The effect of erythromycin on the nasopharyngeal pathogens in children with secretory otitis media

Antibiotics for otitis media with effusion (OME) in children

BACKGROUND

Otitis media with effusion (OME) is an accumulation of fluid in the middle ear cavity, common amongst young children. The fluid may cause hearing loss. When persistent, it may lead to developmental delay, social difficulty and poor quality of life. Management of OME includes watchful waiting, autoinflation, medical and surgical treatment. Antibiotics are sometimes used to treat any bacteria present in the effusion, or associated biofilms.

OBJECTIVES

To assess the effects (benefits and harms) of oral antibiotics for otitis media with effusion (OME) in children.

SEARCH METHODS

The Cochrane ENT Information Specialist searched the Cochrane ENT Register, CENTRAL, Ovid MEDLINE, Ovid Embase, Web of Science, ClinicalTrials.gov, ICTRP and additional sources for published and unpublished studies to 20 January 2023.

SELECTION CRITERIA

We included randomised controlled trials and quasi-randomised trials in children aged 6 months to 12 years with unilateral or bilateral OME. We included studies that compared oral antibiotics with either placebo or no treatment.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were determined following a multi-stakeholder prioritisation exercise and were: 1) hearing, 2) otitis media-specific quality of life and 3) anaphylaxis. Secondary outcomes were: 1) persistence of OME, 2) adverse effects, 3) receptive language skills, 4) speech development, 5) cognitive development, 6) psychosocial skills, 7) listening skills, 8) generic health-related quality of life, 9) parental stress, 10) vestibular function and 11) episodes of acute otitis media. We used GRADE to assess the certainty of evidence for each outcome. Although we included all measures of hearing assessment, the proportion of children who returned to normal hearing was our preferred method to assess hearing, due to challenges in interpreting the results of mean hearing thresholds.

MAIN RESULTS

We identified 19 completed studies that met our inclusion criteria (2581 participants). They assessed a variety of oral antibiotics (including penicillins, cephalosporins, macrolides and trimethoprim), with most studies using a 10- to 14-day treatment course. We had some concerns about the risk of bias in all studies included in this review. Here we report our primary outcomes and main secondary outcome, at the longest reported follow-up time. Antibiotics versus placebo We included 11 studies for this comparison, but none reported all of our outcomes of interest and limited meta-analysis was possible. Hearing One study found that more children may return to normal hearing by two months (resolution of the air-bone gap) after receiving antibiotics as compared with placebo, but the evidence is very uncertain (Peto odds ratio (OR) 9.59, 95% confidence interval (CI) 3.51 to 26.18; 20/49 children who received antibiotics returned to normal hearing versus 0/37 who received placebo; 1 study, 86 participants; very low-certainty evidence). Disease-specific quality of life No studies assessed this outcome. Presence/persistence of OME At 6 to 12 months of follow-up, the use of antibiotics compared with placebo may slightly reduce the number of children with persistent OME, but the confidence intervals were wide, and the evidence is very uncertain (risk ratio (RR) 0.89, 95% CI 0.68 to 1.17; 48% versus 54%; number needed to treat (NNT) 17; 2 studies, 324 participants; very low-certainty evidence). Adverse event: anaphylaxis No studies provided specific data on anaphylaxis. Three of the included studies (448 children) did report adverse events in sufficient detail to assume that no anaphylactic reactions occurred, but the evidence is very uncertain (very low-certainty evidence). Antibiotics versus no treatment We included eight studies for this comparison, but very limited meta-analysis was possible. Hearing One study found that the use of antibiotics compared to no treatment may result in little to no difference in final hearing threshold at three months (mean difference (MD) -5.38 dB HL, 95% CI -9.12 to -1.64; 1 study, 73 participants; low-certainty evidence). The only data identified on the return to normal hearing were reported at 10 days of follow-up, which we considered to be too short to accurately reflect the efficacy of antibiotics. Disease-specific quality of life No studies assessed this outcome. Presence/persistence of OME Antibiotics may reduce the proportion of children who have persistent OME at up to three months of follow-up, when compared with no treatment (RR 0.64, 95% CI 0.50 to 0.80; 6 studies, 542 participants; low-certainty evidence). Adverse event: anaphylaxis No studies provided specific data on anaphylaxis. Two of the included studies (180 children) did report adverse events in sufficient detail to assume that no anaphylactic reactions occurred, but the evidence is very uncertain (very low-certainty evidence).

AUTHORS' CONCLUSIONS

The evidence for the use of antibiotics for OME is of low to very low certainty. Although the use of antibiotics compared to no treatment may have a slight beneficial effect on the resolution of OME at up to three months, the overall impact on hearing is very uncertain. The long-term effects of antibiotics are unclear and few of the studies included in this review reported on potential harms. These important endpoints should be considered when weighing up the potential short- and long-term benefits and harms of antibiotic treatment in a condition with a high spontaneous resolution rate.

Pharyngeal colonization with Haemophilus influenzae type b among healthy Turkish infants and children

BACKGROUND

An absence of Haemophilus influenzae type b (Hib) disease surveillance and epidemiological data on the pharyngeal carriage of Turkish children causes delay in the introduction of conjugated Hib vaccination into proposed national vaccination programs.

METHODS

Oropharyngeal cultures were obtained from 1404 healthy infants and children. Six healthy child clinic (HCC), 11 day-care centers (DCC) and seven elementary schools (ES) were randomly selected in seven different counties at the Anatolian side of Istanbul between January and April 2000.

RESULTS

Haemophilus influenzae was isolated from 315 (22.8%) of all participants and 98 (31%) isolates were serotype b. The carriage rate for Hib was higher in children at DCC (43 out of 448, 9.6%) and ES (46 out of 504, 9.1%) compared to infants 0-24 months of age (nine out of 430, 2.1%) presented to HCC. All Hib isolates were susceptible to azithromycin, chloramphenicol and cefotaxime. Beta-lactamase production was detected in only one isolate. Trimethoprim-sulfamethoxazole resistance was found in 8.5% of Hib isolates. Multivariate analysis showed that DCC and ES attendance were independent predictors of Hib carriage.

CONCLUSION

A significant proportion of healthy Turkish children was shown to be colonized with Hib. The burden of invasive Hib infections should be determined in order to evaluate the Hib conjugated vaccine as a part of a routine immunization program in Turkey.

Treatment of children with secretory otitis media (SOM) with amoxicillin and clavulanic acid (Spektramox) or penicillin-V (Primcillin). Bacteriological findings in the nasopharynx before and after treatment

A total of 386 children, aged 1-10, with secretory otitis media for at least 3 months were randomly allocated to 2 or 4 weeks' treatment with penicillin-V (Primcillin) or amoxicillin + clavulanic acid (Spektramox). Spektramox was superior (p < 0.01) to Primcillin in eradicating Haemophilus influenzae and Branhamella catarrhalis from the nasopharynx. No difference was noted for Streptococcus pneumoniae and haemolytic streptococci, gr. A, B, C, G. No increase in the number of beta-lactamase-producing bacteria was noted after treatment. The nasopharynx was recolonized with the same bacteria within 4 weeks from cessation of treatment.

Erythromycin in acute laryngitis in adults

Moraxella catarrhalis and Hemophilus influenzae are isolated from the nasopharynx in 50% to 55% and 8% to 15%, respectively, of cases of acute laryngitis in adults. This finding indicates that these organisms, M catarrhalis in particular, are in some way involved in the pathogenesis of the disorder. In the present double-blind, placebo-controlled trial, the effect of erythromycin ethylsuccinate (0.5 g twice a day for 5 days) on the elimination of nasopharyngeal pathogens and reduction of clinical signs of upper respiratory tract infection, as well as on subjective complaints, was evaluated in 106 adults with acute laryngitis. The bacterial isolation rates at presentation were M catarrhalis 50%, H influenzae 18%, and Streptococcus pneumoniae 4%. In the 99 patients who completed the study, the elimination of M catarrhalis after 1 week was better in the erythromycin group (25 of 30 cases) than in the placebo group (6 of 19 cases; p < or = .00038). The elimination of H influenzae was unaffected by erythromycin. Otolaryngologic examination did not reveal any significant group differences regarding laryngitis, pharyngitis, or rhinitis. Voice quality was improved after 1 week, irrespective of treatment. However, as compared to the placebo group, the erythromycin group reported fewer voice complaints after 1 week and fewer coughing complaints after 2 weeks. As acute laryngitis in adults is self-limiting, and subjective symptoms are spontaneously reduced after 1 week in most cases, antibiotic treatment does not seem warranted as a general policy. However, erythromycin may be justified in patients who are professionally dependent on voice function.

Nasopharyngeal flora in otitis media with effusion. A comparative semiquantitative analysis

An inflammatory process in the middle ear caused by bacteria or bacterial products emanating from the nasopharynx is one etiological factor considered in the unknown pathogenesis of otitis media with effusion (OME). The nasopharyngeal prevalence of Streptococcus pneumoniae, Haemophilus influenzae, Moraxella (Branhamella) catarrhalis and Streptococcus pyogenes was studied in 191 children with defined OME and in 53 age-matched children without middle ear disease. Duplicate sampling and semiquantitative analysis were performed to assess even minor differences in the distribution of pathogens between the two groups of children. Pathogens were recovered in 91% of OME children. A significantly higher number of pathogen species/patient (1.66 vs. 1.15, p less than 0.01) as well as pathogen colonies/patient was found in OME children compared to control children. Chronic OME in children is associated with an increased pathogen load in the nasopharynx, suggesting a role of these pathogens in the etiology of OME.

Adenoids and otitis media with effusion: nasopharyngeal flora

In order to clarify the role of the microflora of the nasopharynx and adenoids as causative factors of otitis media with effusion (OME), bacteriologic species in middle ear effusions (MEEs), nasopharyngeal smears, and adenoid tissues of children with OME were cultured. The change in the microflora of the nasopharynx after adenoidectomy, and the degree of bacterial agreement between the microflora of the nasopharynx and adenoid tissue were investigated. Nasopharyngeal bacterial flora were investigated in 259 children with OME from November 1984 to November 1987. The patients were divided into two groups: group A (43 patients) underwent adenoidectomy, and group B (216 patients) had no adenoidectomy. Hemophilus influenzae, Streptococcus pneumoniae, Branhamella catarrhalis, and Staphylococcus aureus were cultured in 66.7% of nasopharyngeal smears from group B, and in 46.5% from group A. Adenoid specimens for bacteriologic investigation were obtained from 38 adenoidectomy patients at surgery. Of these, H influenzae were cultured from adenoid specimens taken from 16 of the 26 patients with OME (group C), while only three of the 12 adenoidectomy patients without OME (group D) were found to have H influenzae in their adenoid specimens. The findings of this study suggest that adenoid vegetation plays an important role in the etiology of OME.

Relapse of acute purulent otitis media: antibiotic sensitivities of nasopharyngeal pathogens

The present investigation was conducted to find out if a relapse of acute purulent otitis media is associated with a decreased sensitivity of nasopharyngeal pathogens to commonly used antimicrobial agents. All but one of 63 children with relapse included in this study yielded one or more of the classical middle ear pathogens (Streptococcus pneumoniae, Haemophilus influenzae, Branhamella catarrhalis, S. pyogenes) in their nasopharynx (NPH) secretions. S. pneumoniae was the predominating isolate from NPH (71% of the patients) as well as from middle ear effusion (53%). At a control visit 4 weeks after the start of antibiotic therapy, 91% were NPH carriers of potential pathogens and S. pneumoniae was still the most common isolate (53%). Beta-lactamase was produced by 55% of B. catarrhalis isolates from the NPH specimens on the first visit, but only by 33% of B. catarrhalis isolates on the control visit. Two NPH isolates of H. influenzae produced beta-lactamase. One isolate of S. pneumoniae (serotype 18) was intermediately sensitive to phenoxymethylpenicillin. Generally low MICs were found for erythromycin and cefaclor. H. influenzae isolates were generally sensitive to ampicillin in vitro, but only 1 isolate was fully sensitive to erythromycin. B. catarrhalis isolates were uniformly sensitive to doxycycline and trimethoprim/sulphamethoxazole. No tolerance to penicillin was demonstrated in S. pneumoniae and H. influenzae. The present data indicate that the relapse of acute otitis media is not associated with development of tolerance or resistance to therapeutic antimicrobials commonly used.

Increased use of erythromycin causes resistance in Haemophilus influenzae

The use of erythromycin in Sweden has increased since 1975. An increasing prevalence of Haemophilus influenzae (H.i.) with reduced susceptibility to erythromycin has been noted in our laboratory during the years 1980 to 1985. The largest consumers of erythromycin were found to be children less than 4 years of age. Variations in resistance level of H.i. isolated from patients within this age group and variations in consumption of erythromycin were analysed for each year. The highest prevalence of resistant strains was found during spring and summer. The consumption of the antibiotic was highest during the first quarter of the year, gradually decreasing, and increasing sharply again during the fourth quarter of the year. Judging also from deviations from this pattern there seems to be an association between consumption and resistance. The different levels of resistance reported in the literature may reflect different populations of patients with different consumption of erythromycin, and different levels at different time of the year. Considering the present high level of H.i. with decreased susceptibility to erythromycin the drug is not likely to have clinical effect in H.i. infections.

Effect of erythromycin on adenoid bacteria

Seventy-eight patients with secretory otitis media were given erythromycin ethylsuccinate 50 mg/kg/day, divided into 2 doses, for 7-8 days before undergoing adenoidectomy and tympanostomy. Nasopharyngeal swabs for bacterial culture were obtained before medication and at surgery and the adenoid homogenate was also studied for bacteria. Pneumococci and Branhamella strains became significantly reduced, while Hemophilus influenzae showed no change. Pneumococcus and Branhamella strains partially returned one month after surgery and in part were found in patients who had not had these strains before antimicrobial therapy. Erythromycin ethylsuccinate can sterilize neither the adenoids nor the middle ear space if the causative agent is Hemophilus influenzae.

Endotoxin in middle ear effusions tested with Limulus assay

Endotoxin in middle ear effusion (MEE) from both children and adult patients with otitis media with effusion (OME) was assayed with the Limulus amoebocyte lysate test, in parallel with the detection of microorganisms. Whereas only 17% of MEE from adults, diluted 1:10 showed the presence of endotoxin, endotoxin was found in 69% of MEE from recent and recurrent cases in children, although microorganisms were isolated from only one-quarter of the samples. 83% of mucoid MEE from children contained endotoxin, compared with 41% of serous MEE. In older children, endotoxin was less frequently detected in accordance with the fact that the incidence of OME decreases with age. It is concluded that endotoxin may be one of the important factors in the pathogenesis of onset of, as well as in delayed recovery from OME in children.

The effect of cefaclor on the nasopharyngeal flora in children with chronic OME

About 80% of children with chronic OME carry respiratory pathogens in the nasopharynx, with a remarkably stable spectrum and frequency. In a randomized clinical trial the nasopharyngeal flora was determined in 45 untreated cases and in 32 cases treated with cefaclor (Kefolor), 20 mg/kg body weight b.i.d. for 10 days. Compared to the untreated children, the treated group showed a significantly decreased frequency of Streptococcus pneumoniae and Branhamella catarrhalis, and a reduced number of cultures with mixed pathogens. An approximate quantitative survey showed a decreased growth of Haemophilus influenzae, but the frequency of isolation was unchanged. The results are put in relation to the penetration of cefaclor to adenoid tissue and middle ear effusion in chronic OME.

Cefaclor in the treatment of otitis media with effusion

A randomized clinical trial in which 91 children with chronic OME participated was performed. Cefaclor 20 mg/kg body weight b.i.d. was given to the treated group (n = 46) during 10 days preceding the day appointed for surgery. The control group (n = 45) remained untreated. On the day scheduled for surgery 24 (52%) of the treated cases had healed, compared to 5 (11%) of the untreated cases, a significant difference (p less than 0.001). The long term effects showed that in the treated group 18 of the 24 primarily healed remained unoperated at a median follow-up period of 20 months. In the untreated group two of the five that originally resolved later relapsed and were subjected to surgery.

Inefficacy of penicillin V in acute laryngitis in adults. Evaluation from results of double-blind study

Patients with acute laryngitis following an upper respiratory tract infection are often treated with antibiotics for their voice complaints, although, to our knowledge, the effect of such therapy has not been examined. In the present study, comprising 100 adults with laryngitis, the rate of resolution of vocal symptoms, as estimated from voice recordings or subjectively by the patients, was the same in patients who received penicillin V (pcV) as in those who received placebo. Similarly, the degree of rhinorrhea/nasal congestion and cough was not significantly influenced by pcV treatment. At the acute visit, nasopharyngeal cultures revealed Branhamella catarrhalis in 50%, Hemophilus influenzae in 15% and Streptococcus pneumoniae in 1% of the patients; the rate of elimination of these bacteria was the same in the pcV as in the placebo group. Thus, while suggesting that B catarrhalis and H influenzae are important for the pathogenesis of the disorder, our results do not provide support for the use of pcV in acute laryngitis.