Effectiveness of Centers for Disease Control and Prevention recommendations for outcomes of acute otitis media

Association of cytokine gene polymorphisms and risk factors with otitis media proneness in children

In order to assess the association between gene polymorphisms and otitis media (OM) proneness, tumor necrosis factor alpha (TNFA) -308, interleukin (IL) 10-1082 and -3575, IL6 -597, IL2 -330, and CD14 -159 genotyping was performed in 58 OM-prone children and 85 controls who were exposed to similar number and frequency of environmental and host risk factors. The frequencies of genotypes (wild type vs. genotypes containing at least one polymorphic allele) were not significantly different between groups, except for IL10 -1082. Polymorphic genotypes IL10 -1082 GA and GG were more frequent in OM-prone children than in control group (RR 1.145, 95 % CI 1.011-1.298; p = 0.047). However, logistic regression did not confirm IL10 -1082 polymorphic genotypes as an independent risk factor for OM proneness.

CONCLUSION

The present study indicates that high-producing IL10 -1082 GA/GG genotypes may increase the risk for OM proneness in its carriers when exposed to other environmental/host risk factors (day care attendance, passive smoking, male sex, respiratory infections, and atopic manifestations). This study revealed no significant independent genetic association, but the lack of breastfeeding in infancy was found to be the only independent risk factor for development of OM-prone phenotype, implying that breastfeeding had a protective role in development of susceptibility to OM.

WHAT IS KNOWN

• The pathogenesis of OM is of multifactorial nature, dependent on infection, environmental factors, and immune response of the child. • Cytokines and CD14 play an important role in the presentation and clinical course of otitis media, but a clear link with otitis media proneness was not established. What is new: • This is the first clinical and genetic study on Montenegrin children with the otitis media-prone phenotype. • The study revealed that high-producing IL10 -1082 genotypes may influence otitis media proneness in children exposed to other environmental/host risk factors.

Educational interventions to improve prescription and dispensing of antibiotics: a systematic review

Background

Excessive and inappropriate antibiotic use contributes to growing antibiotic resistance, an important public-health problem. Strategies must be developed to improve antibiotic-prescribing. Our purpose is to review of educational programs aimed at improving antibiotic-prescribing by physicians and/or antibiotic-dispensing by pharmacists, in both primary-care and hospital settings.

Methods

We conducted a critical systematic search and review of the relevant literature on educational programs aimed at improving antibiotic prescribing and dispensing practice in primary-care and hospital settings, published in January 2001 through December 2011.

Results

We identified 78 studies for analysis, 47 in primary-care and 31 in hospital settings. The studies differed widely in design but mostly reported positive results. Outcomes measured in the reviewed studies were adherence to guidelines, total of antibiotics prescribed, or both, attitudes and behavior related to antibiotic prescribing and quality of pharmacy practice related to antibiotics. Twenty-nine studies (62%) in primary care and twenty-four (78%) in hospital setting reported positive results for all measured outcomes; fourteen studies (30%) in primary care and six (20%) in hospital setting reported positive results for some outcomes and results that were not statistically influenced by the intervention for others; only four studies in primary care and one study in hospital setting failed to report significant post-intervention improvements for all outcomes. Improvement in adherence to guidelines and decrease of total of antibiotics prescribed, after educational interventions, were observed, respectively, in 46% and 41% of all the reviewed studies. Changes in behaviour related to antibiotic-prescribing and improvement in quality of pharmacy practice was observed, respectively, in four studies and one study respectively.

Conclusion

The results show that antibiotic use could be improved by educational interventions, being mostly used multifaceted interventions.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2458-14-1276) contains supplementary material, which is available to authorized users.

Evaluation of the efficacy of curcumin in experimentally induced acute otitis media in rats

OBJECTIVES

We investigated the effect of curcumin (CMN) in the treatment of experimentally induced acute otitis media (AOM) in rats.

METHOD

Thirty-two Sprague-Dawley female rats were used, yielding 64 temporal bones. Group 1 was the control group. For groups 2 to 4, AOM was induced experimentally, and saline, antibiotics (sulbactam-ampicillin), or CMN were administered for 14 days to groups 2, 3, and 4, respectively. During the histological examination, thickening of the tympanic membrane, damage to the epithelium, inflammation, and sclerosis were evaluated.

RESULTS

The AOM+antibiotic and AOM+CMN groups exhibited reduced histological damage compared with the AOM+saline group. No significant differences in thickening of the tympanic membrane or damage to the epithelium or inflammation were observed between the AOM+antibiotic and the AOM+CMN groups. However, the sclerosis values of the AOM+CMN group were significantly lower than those of the AOM+antibiotic group.

CONCLUSION

CMN treatment resulted in similar effects on the experimentally induced AOM model as did the antibiotic treatment. The efficacy of this treatment may be related to its effects on the production of various inflammatory cytokines. In light of the worldwide increase in antibiotic resistance and the mild side effects of CMN, we suggest that CMN therapy may be a promising option in AOM treatment.

Reducing antibiotic prescribing for children with respiratory tract infections in primary care: a systematic review

BACKGROUND

Respiratory tract infections (RTIs) in children are common and often result in antibiotic prescription despite their typically self-limiting course.

AIM

To assess the effectiveness of primary care based interventions to reduce antibiotic prescribing for children with RTIs.

DESIGN AND SETTING

Systematic review.

METHOD

MEDLINE(®), Embase, CINAHL(®), PsycINFO, and the Cochrane library were searched for randomised, cluster randomised, and non-randomised studies testing educational and/or behavioural interventions to change antibiotic prescribing for children (<18 years) with RTIs. Main outcomes included change in proportion of total antibiotic prescribing or change in 'appropriate' prescribing for RTIs. Narrative analysis of included studies was used to identify components of effective interventions.

RESULTS

Of 6301 references identified through database searching, 17 studies were included. Interventions that combined parent education with clinician behaviour change decreased antibiotic prescribing rates by between 6-21%; structuring the parent-clinician interaction during the consultation may further increase the effectiveness of these interventions. Automatic computerised prescribing prompts increased prescribing appropriateness, while passive information, in the form of waiting room educational materials, yielded no benefit.

CONCLUSION

Conflicting evidence from the included studies found that interventions directed towards parents and/or clinicians can reduce rates of antibiotic prescribing. The most effective interventions target both parents and clinicians during consultations, provide automatic prescribing prompts, and promote clinician leadership in the intervention design.

Effectiveness of physician-targeted interventions to improve antibiotic use for respiratory tract infections

BACKGROUND

Antibiotic use and concomitant resistance are increasing. Literature reviews do not unambiguously indicate which interventions are most effective in improving antibiotic prescribing practice.

AIM

To assess the effectiveness of physician-targeted interventions aiming to improve antibiotic prescribing for respiratory tract infections (RTIs) in primary care, and to identify intervention features mostly contributing to intervention success.

DESIGN AND SETTING

Analysis of a set of physician-targeted interventions in primary care.

METHOD

A literature search (1990-2009) for studies describing the effectiveness of interventions aiming to optimise antibiotic prescription for RTIs by primary care physicians. Intervention features were extracted and effectiveness sizes were calculated. Association between intervention features and intervention success was analysed in multivariate regression analysis.

RESULTS

This study included 58 studies, describing 87 interventions of which 60% significantly improved antibiotic prescribing; interventions aiming to decrease overall antibiotic prescription were more frequently effective than interventions aiming to increase first choice prescription. On average, antibiotic prescription was reduced by 11.6%, and first choice prescription increased by 9.6%. Multiple interventions containing at least 'educational material for the physician' were most often effective. No significant added value was found for interventions containing patient-directed elements. Communication skills training and near-patient testing sorted the largest intervention effects.

CONCLUSION

This review emphasises the importance of physician education in optimising antibiotic use. Further research should focus on how to provide physicians with the relevant knowledge and tools, and when to supplement education with additional intervention elements. Feasibility should be included in this process.

The use of three strategies to improve quality of care at a national level

BACKGROUND

Improving the quality of care is essential and a priority for patients, surgeons, and healthcare providers. Strategies to improve quality have been proposed at the national level either through accreditation standards or through national payment schemes; however, their effectiveness in improving quality is controversial.

QUESTIONS/PURPOSES

The purpose of this review was to address three questions: (1) does pay-for-performance improve the quality of care; (2) do surgical safety checklists improve the quality of surgical care; and (3) do practice guidelines improve the quality of care? These three strategies were chosen because there has been some research assessing their effectiveness in improving quality, and implementation had been attempted on a large scale such as entire countries.

METHODS

We performed a literature review from 1950 forward using Medline to identify Level I and II studies. We evaluated the three strategies and their effects on processes and outcomes of care. When possible, we examined strategy implementation, patients, and systems, including provider characteristics, which may affect the relationship between intervention and outcomes with a focus on factors that may have influenced effect size.

RESULTS

Pay-for-performance improved the process and to a lesser extent the outcome of care. Surgical checklists reduced morbidity and mortality. Explicit practice guidelines influenced the process and to a lesser extent the outcome of care. Although not definitively showed, clinician involvement during development of intervention and outcomes, with explicit strategies for communication and implementation, appears to increase the likelihood of positive results.

CONCLUSION

Although the cost-effectiveness of these three strategies is unknown, quality of care could be enhanced by implementing pay-for-performance, surgical safety checklists, and explicit practice guidelines. However, this review identified that the effectiveness of these strategies is highly context-specific.

The regional profile of antibiotic prescriptions in Italian outpatient children

PURPOSE

To evaluate paediatric antibiotic prescription patterns in Italy in an extra-hospital setting at the national, regional, and Local Health Unit (LHU) level.

METHODS

Data sources were regional prescription databases. Eight Italian regions participated in the study providing data for the year 2008, with two exceptions (where the data for 2009 and 2006 were provided instead). A total of 4,828,569 children were included: 58% of the Italian population under 15 years old. Antibiotic prevalence rates, prescription rates and prescriptions distribution by class were evaluated at the regional and LHU levels. The correlation among mean latitude, Human Development Index (HDI), hospitalisation rate, satisfaction index for the National Health Service, number of paediatricians per 1,000 resident children and prevalence rate was evaluated by regions.

RESULTS

The estimated pooled average prevalence rate was 50.5% (95%CI 45.7-55.3). Between-regions prevalence rates ranged from 42.6% to 62.1% and at the LHU level they ranged from 35.6% to 68.5%. There was a trend indicating that in southern regions antibiotics are more frequently prescribed than in the northern and central regions (Cochrane-Armitage test Z = -187.5 p < 0.0001). Overall, penicillin covered 53.1% of antibiotic prescriptions, with differences between regions ranging from 39.2% to 62.5%. A direct correlation was found between the prevalence rate and HDI (p = 0.031), while an inverse correlation was found with paediatricians per 1,000 resident children (p = 0.038).

CONCLUSIONS

We found that relevant differences exist between the northern and the southern part of the country, and the heterogeneity among LHUs is higher. The greater use of antibiotics in the southern regions is related to lower HDI and does not seems to be justified by the higher prevalence of infectious diseases.

Interventions in health care professionals to improve treatment in children with upper respiratory tract infections

OBJECTIVE

To analyse which strategies are used to promote evidence based interventions in the management of children with upper respiratory tract infections (URTIs) in daily practice. To assess the effectiveness of these interventions, and when more are effective--which works best. And to analyse the costs associated with these interventions.

METHODS

We systematically searched Pubmed, Embase and CENTRAL bibliographies for studies on the effectiveness of strategies aimed at changing health care professionals' behavior in the management of children with URTIs.

RESULTS

The search yielded 11,788 references, of which 18 studies were eligible, and 10 met the inclusion criteria. Most strategies were aimed at changing antibiotic prescribing behavior in children with acute otitis media. All strategies used (i.e. computer interventions, educational sessions with or without education materials, collaborative development of guidelines and a training video in combination with a risk factor checklist) were effective in changing health care professionals practice regarding children with URTIs. Multifaceted and computer strategies work best. Computer interventions reduced antibiotic prescribing by 4% and 34% and increased guideline compliance by 41%. Educational sessions combined with education materials reduced inappropriate antibiotic prescription by 2% and 17% and increased knowledge of compliance enhancing strategies by 28% and 29%. Collaborative guideline development combined with educational materials reduced inappropriate antibiotic prescription by 24% and 40%. Finally, by a combination of a training video and a risk factor checklist appropriate referrals by the GP to the otolaryngologist increased by 37%. Since the costs associated with the interventions were not explicitly mentioned in the articles, no conclusion on cost-effectiveness can be drawn.

CONCLUSION

Multifaceted and computer strategies appear to be most effective to put evidence into practice in the area of URTIs in children.

Epidemiology, natural history, and risk factors: panel report from the Ninth International Research Conference on Otitis Media

The 2007 Recent Advances in Otitis Media Research Conference Panel Report provides an update on otitis media (OM) research published from 2003 to 2007. This report summarizes important trends in disease incidence and prevalence, describes established and newly identified risk factors for acute and chronic OM and OM with effusion, and conveys information on newly discovered genetic factors. In this report, researchers have described declining rates of OM diagnosis, antibiotic prescriptions, offices visits for OM, and middle ear surgery since the licensure and routine use of pneumococcal conjugate vaccine in infants. The panel report also recommends short and long term goals for current and future OM research.

Systematic Review of Interventions to Improve Prescribing

Objective:

To update 2 comprehensive reviews of systematic reviews on prescribing interventions and identify the latest evidence about the effectiveness of the interventions.

Data Sources:

Systematic searches for English-language reports of experimental and quasi-experimental research were conducted in PubMed(1951–May 2007). EMBASE (1974–March 2008), International Pharmaceutical Abstracts (1970–March 2008), and 11 other bibliographic databases of medical, social science, and business research. Following an initial title screening process and after selecting 6 specific intervention categories (identified from the previous reviews) in community settings, 2 reviewers independently assessed abstracts and then full studies for relevance and quality and extracted relevant data using formal assessment and data extraction tools. Results were then methodically incorporated into the findings of the 2 earlier reviews of systematic reviews.

Data Selection And Synthesis:

Twenty-nine of 26,314 articles reviewed were assessed to be of relevant, high-quality research. Audit and feedback, together with educational outreach visits, were the focus of the majority of recent, high-quality research into prescribing interventions. These interventions were also the most effective in improving prescribing practice. A smaller number of studies included a patient-mediated intervention; this intervention was not consistently effective. There is insufficient recent research into manual reminders to confidently update earlier reviews and there remains insufficient evidence to draw conclusions regarding the effectiveness of local consensus processes or multidisciplinary teams.

Conclusions:

Educational outreach as well as audit and feedback continue to dominate research into prescribing interventions. These 2 prescribing interventions also most consistently show positive results. Much less research is conducted into other types of interventions and there is still very little effort to systematically test why interventions do or do not work.

Otimizando o diagnóstico para o tratamento adequado das principais infecções agudas em otorrinopediatria: tonsilite, sinusite e otite média

As sinusites, otites médias agudas e tonsilites são muito freqüentes em crianças. A maioria dessas infecções é causada por vírus, mas em geral, elas são tratadas com antibióticos. O uso inapropriado de antibióticos favorece a seleção, crescimento e disseminação de bactérias resistentes que colonizam as vias respiratórias, atingindo toda a comunidade. A emergência de bactérias resistentes dificulta os tratamentos das infecções respiratórias, sendo essencial desenvolver estratégias efetivas para restringir o uso de antibióticos sem prejudicar as crianças que realmente precisam desses medicamentos. OBJETIVO: Analisar os resultados de estudos randomizados e controlados sobre critérios clínicos e laboratoriais utilizados para diagnóstico e tratamento das tonsilites, sinusites e otites. MÉTODOS: Levantamento dos estudos randomizados e controlados sobre o tema, publicados no MEDLINE e SCIELO, de 2000 a 2006. CONCLUSÕES: Como a maioria dessas infecções evolui bem sem antibióticos, deve-se evitar o uso desses medicamentos a menos que a criança pertença aos grupos de alto risco para complicações ou apresente persistência ou piora dos sintomas com tratamento sintomático. É necessário que os médicos e leigos conheçam melhor a evolução natural das infecções respiratórias agudas e que seja garantido o acesso das crianças a serviços médicos de boa qualidade para orientação e reavaliação, quando necessária.

Optimizing the management of the main acute infections in pediatric ORL: tonsillitis, sinusitis, otitis media

Sinusitis, acute otitis media and tonsillitis are very frequent in children. Most of these infections are caused by viruses, but are generally treated with antibiotics. Inappropriate use of antibiotics favors the selection, growth and spread of resistant bacteria; these bacteria colonize the airways and affect the entire community. With the emergence of antibiotic-resistant bacteria, respiratory infections have become more difficult to treat. Effective strategies are needed to restrict the use of antibiotics without harming children that truly need these drugs.

AIM

to present a critical analysis of the results of randomized and controlled studies on clinical and laboratory criteria used in diagnosing and treating tonsillitis, sinusitis and otitis.

METHODS

a review of randomized and controlled studies about these conditions published in MEDLINE and SCIELO from 2000 to 2006.

CONCLUSIONS

Given that most of these infections progress favorably without antibiotics, the use of these drugs should be avoided unless the child belongs to a high risk group for complications, or symptoms persist or worsen with despite symptomatic treatment. Physicians and laypersons should have better knowledge about the natural evolution of acute respiratory infections.

Antibiotic prescription and prevalence rate in the outpatient paediatric population: analysis of surveys published during 2000–2005

OBJECTIVE

To evaluate antibiotic paediatric consumption data in the community setting using data from studies published between 2000 and 2005 and to compare inter- and intra-country antibiotic prescribing patterns.

METHODS

A literature search was performed in EMBASE and MEDLINE to identify pharmacoepidemiological studies published between 2000 and 2005.

RESULTS

Large differences between studies were found, with significant heterogeneity in epidemiological indicators. Only 20 studies reporting comparable drug prescription data were considered in the analysis, all of which were from the USA, Canada, North-Central Europe and Italy. Pre-school children were reported as comprising the most exposed age group to antibiotic therapy (prevalence 72%; prescription rate 2.2 prescriptions/person per year). In the overall child and adolescent population (<or=19 years), prevalence varied from 14 to 57% (mean 34%), and the prescription rate from 0.2 to 1.3 prescriptions/person per year. Relevant inter-country qualitative and quantitative differences in antibiotic prescribing were apparent, although these were observed in only a few countries: prevalence was higher in Italy and Canada (prevalence range 42-57%) and lower in the Netherlands and the United Kingdom (prevalence range 14-21%). Penicillins were the most prescribed antibiotics in all cases (40-70% of antibiotic prescriptions), followed by macrolides (16-45%), while cephalosporins accounted for a large proportion of the prescriptions in Italy (30-40%) and Canada, but were practically absent in North European prescriptions.

CONCLUSION

Comparative drug utilisation studies on antibiotic use in children are needed, as are improvements in regulatory and educational programmes aimed at limiting the number prescriptions given for antibiotics. Both approaches would address public health problems, such as bacterial resistance and safety and elevated costs, related to the use and misuse of these drugs.

What is new in otitis media?

The "wait and see" approach in acute otitis media (AOM), consisting of postponing the antibiotic administration for a few days, has been advocated mainly to counteract the increased bacterial resistance in respiratory infections. This approach is not justified in children less than 2 years of age and this for several reasons. First, AOM is an acute inflammation of the middle ear caused in about 70% of cases by bacteria. Redness and bulging of the tympanic membrane are characteristic findings in bacterial AOM. Second, AOM is associated with long-term dysfunction of the inflamed eustachian tube (ET), particularly in children less than 2 years of age. In this age group, the small calibre of the ET together with its horizontal direction result in impaired clearance, ventilation and protection of the middle ear. Third, recent prospective studies have shown poor long-term prognosis of AOM in children below 2 years with at least 50% of recurrences and persisting otitis media with effusion (OME) in about 35% 6 months after AOM. Viruses elicit AOM in about 30% of children. A prolonged course of AOM has been observed when bacterial and viral infections are combined because viral infection is also associated with ET dysfunction in young children. Bacterial and viral testing of the nasopharyngeal aspirate is an excellent tool both for initial treatment and recurrence of AOM. Antibiotic treatment of AOM is mandatory in children less than 2 years of age to decrease inflammation in the middle ear but also of the ET particularly during the first episode. The best choice is amoxicillin because of its superior penetration in the middle ear. Streptococci pneumoniae with intermediary bacterial resistance to penicillin are particularly associated with recurrent AOM. Therefore the dosage of amoxicillin should be 90 mg/kg per day in three doses. In recurrent AOM with beta-lactamase-producing bacilli, amoxicillin should be associated with clavulanic acid at a dose of 6.4 mg/kg per day. The duration of the treatment is not established yet but 10 days is reasonable for a first episode of AOM. OME may be a precursor initiating AOM but also a complication thereof. OME needs a watchful waiting approach. When associated with deafness for 2-3 months in children over 2 years of age, an antibiotic should be given according to the results of the bacterial resistance in the nasopharyngeal aspirate. The high rate of complications of tympanostomy tube insertion outweighs the beneficial effect on hearing loss. The poor results of this procedure are due to the absence of effects on ET dysfunction. Pneumococcal vaccination has little beneficial effects on recurrent AOM and its use in infants needs further studies. Treatment with amoxicillin is indicated in all children younger than 2 years with a first episode of AOM presenting with redness and bulging of the tympanic membrane. Combined amoxicillin and clavulanic acid should be given in patients with beta-lactamase-producing bacteria. The duration of treatment is estimated to be at least 10 days depending on the findings by pneumo-otoscopy and tympanometry. Bacterial and viral testing of the nasopharyngeal aspirate is highly recommended particularly in children in day care centres as well as for regular follow-up. The high recurrence rate is due to the long-lasting dysfunction of the eustachian tube and the immune immaturity of children less than 2 years of age.