Treatment failure in acute otitis media. A clinical study of children during their first three years of life

Acute otitis media in children aged less than 2 years: drug treatment issues

The management of acute otitis media (AOM) in childhood has evolved considerably during recent years as a result of the new insights provided by publication (in 2004) of the American Academy of Pediatrics and the American Academy of Family Physicians guidelines for the treatment of AOM. The new treatment guidelines establish a clear hierarchy among the various antibacterials used in the treatment of this disease and also the use of an age-stratified approach to AOM by recommending an observation strategy ('watchful waiting') without the use of antibacterials for some groups of patients with AOM. Infants and young children aged <2 years represent a target population characterized by a high incidence of AOM (and in particular of recurrent disease), lack of anatomic and physiologic maturity of airways, age-related immune humoral and cellular deficiencies, the presence of antibacterial-resistant pathogens, and a less efficient response to antibacterial treatment. Presently, the evidence accumulated in the literature is not sufficient to conclude that the role of antibacterials is only minimal in the management of AOM and that the watchful waiting policy is the most appropriate choice for patients aged <2 years with a certain AOM diagnosis. However, adherence to such a policy in patients with an uncertain or questionable AOM diagnosis and/or mild-to-moderate symptoms, in addition to its implementation in patients aged >2 years, could reduce substantially the use of antibacterials in children and play a major role in the strategy of decreasing antibacterial resistance.

Large dosage amoxicillin/clavulanate, compared with azithromycin, for the treatment of bacterial acute otitis media in children

BACKGROUND

A large dosage pediatric formulation of amoxicillin/clavulanate with an improved pharmacokinetic/pharmacodynamic profile was developed to eradicate many penicillin-resistant strains of Streptococcus pneumoniae and Haemophilus influenzae (including beta-lactamase-producing strains).

METHODS

This randomized, investigator-blinded, multicenter trial examined treatment of bacterial acute otitis media (AOM) in children 6-30 months of age with amoxicillin/clavulanate (90/6.4 mg/kg/d in 2 divided doses for 10 days) versus azithromycin (10 mg/kg for 1 day followed by 5 mg/kg/d for 4 days). Tympanocentesis was performed at entry for bacteriologic assessment, at the on-therapy visit (day 4-6) to determine bacterial eradication and at any time before the end-of-therapy visit (day 12-14) if the child was categorized as experiencing clinical failure. Clinical assessments were performed at the on-therapy, end-of-therapy and follow-up (day 21-25) visits.

RESULTS

We enrolled 730 children; AOM pathogens were isolated at baseline for 249 of the amoxicillin/clavulanate group and 245 of the azithromycin group. For children with AOM pathogens at baseline, clinical success rates at the end-of-therapy visit were 90.5% for amoxicillin/clavulanate versus 80.9% for azithromycin (P < 0.01), and those at the on-therapy and follow-up visits were 94.9% versus 88.0% and 80.3% versus 71.1%, respectively (all P < 0.05). At the on-therapy visit, pretherapy pathogens were eradicated for 94.2% of children receiving amoxicillin/clavulanate versus 70.3% of those receiving azithromycin (P < 0.001). Amoxicillin/clavulanate eradicated 96.0% of S. pneumoniae (92.0% of fully penicillin-resistant S. pneumoniae) and 89.7% of H. influenzae (85.7% [6 of 7 cases] of beta-lactamase-positive H. influenzae). Corresponding rates for azithromycin were 80.4% (54.5%) for S. pneumoniae and 49.1% (100% [1 of 1 case]) for H. influenzae (all P < 0.01 for between-drug comparisons).

CONCLUSION

Amoxicillin/clavulanate was clinically and bacteriologically more effective than azithromycin among children with bacterial AOM, including cases caused by penicillin-resistant S. pneumoniae and beta-lactamase-positive H. influenzae.

Implications of the AHRQ evidence report on acute otitis media

OBJECTIVE

To familiarize otolaryngologists with the Agency for Healthcare Research and Quality (AHRQ) Evidence Report on Acute Otitis Media (AOM) that reviews the natural history and role of antibiotics in management. The report, by the Southern California Evidence-Based Practice Center (SC-EPC), is the most recent of 15 literature syntheses published by the AHRQ.

DATA SOURCES

MEDLINE (1966 to present), Cochrane Library, EMBASE, BIOSIS, HealthSTAR, and other computerized databases; manual reference search of proceedings, articles, reports, and guidelines.

STUDY SELECTION

Randomized trials and cohort studies relevant to the natural history of AOM and the efficacy of antimicrobial therapy. AOM was defined by the 11-member technical expert panel (including 2 authors, RMR and MLC) as middle-ear effusion with the rapid onset of signs or symptoms of middle ear inflammation.

DATA EXTRACTION

Two physician reviewers at the Southern California Evidence-Based Practice Center independently rated the articles and extracted data.

DATA SYNTHESIS

Children receiving placebo or no antimicrobial had a pooled clinical success rate of 81% at 1 to 7 days (95% CI, 72% to 90%), with no increase in suppurative complications when followed closely. Amoxicillin or ampicillin increased the absolute success rate by 12.3% (95% CI, 2.8% to 21.8%) in 5 studies pooled using random effects meta-analysis. The antimicrobial benefit was robust to sensitivity analysis. In contrast, success rates were not influenced by the choice or duration of therapy.

CONCLUSIONS

The AHRQ report emphasizes middle-ear effusion as a preeminent criteria for AOM diagnosis and provides extensive evidence tables on natural history and antimicrobial impact. About 8 children must receive antibiotics to avoid 1 clinical failure, but children younger than age 2 years or with severe symptoms may benefit more. The report is a starting point for organizations seeking to develop AOM guidelines, performance measures, and other quality improvement tools.

Short-term penicillin-V prophylaxis did not prevent acute otitis media in infants

OBJECTIVE

To determine whether prophylactic, short-term penicillin V treatment during upper respiratory tract infections can prevent the occurrence of recurrent acute otitis media in young children.

METHODS

Seventy children were studied in a prospective, double-blind, placebo-controlled study. All children had suffered their first episode of acute otitis media before the age of 6 months. After inclusion in the study group, administration of penicillin V or placebo was initiated by the parents at subsequent upper respiratory tract infections. The children were examined by otomicroscopy within 3 days after treatment was initiated. The children were scheduled for a total follow-up period of 12 months, including bimonthly visits for check-up irrespective of treatment periods.

RESULTS

There were 304 treated episodes of upper respiratory tract infection. There was no significant difference in the number of acute otitis episodes between groups.

CONCLUSION

Initiation of penicillin V prophylaxis at upper respiratory tract infection in small children did not prevent recurrent acute otitis media in this study.

Observation option toolkit for acute otitis media

The observation option for acute otitis media (AOM) refers to deferring antibiotic treatment of selected children for up to 3 days, during which time management is limited to analgesics and symptomatic relief. With appropriate follow-up complications are not increased, and clinical outcomes compare favorably with routine initial antibiotic therapy. Although used commonly in the Netherlands and certain Scandinavian countries, this approach has not gained wide acceptance in Europe and the United States. This article describes an evidence-based toolkit developed by the New York Region Otitis Project for judicious use of the observation option. The toolkit is not intended to endorse the observation option as a preferred method of management, nor is it intended as a rigid practice guideline to supplant clinician judgement. Rather, it presents busy clinicians with the tools needed to implement the observation option in everyday patient care should they so desire.

Five vs. ten days of antibiotic therapy for acute otitis media in young children

BACKGROUND

Many publications in recent years have argued in favor of shortened therapy for acute otitis media. However, doubt persists regarding children younger than 2 years, and some authors therefore restrict short course therapy to children older than 2 years.

METHODS

In a prospective, comparative, double blind, randomized, multicenter trial we compared cefpodoxime-proxetil, 8 mg/kg/day in two divided doses for 10 days, with an identical 5-day regimen followed by a 5-day placebo period.

RESULTS

Between October, 1996, and April, 1997, 450 children (mean age, 14.3 months) were enrolled, 227 in the 5-day group and 223 in the 10-day group. In the per protocol analysis clinical success was obtained on Days 12 to 14 after the beginning of treatment (main analysis) in 175 (84.1%) of the 208 children receiving the 5-day regimen and 194 (92.4%) of the 210 children receiving the 10-day regimen (P = 0.009). The superiority of the standard regimen was more marked among children cared for outside their homes (92.5% vs. 81.5%). Clinical success persisted on Days 28 to 42 among 134 (85.4%) of the 157 assessable patients in the 5-day group and 144 (83.7%) of the 172 assessable patients in the 10-day group (P = 0.68).

CONCLUSIONS

The 10-day regimen resulted in a higher success rate at the conclusion of therapy, but there were no differences between the two study groups 4 to 6 weeks after enrollment in the study protocol.

Clinical aspects on antibiotic resistance: upper respiratory tract infections

In view of the increased resistance to antibiotics in several upper airway pathogens, the clinical rationale for use of antimicrobial therapy in various upper respiratory tract infections is discussed. The diagnostic skill and the clinical significance of various bacteria are taken into account and strategies for treatment of the different infections, with focus on acute otitis media, are discussed.

[Controversies concerning acute otitis media]

Acute otitis media is the subject of many unresolved points of controversy: 1) correct diagnosis; 2) whether or not bacteria are present in each case of acute otitis media; 3) spontaneous course; 4) indication of antibiotherapy; 5) treatment of recurrent acute otitis media; and 6) the place of alternative medicine, such as homeopathy. There is no ideal response. It is important, however, to take into account the knowledge of the different otoscopic stages of acute otitis media and the fact that the course of the disease is spontaneously favorable in the majority of cases. Selective prescription of an antibiotic in cases of purulent otitis only, and attention directed towards early recognition of complications, appear to be the most appropriate attitudes in the management of the disease, helping to reduce the alarmingly increasing numbers of resistant bacteria.

One dose ceftriaxone vs. ten days of amoxicillin/clavulanate therapy for acute otitis media: clinical efficacy and change in nasopharyngeal flora

OBJECTIVE

To compare the efficacy and the safety of a single intramuscular dose of ceftriaxone, 50 mg/kg, vs. a 10-day course of amoxicillin/clavulanate (amox/clav) therapy, 80 mg/kg/day of amoxicillin: 10 mg/kg/day of clavulanate in three divided doses, in children with acute otitis media (AOM) and to evaluate the changes in nasopharyngeal flora after treatment.

METHODS

In a prospective, comparative, open randomized, multicenter trial, children were scheduled to return for visits on Days 12 to 14 (main end point) and Days 28 to 42 after the beginning of treatment for AOM. A nasopharyngeal swab for bacterial culture was obtained before the treatment and at Days 12 to 14.

RESULTS

Between February, 1995, and May, 1996, 513 children with a mean age of 14.2 +/- 6.7 months were enrolled. All the patients were evaluable for the safety and intent-to-treat analyses and 463 for the per protocol efficacy. At Days 12 to 14 clinical success was obtained in 186 of the 235 children (79%) given ceftriaxone and in 188 of the 228 children (82.5%) treated with amox/clav. Among the patients with clinical success on Days 12 to 14, the success was maintained at Days 28 to 42 for 108 of 183 (59%) patients in the ceftriaxone group and 103 of 187 (55%) patients in the amox/clav group. Before the antibiotic treatment the percentages of children carrying Streptococcus pneumoniae (59.1%), Haemophilus influenzae (39.4%), Moraxella catarrhalis (55.7%) and the rate of penicillin-resistant S. pneumoniae (52.2%) were comparable between the 2 groups. At Days 12 to 14 the carriage of S. pneumoniae and M. catarrhalis was significantly different between the patients treated with ceftriaxone, 43.9 and 42.2, respectively, and the patients treated with amox/clav, 17.4 and 11.1%, respectively. Among the children carrying S. pneumoniae at Days 12 to 14, the percentage of penicillin-resistant strains reached 63.4% in the ceftriaxone treatment group and 83.0% in the amox/clav treatment group, (P = 0.02). Adverse events (mainly diarrhea) related to the study medication were reported more frequently (P < 0.0001) in the amox/clav treatment group.

CONCLUSIONS

In an area with a high rate of penicillin-resistant S. pneumoniae, a single dose of ceftriaxone is as efficient as a 10-day course of amox/clav in the treatment of AOM in young children. There was for the two regimens an increased rate of penicillin-resistant strains among the pneumococci carried, whereas the chance for a child to carry a penicillin resistant S. pneumoniae did not increase after treatment.

A multicenter, randomized, double-blind trial of 5 versus 10 days of antibiotic therapy for acute otitis media in young children

BACKGROUND

All but 2 of the 15 published trials have failed to show a difference in efficacy between short (3 to 5 days) and standard (7 to 10 days) antibiotic regimens for acute otitis media (AOM). These studies involved relatively few patients under 2 years of age, who are at a higher risk for treatment failure.

METHODS

In a prospective, comparative, double-blind, randomized, multicenter trial, we compared amoxicillin/clavulanate in 3 divided doses for 10 days with an identical 5-day regimen, followed by a 5-day placebo period.

RESULTS

Between February 1995 and May 1996, 385 children (mean age, 13.3 months) were enrolled, 194 in the 5-day treatment group and 191 in the 10-day treatment group. In the per protocol analysis, clinical success was obtained on days 12 to 14 after the beginning of treatment (main analysis) in 125 (76.7%) of the 163 children receiving the 5-day regimen and 148 (88.1%) of the 168 receiving the 10-day regimen (P = .006). Clinical success persisted on days 28 to 42 among 57 (40.4%) of the 141 assessable patients in the 5-day group and 64 (46%) of the 139 assessable patients in the 10-day group. (P = .34). Multivariate analysis showed that the 10-day course was statistically superior only among children cared for outside their homes (86.8% vs 70.8%; P = .008).

CONCLUSIONS

When assessed on days 12 to 14 after the outset of treatment, a 5-day regimen is not equivalent to a 10-day regimen among young children with AOM.

Pathogens isolated during treatment failures in otitis

OBJECTIVES

A prospective study in the Paris region to evaluate the clinical and bacteriologic epidemiology of acute otitis media in infants in whom oral antibiotic therapy resulted in clinical failure.

METHODS

The study included 186 children with a mean age of 17.5 +/- 13.1 months. Two-thirds of them attended a day-care center and 40.8% had a history of recurrent otitis media. The most frequently prescribed prior antibiotics were amoxicillin-clavulanic acid (43% of cases), an oral third generation cephalosporin (22.6%), erythromycin-sulfisoxazole (11.8%) and a first generation cephalosporin (10.2%). The average duration of antibiotic therapy was 6.9 +/- 2.65 days. Specimens for bacterial cultures included 188 samples of middle ear fluid obtained by tympanocentesis and 37 collected from otorrhea fluid.

RESULTS

One hundred forty-one samples (62.7%) from 126 children yielded 170 bacterial isolates. In 60 children (32.3%) the culture of the ear pus was sterile. Among the 170 bacterial isolates: 67 (39.4%) were Streptococcus pneumoniae (59 patients), of which 77.6% had reduced susceptibility to penicillin (PRSP with penicillin MIC > or = 0.125 mg/l); 61 (35.9%) were Haemophilus influenzae (56 patients) of which 49.2% were beta-lactamase producers; and 8 were Moraxella catarrhalis (8 patients), of which 87.5% were beta-lactamase producers. Thirty-six patients were infected by S. pneumoniae with penicillin MIC > or =1 mg/l. In our study attending day-care center (P = 0.04), temperature >38 degrees C with signs of otalgia (P = 0.02), age <2 years (P = 0.048) and prior antibiotic treatment with erythromycin-sulfisoxazole (P = 0.006) were independently predictive risk factors for patients infected with penicillin-resistant S. pneumoniae. Pneumococcal serogroups 23, 14 and 19 were predominant (25.4, 25.4 and 23.8%, respectively). Penicillin resistance was mainly associated with serogroups 23 and 14.

CONCLUSIONS

Penicillin-resistant S. pneumoniae isolates are frequently responsible for therapeutic failure in cases of acute otitis media in the Paris region.

Management of acute otitis media caused by resistant pneumococci in infants

OBJECTIVES

To assess the clinical outcome and risk of failure after oral vs. intravenous treatment in otitis media caused by penicillin-resistant pneumococci. To determine the possible correlations between pneumococcal minimal inhibitory concentration (MIC) to penicillin and clinical outcome.

DESIGN

Retrospective study of 156 cases collected between 1993 and 1995. Mean follow-up: 5 months. Setting. Two tertiary academic medical centers in Paris, France.

PATIENTS AND METHODS

Pneumococcus was isolated from 191 of 570 ear samples obtained from children with otitis media and shown to be penicillin-resistant in 156. Medical history, antibiotic therapy during the previous 3 months and day-care center attendance were reviewed. For the current episode microbiologic characteristics of the isolated strains, type of treatment, therapy efficacy and clinical outcome were analyzed. Patients were predominantly young (76.3% were <1 year old) and bacteriologic samples were taken mainly because of previous treatment failure.

RESULTS

Among 156 children with pneumococcal penicillin-resistant otitis media, 72.2% attended day-care centers, 71.8% had been previously treated with aminopenicillin and 52.5% with cephalosporins. Failure of previous empirical oral therapy was noted in 84% (one-third of these had been receiving amoxicillin-clavulanate). Patients treated intravenously had had a more protracted otitis but no greater number of previous episodes of acute otitis media than those receiving oral therapy. Acute mastoiditis occurred in 4 infants resulting in mastoidectomy. Oral treatment (mainly with high dose amoxicillin,120 to 150 mg/kg/day) and intravenous therapy (cephalosporin or glycopeptide) had been used in 59 and 41%, respectively. Mean duration of therapy was 10.7 days. Three failures (1.9%) and 10 recurrences (6.4%, average 28 days) occurred. No statistical difference was found between intravenous and oral therapy with respect to risk of recurrence. A high penicillin MIC value was correlated with previous antibiotic treatment but not with clinical outcome.

CONCLUSIONS

Oral therapy appears to be as effective as intravenous therapy for the treatment of penicillin-resistant pneumococcal otitis media. Intravenous treatment should not necessarily be dictated by the penicillin susceptibility value but should be considered in cases of failure to thrive, persistent otitis or other complications.

Prognosis of acute otitis media: factors associated with poor outcome

Factors associated with poor outcome of acute otitis media (AOM) were analysed in 131 children aged 1/4 to 7 1/2 (median 2 1/2) years. After AOM, altogether 37 (28%) of the children had poor outcome: 15 children (12%) clinical failure (unimprovement or worsening of pre-treatment signs and symptoms within 2 weeks of onset of therapy) and 31 (24%) persistent middle ear effusion (MEE) > or = 1 month post-treatment. Of the different variables studied in multivariate analysis, age < 2 years (p < 0.01), history of allergic skin or respiratory symptoms (p = 0.02), > or = 6 h duration of pre-treatment earache (p = 0.01) and B. catarrhalis in MEE (p = 0.05) were associated with clinical failure. Children with previous adenotomy or unilateral AOM had no failures. Persistence of MEE at 1 month was associated with age < 2 years (p = 0.05), otitis proneness (p = 0.03), bilaterality of AOM (p < 0.01) and S. pneumoniae in MEE (p = 0.01) in univariate but not in multivariate analysis.

Prognosis of acute otitis media. Factors associated with the development of recurrent acute otitis media

Clinical factors associated with the development of recurrent acute otitis media (RAOM) (> or = 3 recurrences during 6 months' follow-up period) after acute otitis media (AOM) were analysed in 121 children aged 3 months to 7 years (median 2 years 6 months). After AOM, 19 (16%) children had primary recurrence (pre-treatment signs and symptoms firstly improved or cured, but worsened or recurred within 30 days' post-treatment) and 33 (27%) developed RAOM during 6 months' follow-up period. It seemed that children < 2 years of age (p = 0.04), children with bilateral disease (p = 0.007), strong infection status (p = 0.05), primary clinical failure (p = 0.04) and development of primary recurrence after AOM (p = 0.001) were significantly related to the development of RAOM in univariate analysis, but only children < 2 years of age (OR 1.5, 95% CI 1.0-5.7, p = 0.04) and the development of primary recurrence (OR 5.1, 95% CI 1.8-14.1, p = 0.002) related to the development of RAOM in multivariate analysis. None of the bacteria cultured from middle ear effusion were related to the development of RAOM.

The antibiotic treatment of acute otitis media and sinusitis in children

The development of resistance among the bacterial pathogens causing acute otitis media and sinusitis in children is causing considerable concern. Although normally a mild infection, acute otitis media can produce serious complications with sequelae that can have long-lasting effects. High levels of resistance are now being seen in the three principal pathogens. Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. Most clinical trials comparing the efficacy of different antibiotics have failed to show differences in clinical efficacy. To overcome this problem, alternative methods of assessing antibiotics have been developed including the "in-vivo sensitivity test" proposed by Howie and retrospective analyses of treatment failures. The treatment of sinusitis is complicated by the difficulty in establishing a clear differential diagnosis. To date, no definitive trials of bacteriologic efficacy in children have been published.

Management of acute otitis media. Assessment of therapeutic strategy in Japan today

Currently, myringotomy is widely used in the routine initial treatment of acute otitis media in Japan. In an attempt to evaluate the validity of this strategy, a number of issues that demand reassessment or clarification have been identified. These issues and factors contributing to the persisting uncertainty about myringotomy are examined.

Clinical outcome of acute otitis media caused by pneumococci with decreased susceptibility to penicillin

Raw data from 4 clinical studies involving pre-inclusion paracentesis were pooled to assess demographic characteristics and clinical outcome of acute otitis media (AOM) due to S. pneumoniae with decreased susceptibility to penicillin (SpRP). Children in the age range 3 months to 10 years were treated with beta-lactam antibiotics for 10 days. 54 children with SpRP AOM were compared with 182 children with penicillin-susceptible pneumococcal (SpSP) (AOM). The groups were found comparable with regard to sex, age at first AOM, and frequency of earlier bouts of AOM. SpRP AOM was significantly more frequent before age 18 months (40/54 versus 85/166 in the SpSP group; p = 0.003) and associated with more clinical failure on days 4-10 (10/54 versus 14/166; p = 0.03). These results suggest that the antibiotic treatment used to treat AOM in children under 18 months should be reconsidered in areas with a high incidence of SpRP.

Effect of viral respiratory tract infection on outcome of acute otitis media

We prospectively studied 271 infants and children (2 months to 7 years of age) with acute otitis media (AOM) for viral and bacterial causes, outcome at the end of therapy, and frequency of recurrence within 1 month. Comprehensive virologic methods, including viral antigen detection, cell culture, and serologic studies, were used to diagnose viral infection of the respiratory tract, middle ear, or both. Evidence of viral infection was found in 46% (124/271) of patients with AOM. Sixty-six patients (24%) had virus or viral antigen in the middle ear fluid; 50 of these patients (76%) also had bacteria in middle ear fluid, and 16 (24%) had virus alone. More patients with AOM and combined bacterial and viral infection (51%) had persistent otitis (3 to 12 days after institution of antibiotic treatment), compared with those with only bacterial otitis (35%; p = 0.05) or patients with only viral infection (19%; p less than 0.01). Of patients with only viral infection, 4 of 10 with virus in middle ear fluid had persistent otitis, compared with none of 11 patients who had virus only in nasal wash specimens or whose viral infection was diagnosed only by serologic studies. Our data suggest that viruses interact with bacteria and that concurrent viral infection can significantly worsen the clinical course of bacterial AOM. The presence of virus in middle ear fluid may contribute to the pathogenesis and outcome of bacterial AOM. The mechanism of these interactions deserve further investigation.

Serum antibodies against respiratory tract viruses in episodes of acute otitis media

Although the findings of epidemiological studies have suggested viral respiratory tract infection (RTI) to be crucially involved in the development of acute otitis media (AOM), the relationship between AOM and viral RTI remains unclear. Serum samples, obtained in the acute and convalescent phases of 57 AOM episodes (in 35 children during the first three years of life) were analysed for IgG antibodies against influenza A viruses, influenza B viruses, parainfluenza virus type 1, respiratory syncytial virus and adenoviruses. One third of the AOM episodes (18/57) could be related to viral RTI, as evidenced by significant increases in viral serum antibody activity. Treatment failure occurred in four AOM episodes where increases in serum viral antibody activity were noted. In three of these failures, antibiotic treatment was unsuccessful despite the bacterial strains not being resistant to the drug used. This suggests that concomitant viral infection may be a determinant of treatment outcome in some AOM episodes.

Host factors and early therapeutic response in acute otitis media

To evaluate the relationship between eradication of bacterial infection and clinical improvement in children with otitis media, we reviewed the clinical outcome of bacterial otitis media in patients enrolled in double-blind trials of antibacterial therapy from 1979 to 1988. Cultures of middle ear exudates showed the distribution of bacterial pathogens to be similar to that observed in other geographic areas. Two hundred ninety-three patients had otitis media caused by bacterial pathogens and underwent repeat tympanocentesis after 3 to 6 days of therapy. Bacteriologic success was demonstrated in 253 patients (86%); 40 patients (14%) had bacteriologic failure. Children who had bacteriologic failure were younger than those with bacteriologic success (median age 10.6 vs 18.5 months; p = 0.001); 38% of patients who had bacteriologic failure were black, compared with 18% of patients with bacteriologic success (p = 0.007). Gender, history of frequent otitis media, and presence of bilateral otitis media were not risk factors for bacteriologic failure. Clinical success was demonstrated in 261 patients (89%); 32 patients (11%) had clinical failure. Agreement between clinical and bacteriologic response was 86% (95% confidence interval: 81.6% to 89.6%). Ninety-three percent (236/253) of subjects whose infection was eliminated had clinical resolution, whereas 37% (15/40) of those with bacteriologic failure had persisting symptoms or signs of clinical failure. We conclude that failure to eliminate bacteria from the middle ear is often associated with persistent signs and symptoms. Bacteriologic failure affects children less than 18 months of age almost exclusively. Bacteriologic and clinical failure are frequently discordant; mechanisms unrelated to the bacterial infection may explain some of the persisting clinical signs.

Double-blind comparison of cefixime and cefaclor in the treatment of acute otitis media in children

In a double-blind study cefixime, an oral cephalosporin of the third generation, was compared to cefaclor in the treatment of acute otitis media in 397 children aged 6 months to 12 years. Clinical evaluation was carried out at the beginning, at day 10-12 and day 28-35 after the start of the treatment. Specimens for bacterial culture and sensitivity testings were taken from the nasopharynx at the initial visit. Patients were randomized either to cefixime in a dose of 8 mg/kg/day or cefaclor in a dose 40 mg/kg/day in the proportion of 2 cefixime patients to 1 cefaclor patient. Two daily doses were administered for 7 days. At day 10-12, 93.5% in the cefixime group and 90.5% in the cefaclor group (p = 0.08) were clinically cured or improved. At day 28-35 the rate of cured or improved patients had decreased, mostly due to reinfections, to 90.1% in the cefixime group and to 86.6% in the cefaclor group (p = 0.12), respectively. 375 patients (69.9%) had positive bacterial culture in the nasopharynx of at least one strain of Haemophilus influenzae, Streptococcus pneumoniae, Branhamella (Moraxella) catarrhalis or combinations of these 3.73.6% of the B. catarrhalis strains were beta-lactamase producing and 11.4% of the H. influenzae strains, respectively. All isolated bacteria were sensitive to cefixime. Adverse events were reported in 17.9% in the cefixime and 10.6% in the cefaclor group. Most reactions were of moderate or mild nature and mostly affected skin or the gastrointestinal region. No serious adverse experiences occurred. In view of the good clinical results obtained cefixime seems to be at least as effective as cefaclor in the treatment of acute otitis media in children.

Respiratory virus infection as a cause of prolonged symptoms in acute otitis media

We studied respiratory viruses in 22 children with acute otitis media who had failed to improve after at least 48 hours of antimicrobial therapy. The mean duration of preenrollment antimicrobial therapy was 4.8 days. For comparison we studied 66 children with newly diagnosed acute otitis media. Respiratory viruses were isolated from middle ear fluid or from the nasopharynx, or both, significantly more often in the patients unresponsive to initial antimicrobial therapy than in the comparison patients (68% vs 41%, p less than 0.05). Viruses were recovered from the middle ear fluid in 32% of the study patients and from 15% of the comparison group. Bacteria were isolated from the middle ear fluid of four (18%) children in the study group; one child had an isolate resistant to initial antimicrobial therapy. All four children with bacteria in the middle ear fluid had evidence of concomitant respiratory virus infection. Our results indicate that respiratory virus infection is often present in patients with acute otitis media unresponsive to initial antimicrobial therapy, and may explain the prolongation of symptoms of infection. Resistant bacteria seem to be a less common cause of failure of the initial treatment.