAP was the preferred option in approximately 81.75% of Monte Carlo iterations, assuming a willingness-to-pay value of 82.2 euros per gained QALD.

CONCLUSIONS

When clinicians are in doubt about whether an antibiotic is needed for children with RTIs attending PC centres, those treated with the DAP strategy will have slightly better efficiency outcomes than those treated with IAP because its costs are lower than those of IAP. DAP is also the most cost-effective strategy over a time horizon of 30 days if AMR is considered, despite higher short-term costs than NAP. However, if in the long term the costs of AMR are larger than estimated, NAP could also be an alternative strategy.

TRIAL REGISTRATION

This trial has been registered at www.

CLINICALTRIALS

gov (identifier NCT01800747; Date: 28/02/2013 (retrospectively registered).

Quantitative transmastoid ultrasound for detecting middle ear effusion in pediatric patients

BACKGROUND AND OBJECTIVE

Ultrasound has emerged as a promising modality for detecting middle ear effusion (MEE) in pediatric patients. Among different ultrasound techniques, ultrasound mastoid measurement was proposed to allow noninvasive detection of MEE by estimating the Nakagami parameters of backscattered signals to describe the echo amplitude distribution. This study further developed the multiregional-weighted Nakagami parameter (MNP) of the mastoid as a new ultrasound signature for assessing effusion severity and fluid properties in pediatric patients with MEE.

METHODS

A total of 197 pediatric patients (n = 133 for the training group; n = 64 for the testing group) underwent multiregional backscattering measurements of the mastoid for estimating MNP values. MEE, the severity of effusion (mild to moderate vs. severe), and the fluid properties (serous and mucous) were confirmed through otoscopy, tympanometry, and grommet surgery and were compared with the ultrasound findings. The diagnostic performance was evaluated using the area under the receiver operating characteristic curve (AUROC).

RESULTS

The training dataset revealed significant differences in MNPs between the control and MEE groups, between mild to moderate and severe MEE, and between serous and mucous effusion were observed (p < 0.05). As with the conventional Nakagami parameter, the MNP could be used to detect MEE (AUROC: 0.87; sensitivity: 90.16%; specificity: 75.35%). The MNP could further identify effusion severity (AUROC: 0.88; sensitivity: 73.33%; specificity: 86.87%) and revealed the possibility of characterizing fluid properties (AUROC: 0.68; sensitivity: 62.50%; specificity: 70.00%). The testing results demonstrated that the MNP method enabled MEE detection (AUROC = 0.88, accuracy = 88.28%, sensitivity = 92.59%, specificity = 84.21%), was effective in assessing MEE severity (AUROC = 0.83, accuracy = 77.78%, sensitivity = 66.67%, specificity = 83.33%), and showed potential for characterizing fluid properties of effusion (AUROC = 0.70, accuracy = 72.22%, sensitivity = 62.50%, specificity = 80.00%).

CONCLUSIONS

Transmastoid ultrasound combined with the MNP not only leverages the strengths of the conventional Nakagami parameter for MEE diagnosis but also provides a means to assess MEE severity and effusion properties in pediatric patients, thereby offering a comprehensive approach to noninvasive MEE evaluation.

Structure-constrained deep feature fusion for chronic otitis media and cholesteatoma identification

Chronic suppurative otitis media (CSOM) and middle ear cholesteatoma (MEC) were two most common chronic middle ear disease(MED) clinically. Accurate differential diagnosis between these two diseases is of high clinical importance given the difference in etiologies, lesion manifestations and treatments. The high-resolution computed tomography (CT) scanning of the temporal bone presents a better view of auditory structures, which is currently regarded as the first-line diagnostic imaging modality in the case of MED. In this paper, we first used a region-of-interest (ROI) network to find the area of the middle ear in the entire temporal bone CT image and segment it to a size of 100*100 pixels. Then, we used a structure-constrained deep feature fusion algorithm to convert different characteristic features of the middle ear in three groups as suppurative otitis media (CSOM), middle ear cholesteatoma (MEC) and normal patches. To fuse structure information, we introduced a graph isomorphism network that implements a feature vector from neighbourhoods and the coordinate distance between vertices. Finally, we construct a classifier named the "otitis media, cholesteatoma and normal identification classifier" (OMCNIC). The experimental results achieved by the graph isomorphism network revealed a 96.36% accuracy in all CSOM and MEC classifications. The experimental results indicate that our structure-constrained deep feature fusion algorithm can quickly and effectively classify CSOM and MEC. It will help otologist in the selection of the most appropriate treatment, and the complications can also be reduced.

Case-control study of relationship of infection by respiratory viruses with acute otitis media in Chinese children

Background

Acute otitis media (AOM) may occur as a complication of viral upper respiratory infection (URI) in children. Our objective was to examine children with URI + AOM or URI alone to determine the association of infection by different common respiratory viruses with AOM.

Methods

Nasopharyngeal swabs were collected from March 2014 to February 2015. Quantitative PCR was then used to identify the following 10 common respiratory viruses: respiratory syncytial virus (RSV); parainfluenza viruses 1-4 (PIVs); influenza virus type A (IFVA); influenza virus type B; human rhinovirus (HRV); enterovirus; human metapneumovirus; human coronavirus OC43, 229E, NL63, and HKU1; adenovirus; and human bocavirus.

Results

We examined 255 children with URIs (mean age: 32.9 ± 18.7 months), and 164 (64.1%) of them tested positive for at least one respiratory virus. The most common viruses were RSV (44, 24.3%), PIVs (28, 15.5%), and IFVA (25, 13.8%). Positivity for RSV was significantly greater in the URI + AOM group than in the URI group, but these groups did not differ in infection rates for the other 9 viruses. There were also significant seasonal differences in positivity for RSV, IFVA, HRV,HBoV, PIVs and EV.

Conclusion

Our results indicated a relationship between infection by common respiratory viruses and AOM in children from Beijing. A URI with RSV significantly increased the risk of AOM in these children.

Incidence of acute otitis media from 2003 to 2019 in children ≤ 17 years in England

BACKGROUND

The 7-valent pneumococcal conjugate vaccine (PCV7) was introduced in 2006 and the 13-valent pneumococcal conjugate vaccine (PCV13) in 2010 in the UK. PCVs are active immunization for the prevention of invasive disease, pneumonia and acute otitis media (AOM) caused by Streptococcus pneumoniae in children. The aim of this observational study was to estimate incidence rates (IRs) of AOM in children ≤17 years from 2003 to 2019 in England, before and after the introduction of pneumococcal conjugate vaccines (PCVs).

METHODS

AOM episodes were identified using Read diagnosis codes in children aged ≤17 years in the Clinical Practice Research Datalink (CPRD) Gold database from 2003 to 2019. Annual IRs with 95% confidence intervals (CI) by age group were calculated as the number of episodes/person-years (PY) at risk. Interrupted time series analyses were conducted to estimate incidence rate ratios (IRR) across post-PCV7 (2007-2009), early post-PCV13 (2011-2014) and late post-PCV13 (2015-2019) periods compared to the pre-PCV7 period (2003-2005) using generalized linear models.

RESULTS

From 2003 to 2019, 274,008 all-cause AOM episodes were identified in 1,500,686 children. The overall AOM IR was 3690.9 (95% CI 3677.1-3704.8) per 100,000 PY. AOM IRs were highest in children aged < 5 years and decreased by age; < 2 years: 8286.7 (95% CI 8216.8-8357.1); 2-4 years: 7951.8 (95% CI 7902.5-8001.4); 5-17 years: 2184.4 (95% CI 2172.1-2196.8) (per 100,000 PY). Overall AOM IRs declined by 40.3% between the pre-PCV7 period and the late-PCV13 period from 4451.9 (95% CI 4418.1-4485.9) to 2658.5 (95% CI 2628.6-2688.7) per 100,000 PY, and across all age groups. IRRs indicated a significant decrease in AOM IRs in all the post-vaccination periods, compared to the pre-PCV7 period: post-PCV7 0.87 (95% CI 0.85-0.89), early post-PCV13 0.88 (95% CI 0.86-0.91), and late post-PCV13 0.75 (95% CI 0.73-0.78).

CONCLUSIONS

The AOM IRs declined during the 2003-2019 period; however, the clinical burden of AOM remains substantial among children ≤17 years in England.

Streptococcus pneumoniae as cause of acute otitis media (AOM) in Slovak children in the pneumococcal conjugate vaccine era (2008-2019)

AIM

Little data is available on pneumococcal serotypes and their antimicrobial resistance in the pneumococcal conjugate vaccination era in young children with acute otitis media (AOM). Here such data is provided from Slovakia, acountry with sequential introduction and parallel-use of the three commercially available pneumococcal conjugate vaccines (PCVs; PCV7; PCV13; PCV10).

METHODS

This observational study takes advantage of the fact that tympanocentesis is the standard of care in children with AOM in Slovakia. Over the 12 year observation period, participating pediatric ENT specialists sent samples taken during tympanocentesis from children with AOM to their local MEDIRIX laboratories for identification of bacteria. Pneumcoccal isolates were serotyped and tested for antimicrobial resistance. Incidence data could be calculated from 1 region.

RESULTS

Study participation and completeness of typing increased over time. Based on testing of 1,131 isolates over 12 years, PCV7-serotypes rapidly waned after PCV7 introduction in 2009 and had virtually disappeared in 2014. The maximum fraction of PCV10-only isolates (1, 5, 7F) was 2.7 % (2009) whereas the additional 3 PCV-serotypes (3, 6A, 19A) in PCV13 represented the largest proportion of pneumococcal AOM cases as of 2010. This finding remained unchanged during the period of highest PCV10-market share (2012-2017) and even until the end of the observation period (2019). The fraction of untypeable pneumococci (<6 %) and non-PCV13-serotypes (16-34 %) increased 2012-2017, but decreased again thereafter. Serotype 19A evolved as the most relevant (multidrug-) resistant pneumococcal serotype, again particularly during the time with high sales of PCV10 (2012-2017). Incidence data from the Bratislava region document a huge impact of PCV use (77 % vaccine uptake: mainly PCV13) on AOM in children < 6 years. Serotypes 19A and 3 remain the only relevant pneumococcal serotypes in young Slovakian children with AOM.

CONCLUSIONS

As AOM is one of the most common bacterial infections in children < 6 years, the observed benefits of PCVs in reducing vaccine serotypes have been tremendous. With sequential / parallel-use of PCVs, serotypes 3 and (MDR-) 19A today make the largest proportion (about 2/3) of pneumococcal AOM in Slovakia. This data will help to further guide the choice of pneumococcal conjugate vaccines for pediatricians and parents.

Early Life Antibiotic Prescription for Upper Respiratory Tract Infection Is Associated With Higher Antibiotic Use in Childhood

BACKGROUND

Antibiotic prescription for uncomplicated upper respiratory tract infection (URTI) in children is not recommended but remains common. The primary objective was to evaluate the relationship between antibiotic prescription for URTI prior to age 2 and antibiotic prescription for URTI after age 2. It was hypothesized that antibiotic prescription for URTI in early childhood may increase the risk of antibiotic use for subsequent URTIs. The secondary objective was to investigate whether this relationship was different for acute otitis media (AOM), for which antibiotics may be indicated.

METHODS

A prospective cohort study was conducted between December 2008 and March 2016 at 9 primary care practices in Toronto, Canada. Healthy children aged 0-5 years that met TARGet Kids! cohort eligibility criteria were included if they had at least one sick visit prior to age 2 and least one sick visit after age 2. Generalized Estimating Equation (GEE) models were used to evaluate this relationship while considering within-subject correlation.

RESULTS

Of 2380 participants followed for a mean duration of 4.6 years, children who received an antibiotic prescription for URTI prior to age 2 had higher odds of receiving an antibiotic prescription for URTI in later childhood (adjusted odds ratio: 1.39; 95% confidence interval: 1.19 to 1.63; P < .001). This relationship did not appear to be different for AOM compared to non-AOM URTI.

CONCLUSION

Antibiotic prescription for URTI before age 2 was associated with antibiotic prescription for URTI in later childhood. Reducing early life antibiotic prescription for URTI may be associated with reduction in antibiotic prescription for subsequent URTIs.

A Review of Noninfectious Diseases Masquerading as Acute Mastoiditis

OBJECTIVE

Acute mastoiditis is commonly attributed to infection. Rarely do clinicians encounter cases that do not respond to traditional antibiotics or surgical management. The goal of this study was to systematically review the literature to characterize diseases masquerading as acute infectious mastoiditis.

DATA SOURCES

PubMed, Embase, and Scopus.

REVIEW METHODS

A systematic review was performed to identify all publications that reported on diseases with presentations mimicking acute mastoiditis, defined as postauricular redness, swelling, and tenderness. We included clinical prospective studies, retrospective studies, and case series/reports. Exclusion criteria included non-English articles, letters/commentaries, abstracts, and review articles.

RESULTS

Out of 3339 results, 35 studies met final inclusion criteria. In children, 11 diseases were reported to mimic mastoiditis, including solid tumors, hematologic diseases, and autoimmune/inflammatory diseases. The most common disease in children was Langerhans cell histiocytosis, followed by rhabdomyosarcoma and acute myelogenous leukemia. In adults, 8 additional diseases were reported. The most common disease in adults was squamous cell carcinoma, followed by nasopharyngeal carcinoma and Langerhans cell histiocytosis. Presenting symptoms are reviewed, as well as characteristic radiographic, laboratory, and intraoperative features that may assist with diagnosis. A diagnostic algorithm for atypical cases of acute mastoiditis is proposed.

CONCLUSION

A small but significant group of diseases in children and adults can mimic acute mastoiditis. In such cases, history and examination alone may be insufficient to reach a diagnosis, and further investigation may be necessary. Otolaryngologists should always be mindful of the possibility that noninfectious pathologies may present with a constellation of symptoms similar to mastoiditis.

Haemophilus influenzae drug resistance in France from 2017 to 2021: consideration for treatment of otitis media

OBJECTIVES

Haemophilus influenzae is a prevalent agent of respiratory infections, including acute otitis media (AOM), that lead to high antibiotic prescription and may contribute to the development of bacterial resistance to antibiotics. The objective of this work was to describe and analyse antibiotic resistance of H. influenzae from 2017 to 2021 in France.

METHODS

We characterized H. influenzae isolates transmitted to the French national reference centre for H. influenzae between 2017 and 2021. We included all the 608 non-invasive respiratory isolates. Resistance rates to the main antibiotics were described. The relationship between resistance rate, age, and sex of patients and germ serotype was investigated.

RESULTS

Isolates were mainly from alveolar lavage (29.3%), expectoration (22.9%), or sputum (15%). Resistance to amoxicillin (61.4%), amoxicillin/clavulanic acid (47.4%), and cefotaxime (39.3%) was high and correlated with the presence of β-lactamase and/or modifications of the ftsI gene encoding penicillin-binding protein 3. Resistance to sulfamethoxazole/trimethoprim (33.2%) was more moderate. There were no significant differences according to serotype, age, or gender.

CONCLUSIONS

The benefit/risk balance of first choice use of amoxicillin and even of amoxicillin/clavulanic acid in AOM is questionable in view of the significant resistance to H. influenzae. The use of sulfamethoxazole/trimethoprim could be an alternative but may still need further evaluation.

Complementary/Integrative Medicine for Pediatric Otitis Media

Complementary/integrative medicine can be used in treating otitis media, especially during the watchful waiting phase. Elimination of risk factors can be important. Products such as echinacea, xylitol, and probiotics may help in prevention. Herbal eardrop formulations can relieve symptoms in some patients. Other modalities such as homeopathy can lead to faster relief of symptoms in combination with conventional therapy. Chinese, Japanese, and other forms of traditional medicine have varying formulations with unclear safety, but initial results are promising. Most studies are limited by methodological failures and small sample sizes, emphasizing the need for continued research in this area.

Recurrent Acute Otitis Media Could Be Related to the Pro-Inflammatory State That Causes an Incorrect Diet

Introduction: Acute Otitis Media (AOM) is the most commonly-occurring bacterial complication in childhood. After making certain corrections to the patients’ dietary habits, which we found to be excessively high in animal-based and industrially-processed foods, we observed a significant reduction in recurrent colds and their bacterial complications. We promote an original way of treating these diseases, since until now the conventional treatment is based on pharmacological and surgical treatment. From our point of view, the mucosa that covers the entire ENT area is in a pro-inflammatory and hyper-reactive state, as a consequence of the alterations produced by an inadequate diet. For us there is no difference in the nutritional treatment of the different mucous membranes that cover the ENT area. The purpose of the study was to assess the effects of the Traditional Mediterranean Diet (TMD) on patients diagnosed with Recurring Acute Otitis Media (RAOM). Methods: prospective pre-postest comparison study with 48 girls and 42 boys aged 1–5 years, each of whom had been and included on the 1-year programme “Learning to eat the Mediterranean Way”, designed to encourage the adoption of the TMD. We studied clinical and therapeutic variables and various anthropometric parameters. Results: all the symptomatic indicators studied (number and intensity of episodes of otitis and emergency admissions) showed a positive and statistically significant evolution in RAOM. By the end of the study, none of the patients met the criteria for classification as RAOM, and 60% percent of patients did not present any further episodes of AOM. In line with the above, the use of anti-microbial drugs and symptomatic treatments reduced considerably; the use of antibiotics dropped from 4.30 occasions/patient/year, to 0.66 (p < 0.001), and the used of symptomatic treatments dropped from 7.63 to 2.75 (p < 0.001). The level of family satisfaction was very high. Conclusions: the adoption of the Traditional Mediterranean Diet has been demonstrated to significantly reduce occurrence of acute otitis media and may contribute to the treatment of patients diagnosed with recurrent acute otitis media.

Etiology, Diagnosis, Complications, and Management of Acute Otitis Media in Children

Acute otitis media (AOM) is the most common infectious disease encountered by children under the age of two years and the most common cause of antibiotic use in children in the United States. AOM causes irritability, sleeplessness, decreased appetite, imbalance, and dizziness in patients, especially young children. This assessment was conducted to measure the effectiveness of surgical interventions in treating AOM. We reviewed the present findings regarding the etiology, clinical presentations, diagnosis, treatment, and surgical treatment of complications of AOM. Pain associated with AOM (otalgia) can be severe enough to cause parents to seek treatment for their infants or children. Various suggested measures have been used to treat AOM; antibiotic treatment with amoxicillin is still the treatment of choice for AOM, yet other antibiotics may be used in cases of allergy to penicillin or recent use of amoxicillin. Surgical intervention has been introduced and studied as a diagnostic, therapeutic, and preventive measure for AOM; nevertheless, a few studies have shown that surgical interventions are beneficial in treating and preventing AOM compared to the common practice of using antibiotics. Overdiagnosis of AOM is widespread, leading to injudicious antibiotic use, which contributes to antibiotic resistance. Further management should be determined together with the parent, particularly if observation is the primary intervention.

The Outcome of Cerumen Removal in the Pediatric Emergency Department

OBJECTIVE

Cerumen obstructs the visualization of the tympanic membrane (TM) in up to 40% of children, sometimes posing a challenge to rule out the diagnosis of acute otitis media (AOM) as the source of otalgia (for verbal children), irritability, fever, and febrile seizures. We aim to determine the rate at which removing the cerumen from blocking the view of the TM could change the management of these patients in the pediatric emergency department (PED).

METHODS

We retrospectively investigated all medical records of patients who underwent cerumen removal in the PED at a tertiary children's hospital from 2018 to 2019. We analyzed the effect of the procedure on the subsequent workup during their PED visit.

RESULTS

Of 482 children who presented to the PED with otalgia, irritability, fever, and/or febrile seizures and who were referred to an otolaryngologist for subsequent treatment after preliminary evaluation in the PED, 176 were included in the study group after having the cerumen removed from one or both ears. Seventy-three of them were given a diagnosis of AOM, 93 had a normal-appearing TM, and 10 had external otitis. Twenty-one percent of those with AOM and 46% of those with a normal TM ( P = 0.008) had blood drawn as part of their workup in their PED visit. The rate of chest x-rays was also significantly less for the AOM group (16% vs 30%, P = 0.03), and they also underwent fewer urine tests ( P = NS).

CONCLUSION

Cerumen removal changes the management of children in the PED who present with a possible diagnosis of an ear infection. Cerumen removal could avoid unnecessary laboratory and imaging studies, which could save time, costs, and suffering.

Watchful Waiting for Acute Otitis Media

BACKGROUND AND OBJECTIVES

Updated guidelines continue to support watchful waiting as an option for uncomplicated acute otitis media (AOM) and provide explicit diagnostic criteria. To determine treatment prevalence and associated determinants of watchful waiting for AOM in commercially insured pediatric patients.

METHODS

This was a retrospective cohort study using IBM Marketscan Commercial Claims Databases (2005 to 2019) of patients 1 to 12 years old with AOM, without otitis-related complications within 6 months prior, with no tympanostomy tubes, and no other infections around index diagnosis of AOM. We examined monthly antibiotic treatment prevalence (defined as pharmacy dispensing within 3 days of AOM diagnosis) and used multivariable logistic regression models to examine determinants of watchful waiting.

RESULTS

Among 2 176 617 AOM episodes, 77.8% were treated within 3 days. Whereas some clinical characteristics were moderate determinants for watchful waiting, clinician antibiotic prescribing volume and specialty were strong determinants. Low-volume antibiotic prescribers (≥80% of AOM episodes managed with watchful waiting) had 11.61 (95% confidence interval 10.66-12.64) higher odds of using watchful waiting for the index AOM episode than high-volume antibiotic prescribers (≥80% treated). Otolaryngologists were more likely to adopt watchful waiting (odds ratio 5.45, 95% CI 5.21-5.70) than pediatricians, whereas other specialties deferred more commonly to antibiotics.

CONCLUSIONS

Adoption of watchful waiting for management of uncomplicated, nonrecurrent AOM was limited and stagnant across the study period and driven by clinician rather than patient factors. Future work should assess motivators for prescribing and evaluate patient outcomes among clinicians who generally prefer versus reject watchful waiting approaches to guide clinical decision-making.

Management of Acute Complicated Mastoiditis: A Systematic Review and Meta-analysis

BACKGROUND

The objective of our study was to evaluate the efficacy of treatment options for the most frequently reported complications of acute mastoiditis in the English literature. PubMed, EMBASE, and The Cochrane Library were searched from database inception through March 29, 2019.

METHODS

Two independent reviewers (M.R.K., K.S.) evaluated search results for study inclusion. References cited in publications meeting inclusion criteria were reviewed. Twenty-three included studies were published from 1998 through 2018. Treatment efficacy was determined by comparing the change in number of complication subtypes in each treatment subgroup (medical, conservative, or surgical) from admission to discharge (range: 5-30 days) or postdischarge follow-up (range: 1-27.5 months) with a random effects model.

RESULTS

Among 733 identified articles, 23 met inclusion criteria. Of the 883 included patients, 203 were managed medically (23%), 300 conservatively (34%) and 380 surgically (43%). Conservative patients had more extracranial complications (ECC, P = 0.04) and intratemporal complications (IT, P = 0.04) at follow-up compared with medical patients. Medical patients had more total number of complications (TNC, P = 0.03), ECC (P = 0.02), and IT (P = 0.01) at discharge compared with surgical patients. Conservative patients had more of all complications except intracranial/extracranial abscess and "other" at discharge and follow-up compared with surgical patients.

CONCLUSIONS

There were larger reductions in TNC, ECC, and IT at discharge and follow-up among surgical patients compared with medical and conservative patients. There were greater reductions in TNC, ECC, IT, intracranial complications, subperiosteal abscess and lateral sinus thrombosis at discharge and follow-up among surgical patients compared with conservative patients.

Otitis Media and Tympanostomy Tubes

Acute otitis media (AOM) is an acute infection of the middle ear and, depending on the age of the child, the certainty of diagnosis, and the severity of symptoms, should be either observed closely or treated (with high-dose amoxicillin, if not allergic). Host-related risk factors such as age, sex, cleft palate, or genetic predisposition or environmental risk factors such as seasonality, day care attendance, or tobacco smoke exposure may contribute to recurrent AOM (RAOM) episodes. Tympanostomy tubes are recommended in children with RAOM and an abnormal ear examination at the time of the clinic evaluation.

The broader impacts of otitis media and sequelae for informing economic evaluations of pneumococcal conjugate vaccines

INTRODUCTION

Otitis media (OM) is a common childhood infection. Pneumococcal conjugate vaccines (PCVs) prevent OM episodes, thereby reducing short- and long-term clinical, economic, humanistic, and societal consequences. Most economic evaluations of PCVs focus on direct health gains and cost savings from prevented acute episodes but do not fully account for the broader societal impacts of OM prevention.

AREAS COVERED

This review explores the broader burden of OM on children, caregivers, and society to better inform future economic evaluations of PCVs.

EXPERT OPINION

OM causes a substantial burden to society through long-term sequelae, productivity losses, reduced quality of life for children and caregivers, and contribution to antimicrobial resistance from inappropriate antibiotic use. The effect of PCVs on acute OM has been recognized globally, yet the broader impact has not been consistently quantified, studied, or communicated. Economic evaluations of PCVs must evolve to include broader effects for patients, caregivers, and society from OM prevention. Future PCVs with broader coverage may further reduce OM incidence and antimicrobial resistance, but optimal uptake will depend on increasing the recognition and use of novel frameworks that include broader benefits. Communicating the full value of PCVs to decision makers may result in wider access and positive societal returns.

Effects of the Mediterranean Diet on Morbidity from Inflammatory and Recurrent Diseases with Special Reference to Childhood Asthma

Objective: For 15 years, we have been working with a nutritional programme based on the traditional Mediterranean diet (TMD) to complete the treatment of inflammatory and recurrent diseases (IRD), such as childhood asthma. The objective of this study is to verify the effects of TMD in the prevention and treatment of IRD by measuring the incidence of infant morbidity over 8 years. Material and Methods: The number of patients who suffered from IRD each year (just before the pandemic) was determined, as well as the frequentation and the percentage of scheduled and on-demand consultations. Results: The incidence of infant morbidity decreased as they were incorporated into a TMD, and we observed a progressive disappearance of IRD. At the beginning of the study, 20% of the patients had been diagnosed with some type of IRD. At the study’s end, the prevalence of IRD decreased to less than 2%, and the use of drugs and surgical interventions decreased markedly. Conclusions: A diet based on the TMD reduces the incidence of infant morbidity and contributes to the disappearance of IRD, whereas some non-traditional foods with high antigenic power could be involved in the appearance of IRD.

In vivo effect of fluoride combined with amoxicillin on enamel development in rats

Some evidence in vitro suggested that amoxicillin and fluoride could disturb the enamel mineralization. Objective: To assess the effect of amoxicillin and of the combination of amoxicillin and fluoride on enamel mineralization in rats. Methodology: In total, 40 rats were randomly assigned to four groups: control group (CG); amoxicillin group (AG - amoxicillin (500 mg/kg/day), fluoride group (FG - fluoridated water (100 ppm -221 mg F/L), and amoxicillin + fluoride group (AFG). After 60 days, the samples were collected from plasma and tibiae and analyzed for fluoride (F) concentration. The incisors were also collected to determine the severity of fluorosis using the Dental Fluorosis by Image Analysis (DFIA) software, concentration of F, measurements of enamel thickness, and hardness. The data were analyzed by ANOVA, Tukey’s post-hoc test, or Games-Howell post-hoc test (α=0.05). Results: Enamel thickness of the incisors did not differ statistically among the groups (p=0.228). Groups exposed to fluoride (AFG and FG) have higher F concentrations in plasma, bone and teeth than those not exposed to fluoride (CG and AG). The groups showed a similar behavior in the DFIA and hardness test, with the FG and AFG groups showing more severe fluorosis defects and significant lower hardness when compared with the AG and CG groups, with no difference from each other. Conclusion: The rats exposed to fluoride or fluoride + amoxicillin developed dental fluorosis, while exposure to amoxicillin alone did not lead to enamel defects.

Otoendoscopes to Enhance Telemedicine During the COVID-19 Pandemic

OBJECTIVES

As telemedicine has become increasingly utilized during the COVID-19 pandemic, portable otoendoscopy offers a method to perform an ear examination at home. The objective of this pilot study was to assess the quality of otoendoscopic images obtained by non-medical individuals and to determine the effect of a simple training protocol on image quality.

METHODS

Non-medical participants were recruited and asked to capture images of the tympanic membrane before and after completion of a training module, as well as complete a survey about their experience using the otoendoscope. Images were de-identified, randomized, and evaluated by 6 otolaryngologists who were blinded as to whether training had been performed prior to the image capture. Images were rated using a 5-point Likert scale.

RESULTS

Completion of a training module resulted in a significantly higher percentage of tympanic membrane visible on otoendoscopic images, as well as increased physician confidence in identifying middle ear effusion/infection, cholesteatoma, and deferring an in-person otoscopy (P < .0001). However, even with improved image quality, in most cases, physicians reported that they would not feel comfortable using the images to for diagnosis or to defer an in-person examination. Most participants reported that the otoendoscope was simple to use and that they would feel comfortable paying for the device.

CONCLUSIONS

At-home otoendoscopes can offer a sufficient view of the tympanic membrane in select cases. The use of a simple training tool can significantly improve image quality, though often not enough to replace an in-person otoscopic exam.

Effect of Erdosteine on Middle Ear Effusion in Rats by Mediating TLR4 Signaling Pathway

The study aimed to investigate the effect of erdosteine on middle ear effusion in rats through mediating the Toll-like receptor 4 (TLR4) signaling pathway. Rats were injected with endotoxin to prepare the model of acute secretory otitis media (SOM). Then, they were divided into an acute SOM model group (model group, n = 15) and erdosteine treatment group (18 mg/kg, gavage, treatment group, n = 15). Besides, a normal group (n = 15) was set up. Two weeks later, routine biochemical indicators such as aspartate aminotransferase (AST) and alkaline phosphatase (ALP) were detected. The inflammatory effusion due to otitis media was scored. The content of myeloperoxidase (MPO), matrix metalloproteinase (MMP), and tumor necrosis factor-beta (TNF-β) in middle ear lavage fluid was detected via enzyme-linked immunosorbent assay (ELISA). Additionally, histomorphological changes were observed with the help of hematoxylin-eosin (HE) staining, and quantitative reverse transcription-polymerase chain reaction (qRT-PCR) and Western blotting assays were carried out to measure the expression levels of TLR4 pathway genes and proteins as well as the messenger ribonucleic acid (mRNA) expression levels of key factors for otitis media (mucin 2 (MUC2) and MUC5A). In the model group, the levels of AST, ALP, and glutamic-pyruvic transaminase (GPT) were significantly increased (p < 0.05). Besides, the content of MPO, MMP, and TNF-β was overtly raised in the model group (p < 0.05), while it was notably lowered in the treatment group (p < 0.05). In the treatment group, the cilia were slightly swollen, and inflammatory cells were fewer. The mRNA levels of MUC2, MUC5A, and pathway genes TLR4 and c-Jun N-terminal kinase (JNK) were elevated in the model group. In addition, the protein assay results revealed that the protein levels of TLR4 and JNK were evidently increased in the model group. Erdosteine can treat the middle ear effusion in rats by repressing the activation of the TLR4 signaling pathway.

Effects of the Traditional Mediterranean Diet in Childhood Recurrent Acute Rhinosinusitis

Introduction: There are more and more studies that demonstrate the anti-inflammatory effects of the traditional Mediterranean diet (TMD). The aim of the study was to assess the effects of an intervention with the TMD in patients with recurrent acute and chronic rhinosinusitis. Material and Methods: We performed a pretest–posttest comparison study in 114 patients (56 girls and 58 boys) aged one to five years who had three or more acute rhinosinusitis episodes in the period of 1 year. They were included for a year in the nutritional program “Learning to eat from the Mediterranean”. The anthropometric, clinical, and therapeutic characteristics were studied. Results: All the studied indicators showed a positive and statistically significant evolution. Of the patients, 53.5% did not have any episode of acute rhinosinusitis, and 26.3% had only one, compared to the 3.37 they had on average in the previous year. The use of antibiotics decreased by 87.6%. The degree of satisfaction of the families was very high. The Mediterranean Diet Quality Index (KIDMED) that assesses the quality of the TMD rose from 7.7 to 11 points. Conclusions: The adoption of the TMD could have promising effects in the prevention and treatment of recurrent acute and chronic rhinosinusitis, limiting the pharmacological and surgical intervention in many of these patients.

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.

Effects of the Traditional Mediterranean Diet in Patients with Otitis Media with Effusion

INTRODUCTION

Otitis media with effusion (OME) is common in pediatric primary care consultations. Its etiology is multifactorial, although it has been proven that inflammation factors mediate and that immunity is in a phase of relative immaturity. The objective of this study was to assess the effects of the Traditional Mediterranean Diet (TMD) modulating inflammation and immunity in patients diagnosed with OME.

MATERIALS AND METHODS

A analysis as a single-group pre-test/post-test was conducted on 40 girls and 40 boys between 18 months and 5 years old. Tympanometry normalization was the main test to control the benefit of diet. Clinical and therapeutic variables were studied through evaluation questionnaires, a quality test of the diet, as well as various anthropometric parameters.

RESULTS

At the end of one year, tympanometry had normalized in 85% of patients. The remaining 15% had normal audiometry and/or associated symptoms had decreased. Likewise, episodes of recurrent colds decreased from 5.96 ± 1.41 to 2.55 ± 0.37; bacterial complications of 3.09 ± 0.75 to 0.61 ± 0.06 and persistent nasal obstruction of 1.92 ± 0.27 to 0.26 ± 0.05. The degree of satisfaction of the families with the program was very high.

CONCLUSIONS

The application of the Traditional Mediterranean Diet could have promising effects in the prevention and treatment of otitis media with effusion.

Shortwave infrared otoscopy for diagnosis of middle ear effusions: a machine-learning-based approach

Otitis media, a common disease marked by the presence of fluid within the middle ear space, imparts a significant global health and economic burden. Identifying an effusion through the tympanic membrane is critical to diagnostic success but remains challenging due to the inherent limitations of visible light otoscopy and user interpretation. Here we describe a powerful diagnostic approach to otitis media utilizing advancements in otoscopy and machine learning. We developed an otoscope that visualizes middle ear structures and fluid in the shortwave infrared region, holding several advantages over traditional approaches. Images were captured in vivo and then processed by a novel machine learning based algorithm. The model predicts the presence of effusions with greater accuracy than current techniques, offering specificity and sensitivity over 90%. This platform has the potential to reduce costs and resources associated with otitis media, especially as improvements are made in shortwave imaging and machine learning.

Persistent Nasal Obstruction: An Expression of the Pro-Inflammatory State?

Introduction: During the first years of life, the oro-pharyngeal lymphoid tissue gradually increases in size, causing in some children difficulty breathing and often leading to surgical removal of the tonsils and adenoids. The objective of the study is to assess the effects of the Mediterranean diet in children who had chronic upper airway obstruction. Material and methods: This was a prospective study pre-test/post-test comparison. Eighty-seven patients from two to eight years old were recruited. A food reeducation program based on the Mediterranean diet was applied for one year. Clinical, therapeutic, and anthropometric variables were studied. Results: The degree of nasal obstruction decreased in 95.1% of the patients. After the nutritional intervention, the number of colds with bacterial complications decreased by 80.26%; 60.9% had no bacterial complications during the year of the study. The use of antibiotics decreased by 81.94%. Symptomatic treatment decreased by 61.2%. Most patients did not require surgical intervention, and clinical evolution suggested that it would no longer be necessary. Conclusions: We can conclude by saying that the application of the traditional Mediterranean diet could be effective in the prevention and treatment of persistent nasal obstruction, limiting pharmacological and surgical intervention in many of these patients.

Drug utilization pattern and cost-effectiveness analysis of five most common antibiotics used in Saudi Arabia

Objectives

Inappropriate use of antibiotics is a matter of concern worldwide as that may lead to antimicrobial drug resistance. The objective of current study was to assess drug utilization pattern and cost-effectiveness. Studies are conducted to analyze the pattern of antibiotics prescribing their adherence to standard guidelines and economic impact on the patients in order to promote their rational use.

Methods

The study was designed as a single-centred, cross-sectional retrospective pharmacy database study of prescribing patterns and cost-utility analysis of five most common antibiotics used in Saudi Arabia. Data for the period from 1 January 2019 to 31 December 2019 were used in the study. Demographic characteristics were demonstrated as frequencies and percentages (with Wilson 95% confidence intervals for proportions). The chi-square test (for P-value calculation) was used to compare the adherence of National Antimicrobial Guidelines for prescribing antibiotics in Saudi Arabia.

Key findings

The maximum number of patients was recorded from the age group of 18–35 years (35.97%) and minimum from 72 to 88 years (1.82%). The number of units prescribed was highest for amoxicillin, clavulanic acid (22487) to 42.93% of patients and was lowest for ciprofloxacin (4215) with 8.04%. The longest duration of therapy was for Cefdenir (7.23 days) and lowest for azithromycin (3.58 days). The cost was highest for Cefdenir 38.66SR (10.31USD), and lowest cost was estimated for Cefuroxime 12.43SR (3.31USD).

Conclusions

Our study declared that (amoxicillin with clavulanic acid) was used the most as first-line agents in treating bacterial infections due to their broad coverage against different microbes. Conducting laboratory tests to identify the type of microbe before prescribing could prevent the development of drug resistance and save the antibiotic for future. The cost-to-benefit analysis studies of antibiotics must be conducted for each indication that may promote their rational use.

Evaluation of Clinical Graded Treatment of Acute Nonsuppurative Otitis Media in Children with Acute Upper Respiratory Tract Infection

Objective

To treat children with acute nonsuppurative otitis media induced by acute upper respiratory tract infection of varying severity and evaluate its therapeutic effects.

Materials and Methods

Patients from the emergency department with acute nonsuppurative otitis media were followed up between September 2015 and December 2018. A total of 420 patients were classified into grades I to III according to tympanic membrane intactness and systemic reactions and treated according to grading.

Results

Grade I patients showed no significant difference in the recovery of acute symptoms whether antibiotics are used or not. Grade II patients, after 3 months of follow-up, showed no tympanic membrane perforation, and 9 cases of binaural B-type children did not improve but were cured by operation. In grade III patients, after treatment for 4 hours in the experimental group 3, the earache subsided, 1 case had tympanic membrane perforation, and the patients recovered after 2 weeks (64/92) and after 3 months (28/92) of drug treatment. After treatment for 4 h in the control group 3, the earache eased, and 3 patients developed tympanic membrane perforation and were treated for 3 months. 4 binaural B-type children did not improve but recovered after surgical treatment.

Conclusion

Grade I patients could be closely followed up by clinical observation. For anti-inflammatory patients with grade II disease, treatment has therapeutic significance. For patients with grade III, some patients still have TMP, but the use of cephalosporin third-generation drugs plus an appropriate amount of hormone therapy is effective in reducing symptoms and tympanic local reactions.

Delayed Antibiotic Prescription for Children With Respiratory Infections: A Randomized Trial

OBJECTIVES

To assess the effectiveness and safety of delayed antibiotic prescription (DAP) compared to immediate antibiotic prescription (IAP) and no antibiotic prescription (NAP) in children with uncomplicated respiratory infections.

METHODS

Randomized clinical trial comparing 3 antibiotic prescription strategies. The participants were children with acute uncomplicated respiratory infections attended to in 39 primary care centers. Children were randomly assigned into prescription arms as follows: (1) DAP, (2) IAP, or (3) NAP. Primary outcomes were symptom duration and severity. Secondary outcomes were antibiotic use, parental satisfaction, parental beliefs, additional primary care visits, and complications at 30 days.

RESULTS

In total, 436 children were included in the analysis. The mean (SD) duration of severe symptoms was 10.1 (6.3) for IAP, 10.9 (8.5) for NAP, and 12.4 (8.4) for DAP (P = .539), although the differences were not statistically significant. The median (interquartile range) of the greatest severity for any symptom was similar for the 3 arms (median [interquartile range] score of 3 [2-4]; P = .619). Antibiotic use was significantly higher for IAP (n = 142 [96%]) compared to DAP (n = 37 [25.3%]) and NAP (n = 17 [12.0%]) (P < .001). Complications, additional visits to primary care, and satisfaction were similar for all strategies. Gastrointestinal adverse effects were higher for IAP.

CONCLUSIONS

There was no statistically significant difference in symptom duration or severity in children with uncomplicated respiratory infections who received DAP compared to NAP or IAP strategies; however, DAP reduced antibiotic use and gastrointestinal adverse effects.

Population-based otoscopic and audiometric assessment of a birth cohort recruited for a pneumococcal vaccine trial 15-18 years earlier: a protocol

INTRODUCTION

A cohort of 12 000 children in the Philippines who had enrolled in a 2000-2004 (current ages 16 to 20 years) Phase 3 11-valent pneumococcal conjugate vaccine for the prevention of radiographically confirmed pneumonia are now being asked to participate in a separate study (expected completion date September 2021) to assess the cohort's current long-term audiometric and otologic status. This new study would allow assessments of the utility of the pneumococcal vaccine in conferring its protective effects on the long-term sequelae of otitis media (OM), if any. Lack of trained local healthcare providers in otolaryngology/audiology and testing equipment in Bohol, Philippines, necessitates the development of a distinct methodology that would lead to meaningful data analysis.

METHODS AND ANALYSIS

Reliable data collection and transfer are achieved by a US otolaryngologist/audiologist team training local nurses on all procedures in a didactic and hands-on process. An assortment of portable otolaryngologic and audiologic equipment suitable for field testing has been acquired, including an operating otoscope (Welch-Allyn), a video-otoscope (JedMed), a tympanometer with distortion product otoacoustic emission measurements (Path Sentiero) and a screening audiometer (HearScreen). Data will then be uploaded to a Research Electronic Data Capture database in the USA.Tympanometric and audiologic data will be codified through separate conventional algorithms. A team of paediatric otolaryngology advanced practice providers (APPs) have been trained and validated in interpreting video otoscopy. The protocol for classification of diagnostic outcome variables based on video otoscopy and tympanometry has been developed and is being used by APPs to evaluate all otoscopy data.

ETHICS AND DISSEMINATION

The study was approved by the Research Institute of Tropical Medicine, Alabang, Manila, Philippines, and the institutional review board and the Colorado Multiple Institutional Review Board of the University of Colorado School of Medicine, Aurora, Colorado, USA.Research results will be made available to children and their caregivers with abnormal audiologic outcomes, the funders and other researchers.

TRIAL REGISTRATION NUMBER

ISRCTN 62323832; Post-results.

The impact of PM2.5 on acute otitis media in children (aged 0-3): A time series study

BACKGROUND

Experimental studies have reported that air pollution could make the middle ear more susceptible to infections. However, the associations between specific air pollutants and AOM were inconsistent in previous epidemiologic studies. This study aimed to investigate the association between PM_2.5 exposure and the AOM events in seven major cities in the Republic of Korea.

METHODS

We performed a nationwide time series analysis of children aged 0-3 years living in seven major Korean cities between 2008 and 2016. We used a quasi-Poisson regression to estimate the short-term association between incident AOM and the 5-day moving average of particulate matter smaller than 2.5 μm (PM_2.5) for each city. Then, we conducted a meta-analysis to combine the city-specific associations. The exposure unit was 10 μg/m³, and all models were adjusted for time, daily mean apparent temperature and day of the week.

RESULTS

A higher risk of incident AOM was significantly associated with higher 5-day moving PM_2.5 averages in five cities, except for Gwangju and Ulsan. The combined relative risk (RR) was 1.011 (95% confidence interval [CI]: 1.008, 1.014). In the subgroup analysis by season, PM_2.5 exposure was significantly associated with incident AOM in the warm season (RR: 1.016, 95% CI: 1.009, 1.022). In addition, among children with a URI history within 4 weeks, children with a more recent URI history were more sensitive to the impact of PM_2.5 exposure on incident AOM (RR for 1st week: 1.017, 95% CI: 1.011, 1.024; RR for 2nd week: 1.013, 95% CI: 1.008, 1.018; RR for 3rd week: 1.008, 95% CI: 1.003, 1.013; RR for 4th week: 1.005, 95% CI: 1.001, 1.009).

CONCLUSION

Higher PM_2.5 concentrations are associated with a higher risk of incident AOM, particularly in the warm season and children with recent URI history. Our findings could have important implications for preventing AOM in children.

The Epidemiological and Financial Effects of Pneumococcal Vaccination on Otitis Media Related Admissions in the United States

OBJECTIVE

To quantify the prevalence of hospital admissions, the financial impact, and the trends in surgical procedure rates for AOM and CAOM for all ages before and after 13-valent pneumococcal conjugate vaccine (PCV13) introduction.

METHODS

Retrospective analysis of the National Inpatient Sample (NIS) from 1998 to 2013 to determine the prevalence of AOM/CAOM related admissions and weighted frequencies of AOM/CAOM related International Classification of Diseases, ninth revision (ICD-9) hospital diagnoses. Prevalence of surgical procedures to treat CAOM, cost of admission, length of stay, and cost per day of admission were tabulated. Trend analysis of this data was performed.

RESULTS

A total of 46 580 patients were hospitalized with AOM in the designated time period, of which 37 366 had CAOM. The prevalence of hospital admission due to AOM had the most pronounced decrease from pre-vaccine era (1998) to post-PCV13 implementation (2013) in age group 0 to 4 (32%) followed by age group 5 to 19 (7%). Age groups 20-64 and 65+ showed slight increases in prevalence. The trend in prevalence of admissions due to CAOM mirrors that of overall admissions with an 18% and 5.8% decrease in age groups 0-4 and 5-19, respectively, and a 1% increase in ages 20+. The inflation adjusted mean cost of admission did not significantly increase between 2001 and 2013. The total cost per admission was $4428 and $7546 for those with AOM and CAOM, respectively. Mastoidectomy rates increased by 17% in hospitalized children during the post-vaccine era but decreased in the elderly population.

CONCLUSION

The prevalence of AOM/CAOM hospital admissions decreased from the pre-vaccine era (1998) to post-PCV13 implementation (2013) in pediatric patients. Surgical procedure utilization and cost of hospital admission for AOM/CAOM did not increase throughout the study period.

Perceptions of the Benefits and Risks of Antibiotics Among Adult Patients and Parents With High Antibiotic Utilization

Background

Inappropriate antibiotic use is common. Understanding how patients view antibiotic risks and/or benefits could inform development of patient education materials and clinician communication strategies. We explored current knowledge, attitudes, and behaviors related to antibiotics among populations with high antibiotic use.

Methods

We conducted 12 focus groups with adult patients and parents across the United States by telephone in March 2017. Purposive sampling was used to identify participants with high antibiotic use. We transcribed the discussions verbatim and performed thematic analysis.

Results

We identified 4 major themes. First, participants expressed uncertainty regarding which clinical syndromes required antibiotics, and emotion often influenced their desire for antibiotics. Second, they had a limited understanding of antibiotic risks. Antibiotic resistance was viewed as the primary risk but was seen as a “distant, future” issue, whereas immediate adverse events, such as side effects, were minimized; however, patients expressed concern when told about the risk of serious adverse events. Third, they prioritized antibiotic benefits over risks in their decision-making, both due to an inaccurate estimation of antibiotic risks and/or benefits and a tendency to prioritize instant gratification. Fourth, most participants were willing to defer to their clinicians’ decisions about antibiotics, especially if their clinician provided symptomatic treatment and anticipatory guidance.

Conclusions

Patients have a limited understanding of antibiotic risks, potentially explaining why they are willing to try antibiotics even if it is unclear antibiotics will help. Educating patients on the potential antibiotic risks versus benefits, rather than just antibiotic resistance, may have a bigger impact on their decision-making.

The Nontypeable Haemophilus influenzae Major Adhesin Hia Is a Dual-Function Lectin That Binds to Human-Specific Respiratory Tract Sialic Acid Glycan Receptors

Host-adapted bacterial pathogens like NTHi have evolved specific mechanisms to colonize their restricted host niche. Relatively few of the adhesins expressed by NTHi have been characterized as regards their binding affinity at the molecular level. In this work, we show that the major NTHi adhesin Hia preferentially binds to Neu5Ac-α2-6-sialyllactosamine, the form of sialic acid expressed in humans. The receptors targeted by Hia in the human airway mirror those targeted by influenza A virus and indicates the broad importance of sialic acid glycans as receptors for microbes that colonize the human airway.

NTHi is a human-adapted pathogen that colonizes the human respiratory tract. Strains of NTHi express multiple adhesins; however, there is a unique, mutually exclusive relationship between the major adhesins Hia and HMW1 and HMW2 (HMW1/2). Approximately 25% of NTHi strains express Hia, a phase-variable autotransporter protein that has a critical role in colonization of the host nasopharynx. The remaining 75% of strains express HMW1/2. Previous work has shown that the HMW1 and HMW2 proteins mediate binding to 2-3- and 2-6-linked sialic acid glycans found in the human respiratory tract. Here, we show that the high-affinity binding domain of Hia, binding domain 1 (BD1), is responsible for binding to α2-6-sialyllactosamine (2-6 SLN) glycans. BD1 is highly specific for glycans that incorporate the form of sialic acid expressed by humans, N-acetylneuraminic acid (Neu5Ac). We further show that Hia has lower-affinity binding activity for 2-3-linked sialic acid and that this binding activity is mediated via a distinct domain. Thus, Hia with its dual binding activities functionally mimics the combined activities of the HMW1 and HMW2 adhesins. In addition, we show that Hia has a role in biofilm formation by strains of NTHi that express the adhesin. Knowledge of the binding affinity of this major NTHi adhesin and putative vaccine candidate will direct and inform development of future vaccines and therapeutic strategies for this important pathogen.

Sensorineural hearing loss in the acute phase of a single episode of acute otitis media

Introduction

Acute otitis media is a disease with high global prevalence, that can lead to several acute complications and auditory sequelae. Data regarding the auditory evaluation in the acute phase of acute otitis media are scarce.

Objective

To evaluate the main audiometric changes (air and bone conduction thresholds) in the initial phase of an acute otitis media episode.

Methods

A case-control study was performed. Patients diagnosed with acute otitis media with less than 7 days of evolution in relation to the complaint onset were selected, and healthy volunteers were selected as controls. The acute otitis media and control groups were submitted to pure tone and vocal audiometry.

Results

The acute otitis media group included a total of 27 patients (30 ears). Hearing loss was present in 90.0% of the ears with acute otitis media, with conductive loss in 14 (46.67%) and mixed loss in 13 (43.33%). Both the air and bone conduction thresholds obtained with the tonal audiometry in the acute otitis media group were significantly worse than the controls at all tested frequencies (p < 0.05). In patients with acute otitis media, we observed that the thresholds for frequency >1 kHz (bone conduction) and 3 kHz (air conduction) were significantly worse in patients with tinnitus compared to patients without tinnitus.

Conclusion

During the first 7 days of evolution after the onset of an isolated episode of acute otitis media, we observed significant increases in bone and air thresholds at all frequencies, especially >2 kHz, compared to healthy ears.

Rapid imaging of tympanic membrane vibrations in humans

Functional imaging of the human ear is an extremely challenging task because of its minute anatomic structures and nanometer-scale motion in response to sound. Here, we demonstrate noninvasive in vivo functional imaging of the human tympanic membrane under various acoustic excitations, and identify unique vibration patterns that vary between human subjects. By combining spectrally encoded imaging with phase-sensitive spectral-domain interferometry, our system attains high-resolution functional imaging of the two-dimensional membrane surface, within a fraction of a second, through a handheld imaging probe. The detailed physiological data acquired by the system would allow measuring a wide range of clinically relevant parameters for patient diagnosis, and provide a powerful new tool for studying middle and inner ear physiology.

Parents Need More Support: A Qualitative Study of the Experiences of Australian Parents Who Are Waiting for Surgical Intervention for Their Children With Otitis Media

OBJECTIVE

To explore the experiences, expectations, and motivations of parents/caregivers of children with otitis media who were booked to undergo tympanostomy tube insertion.

METHOD

A cross-sectional cohort study was conducted using semistructured interviews with 39 parents. Interviews were conducted via telephone and analyzed for key themes.

RESULTS

Three themes emerged that incorporated a range of subthemes: (1) the impact of the child's underlying condition on the family, (2) the cues and prompts that influenced parents to seek intervention, and (3) the parents' expectations of the health-care system. The child's otitis media disrupted the day-to-day functioning of the family and the child's well-being, but despite this, the families found ways to adapt and cope. Parents were influenced by their friends, family, and medical practitioners when making treatment decisions and had differing expectations of the health-care system.

CONCLUSION

Parents need support during their child's illness to help with pressures placed on the family and also in making health-care decisions for their child. Clinicians should consider these issues when discussing treatment options with parents.

The effect of amoxicillin on dental enamel development in vivo

The exposure to amoxicillin has been associated with molar incisor hypomineralization. This study aimed to determine if amoxicillin disturbs the enamel mineralization in in vivo experiments. Fifteen pregnant rats were randomly assigned into three groups to received daily phosphatase-buffered saline or amoxicillin as either 100 or 500 mg/kg. Mice received treatment from day 13 of pregnancy to day 40 postnatal. After birth, the offsprings from each litter continued to receive the same treatment according to their respective group. Calcium (Ca) and phosphorus (P) content in the dental hard tissues were analyzed from 60 upper first molars and 60 upper incisors by the complexometric titration method and colorimetric analysis using a spectrophotometer at 680 nm, respectively. Lower incisors were analyzed by X-ray microtomography, it was measured the electron density of lingual and buccal enamel, and the enamel and dentin thickness. Differences in Ca and P content and electron density among the groups were analyzed by one-way ANOVA. There was no significant difference on enamel electron density and thickness among the groups (p > 0.05). However, in incisors, the higher dose of amoxicillin decreased markedly the electron density in some rats. There were no statistically significant differences in Ca (p = 0.180) or P content (p = 0.054), although the higher dose of amoxicillin could affect the enamel in some animals. The amoxicillin did not significantly alter the enamel mineralization and thickness in rats.

A bench-top model of middle ear effusion diagnosed with optical tympanometry

OBJECTIVES

To assess the validity of a bench-top model of an optical tympanometry device to diagnose in vitro model of middle ear effusion (MEE).

METHODS AND MATERIALS

We illuminated an in vitro model of ear canal and tympanic membrane with broadband light and relayed remitted light to a spectrometer system. We then used our proprietary algorithm to extract spectral features that, together with our logistic regression classifiers, led us to calculate a set of simplified indices related to different middle ear states. Our model included a glass vial covered with a porcine submucosa (representing the tympanic membrane) and filled with air, water, or milk solution (representing different MEE), and a set of cover-glass slips filled with either blood (representing erythema) or cerumen. By interchanging fluid types and cover-glass slips, we made measurements on combinations corresponding to normal healthy ear and purulent or serous MEE.

RESULTS

Each simulated condition had a distinct spectral profile, which was then employed by our algorithm to discriminate clean and cerumen-covered purulent and serous MEE. Two logistic purulent and serous MEE classifiers correctly classified all in vitro middle ear states with 100% accuracy assessed by leave-one-out and k-fold cross validation.

CONCLUSIONS

This proof-of-concept in vitro study addressed an unmet need by introducing a device that easily and accurately can assess middle ear effusion. Future in vivo studies aimed at collecting data from clinical settings are warranted to further elucidate the validity of the technology in diagnosing pediatric acute otitis media.

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.

Interpretation of within-group change in randomised trials

In medicine, it is common to observe improvement after intervention, at least partly because patients present for care in extremis and would have improved without intervention. Controlling for this counterfactual explanation for improvement is the principle reason to conduct a trial in which patients are randomised to treatment or a control group. Accordingly, it is not reasonable to infer that both interventions are effective when the groups show similar improvements in outcome.