Search

Objective: To present and evaluate the treatment of ciprofloxacin-resistant Pseudomonas mastoid cavity otorrhea with a ceftazidime thermosensitive poloxamer gel., Study Design: A retrospective clinical capsule report., Patients: Three patients diagnosed with ciprofloxacin-resistant Pseudomonas otorrhea in the setting of a previous canal-wall-down mastoidectomy between March 2019 and June 2023 visiting our tertiary care institution were retrospectively reviewed., Intervention: Application of a 2% ceftazidime thermosensitive poloxamer gel to mastoid cavity., Main Outcome Measures: No evidence of disease during microscopic inspection of the ear within a month of initial treatment or bacterial eradication on subsequent culture., Results: Two patients had complete resolution of symptoms and achieved a safe and dry ear after topical application of the hydrogel. The second patient had pseudomonal eradication on culture, but persistent otorrhea due to other multidrug-resistant bacteria and an anatomically unfavorable mastoid cavity, which ultimately resolved after revision surgery., Conclusions: This small case series suggests that topical treatment of mastoid cavity otorrhea with a 2% ceftazidime poloxomer gel is a potential therapeutic avenue in patients with ciprofloxacin-resistant Pseudomonas ., Competing Interests: The authors disclose no conflicts of interest., (Copyright © 2024, Otology & Neurotology, Inc.)

Objectives: To present the otologic findings of a patient with COVID-19 and complicated acute otitis media, evaluate for the presence of SARS-CoV-2 in middle ear fluid, and assess whether suctioning of middle ear fluid may be aerosol- generating., Methods: The case of a man with SARS-CoV-2 infection and complicated acute otitis media with facial paralysis is presented to illustrate unique clinical decisions made in context of the COVID-19 pandemic. A cadaveric temporal bone was used to simulate droplet spread during suctioning of fluorescein-labelled middle ear fluid and visualized with a blue-light filter., Results: A 23-year-old male who presented with complicated acute otitis media with facial paralysis was found to have an acute infection with SARS-CoV-2, with positive viral PCR of nasopharyngeal swab, and a negative PCR of the middle ear fluid. He was placed on isolation precautions and treated with myringotomy, topical and systemic antibiotics, and antivirals. Consistent with observations during endonasal suctioning, suctioning of middle ear fluid was not found to be aerosol or droplet generating., Conclusion: The case of a patient with active COVID-19 presenting with complicated acute otitis media in whom middle ear fluid was sampled to evaluate the etiology of the infection and the potential middle ear predilection of SARS-CoV-2 is described. This study has implications for the clinical management of patients with both known and unknown SARS-CoV-2 infection who present with ear disease. While middle ear suctioning may not be aerosol-generating, the risk of coughing or prolonged close contact requires heightened precautions during otologic procedures in patients with suspected or confirmed COVID-19.

Objectives: Only a few medications have a United States Food and Drug Administration indications for prevention and/or treatment of infections in patients with tympanic perforations or tympanostomy tubes. We examined 3 off-label agents that have become important in tympanostomy tube care hoping to demonstrate the effectiveness and safety of each in experimental assays and human application., Methods: Computerized literature review., Results: (1) Oxymetazoline nasal spray applied at the time of surgery is equivalent to fluoroquinolone ear drops in the prevention of early postsurgical otorrhea and tympanostomy tube occlusion at the first postoperative visit. (2) Topical mupirocin 2% ointment is effective alone or in combination with culture-directed systemic therapy for the treatment of tympanostomy tube otorrhea caused by community-acquired, methicillin-resistant Staphylococcus aureus . (3) Topical clotrimazole 1% cream is highly active against the common yeast and fungi that cause otomycosis. A single application after microscopic debridement will cure fungal tympanostomy tube otorrhea in most cases. None of these 3 agents is ototoxic in animal histological or physiological studies, and each has proved safe in long-term clinical use., Conclusions: Oxymetazoline nasal spray, mupirocin ointment, and clotrimazole cream are safe and effective as off-label medications for tympanostomy tube care in children.

Objectives: Following the increased use of antibiotics, the emergence of antibiotic-resistant species in pediatric patients with otitis media has become a problem in recent years. The aim of this study was to investigate change in bacterial species, antibiotic resistance, and detection rate of highly pathogenic species, such as Methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa according to the number of repeated ventilation tube insertion (VTI) procedures in pediatric patients diagnosed with otitis media with effusion (OME)., Materials & Methods: From May 2010 to June 2018, 158 patients under 17 years of age who were admitted to the outpatient clinic of Kyung Hee Medical Center and diagnosed as OME and underwent unilateral or bilateral VTI were included in this study. Bacterial cultures were performed on aseptically collected middle ear effusion (MEF) at the time of VTI and antibiotic sensitivity tests were performed on the identified bacteria., Results: Bacteria were not identified in 195 (70.1%) cultures and identified in 83 (29.9%) cultures. Coagulase-negative staphylococci (CNS) was the most frequently detected species in both the non-recurrent group and the recurrent group. MRSA detection rate was found to be significantly higher in the recurrent group than in the non-recurrent group (p = 0.029). The two groups showed no significant difference in antibiotic resistance against all antibiotics (p > 0.05)., Conclusion: Staphylococcus species were detected most frequently in the MEF of pediatric OME patients, and the MRSA detection rate was higher in the recurrent group than in the non-recurrent group. There was no difference in antibiotic sensitivity between the two groups against all antibiotics, but resistance to penicillin G and cefoxitin was newly appeared in patients with repeated detection of same bacterial isolates., (Copyright © 2019. Published by Elsevier B.V.)

Otitis media with effusion (OME) is a biofilm driven disease and commonly accepted otopathogens, such as Haemophilus influenzae, Streptococcus pneumonia, and Moraxella catarrhalis , have been demonstrated to form polymicrobial biofilms within the middle ear cleft. However, Alloiococcus otitidis ( A. otitidis ), which is one of the most commonly found bacteria within middle ear aspirates of children with OME, has not been described to form biofilms. The aim of this study was to investigate whether A. otitidis can form biofilms and investigate the impact on antibiotic susceptibility and survivability in polymicrobial biofilms with H. influenzae in vitro . The ability of A. otitidis to form single-species and polymicrobial biofilms with H. influenzae was explored. Clinical and commercial strains of A. otitidis and H. influenzae were incubated in brain heart infusion with and without supplementation. Biofilm was imaged using confocal laser scanning microscopy and scanning electron microscopy. Quantification of biofilm biomass and viable bacterial number was assessed using crystal violet assays and viable cell counting in both optimal growth conditions and in adverse growth conditions (depleted media and sub-optimal growth temperature). Antimicrobial susceptibility and changes in antibiotic resistance of single-species and multi-species co-culture were assessed using a microdilution method to assess minimal bactericidal concentration and E-test for amoxicillin and ciprofloxacin. A. otitidis formed single-species and polymicrobial biofilms with H. influenzae . Additionally, whilst strain dependent, combinations of polymicrobial biofilms decreased antimicrobial susceptibility, albeit a small magnitude, in both planktonic and polymicrobial biofilms. Moreover, A. otitidis promoted H. influenzae survival by increasing biofilm production in depleted media and at suboptimal growth temperature. Our findings suggest that A. otitidis may play an indirect pathogenic role in otitis media by altering H. influenzae antibiotic susceptibility and enhancing growth under adverse conditions.

Background: Acute otitis media is a common childhood infection. Prompt diagnosis and appropriate treatment are very important., Objective: To review in depth the epidemiology, pathophysiology, clinical manifestations, diagnosis, complications and particularly treatment of acute otitis media in children., Methods: A PubMed search was completed in Clinical Queries using the key term "acute otitis media". Patents were searched using the key term "acute otitis media" from www.google.com/patents, http://espacenet.com, and www.freepatentsonline.com., Results: Acute otitis media affects over 80% of children before their third birthday and 30 to 45% of these children have suffered two or more episodes. Streptococcus pneumoniae, nontypable Haemophilus influenzae, and Moraxella catarrhalis are the most frequently isolated middle-ear pathogens. The diagnosis is based on acute onset of symptoms such as otalgia and fever, middle ear inflammation such as erythema of the tympanic membrane, and middle ear effusion. The choice of treatment method depends on the age of the child, laterality, and the severity of the disease. Recent patents related to the management of acute otitis media are also retrieved and discussed., Conclusion: Antimicrobial treatment is recommended for all children less than two years of age, as well as in children ≥ two years of age who have a temperature ≥ 39oC; are toxic looking; have otalgia > 48 hours; have bilateral otitis media or otorrhea; have craniofacial abnormalities; are immunocompromised; or have uncertain access to follow-up. Amoxicillin is the drug of choice. Observation without antibiotic is an option in immunocompetent children ≥ two years of age who have an acute uncomplicated otitis media and non-severe illness if appropriate follow-up can be arranged., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.org.)

Objective: To investigate the efficacy, safety, and microbiology of a thermosensitive otic suspension of ciprofloxacin (OTO-201) in children with bilateral middle ear effusion undergoing tympanostomy tube placement., Study Design: Two randomized, double-blind, sham-controlled phase 3 trials. Patients were randomized to intratympanic OTO-201 or sham., Setting: Children with bilateral middle ear effusion undergoing tympanostomy tube placement., Subjects/methods: Studies evaluated 532 patients (6 months to 17 years old) in a combined analysis of efficacy (treatment failure: presence of otorrhea, otic or systemic antibiotic use, lost to follow-up, missed visits), safety (audiometry, otoscopy, tympanometry), and microbiology., Results: There was a lower cumulative proportion of treatment failures in patients receiving OTO-201 vs tympanostomy tubes alone (1) on days 4, 8, 15, and 29; (2) on day 15, primary end point (23.0% vs 45.1%; age-adjusted odds ratio, 0.341; P < .001; reduction in relative risk, 49%); and (3) on day 15, blinded-assessor otorrhea treatment failure (7.0% vs 19.4%; age-adjusted odds ratio, 0.303; P < .001; reduction in relative risk, 64%). Per-protocol and subgroup analyses (baseline demographics, pathogen type, culture status, effusion type, microbiologic response) supported these findings. There were no drug-related serious adverse events; the most frequent treatment-emergent adverse events in both groups were pyrexia, postoperative pain, nasopharyngitis, cough, and upper respiratory tract infection. OTO-201 administration had no evidence of increased tube occlusion and no negative effect on audiometry, tympanometry, or otoscopy., Conclusions: Combined analysis of 2 phase 3 trials demonstrated a lower cumulative proportion of treatment failures through day 15 compared with TT alone when OTO-201 was administered intratympanically for otitis media with bilateral middle ear effusion at time of tympanostomy tube placement., (© American Academy of Otolaryngology—Head and Neck Surgery Foundation 2016.)

Background: Otitis media with effusion (OME) is characterised by an accumulation of fluid in the middle ear behind an intact tympanic membrane, without the symptoms or signs of acute infection. Since most cases of OME will resolve spontaneously, only children with persistent middle ear effusion and associated hearing loss potentially require treatment. Previous Cochrane reviews have focused on the effectiveness of ventilation tube insertion, adenoidectomy, nasal autoinflation, antihistamines, decongestants and corticosteroids in OME. This review, focusing on the effectiveness of antibiotics in children with OME, is an update of a Cochrane review published in 2012., Objectives: To assess the benefits and harms of oral antibiotics in children up to 18 years with OME., Search Methods: The Cochrane ENT Information Specialist searched the ENT Trials Register; Central Register of Controlled Trials (CENTRAL 2016, Issue 3); PubMed; Ovid EMBASE; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 14 April 2016., Selection Criteria: Randomised controlled trials comparing oral antibiotics with placebo, no treatment or therapy of unproven effectiveness in children with OME., Data Collection and Analysis: We used the standard methodological procedures expected by Cochrane., Main Results: Twenty-five trials (3663 children) were eligible for inclusion. Two trials did not report on any of the outcomes of interest, leaving 23 trials (3258 children) covering a range of antibiotics, participants, outcome measures and time points for evaluation. Overall, we assessed most studies as being at low to moderate risk of bias.We found moderate quality evidence (six trials including 484 children) that children treated with oral antibiotics are more likely to have complete resolution at two to three months post-randomisation (primary outcome) than those allocated to the control treatment (risk ratio (RR) 2.00, 95% confidence interval (CI) 1.58 to 2.53; number needed to treat to benefit (NNTB) 5). However, there is evidence (albeit of low quality; five trials, 742 children) indicating that children treated with oral antibiotics are more likely to experience diarrhoea, vomiting or skin rash (primary outcome) than those allocated to control treatment (RR 2.15, 95% CI 1.29 to 3.60; number needed to treat to harm (NNTH) 20).In respect of the secondary outcome of complete resolution at any time point, we found low to moderate quality evidence from five meta-analyses, including between two and 14 trials, of a beneficial effect of antibiotics, with a NNTB ranging from 3 to 7. Time periods ranged from 10 to 14 days to six months.In terms of other secondary outcomes, only two trials (849 children) reported on hearing levels at two to four weeks and found conflicting results. None of the trials reported data on speech, language and cognitive development or quality of life. Low quality evidence did not show that oral antibiotics were associated with a decrease in the rate of ventilation tube insertion (two trials, 121 children) or in tympanic membrane sequelae (one trial, 103 children), while low quality evidence indicated that children treated with antibiotics were less likely to have acute otitis media episodes within four to eight weeks (five trials, 1086 children; NNTB 18) and within six months post-randomisation (two trials, 199 children; NNTB 5). It should, however, be noted that the beneficial effect of oral antibiotics on acute otitis media episodes within four to eight weeks was no longer significant when we excluded studies with high risk of bias., Authors' Conclusions: This review presents evidence of both benefits and harms associated with the use of oral antibiotics to treat children up to 16 years with OME. Although evidence indicates that oral antibiotics are associated with an increased chance of complete resolution of OME at various time points, we also found evidence that these children are more likely to experience diarrhoea, vomiting or skin rash. The impact of antibiotics on short-term hearing is uncertain and low quality evidence did not show that oral antibiotics were associated with fewer ventilation tube insertions. Furthermore, we found no data on the impact of antibiotics on other important outcomes such as speech, language and cognitive development or quality of life.Even in situations where clear and relevant benefits of oral antibiotics have been demonstrated, these must always be carefully balanced against adverse effects and the emergence of bacterial resistance. This has specifically been linked to the widespread use of antibiotics for common conditions such as otitis media.

Acute otitis media and otitis media with effusion (OME) are the main causes of hearing impairment in children which require proper treatment, mainly antibiotic therapy. Patients whom were appropriate candidates for adenoidectomy were divided into two groups regarding the presence of middle ear effusion. Adenoid tissue specimens were cultured in both groups and the bacterial flora and anti-microbial resistance pattern were determined. 72 patients were studied, 42 % had OME while 58 % did not. The following bacteria were isolated and cultured from both groups with no meaningful difference in prevalence: Streptococcus viridans (p = 0.265), Staphylococcus aureus (p = 0.72), H. influenza (p = 0.806), Entrococcus. spp (0.391), Streptococcus pneumonia (p = 0.391), nonhemolytic Streptococcus (p = 0.230). Bacterial sensitivity was similar for Amoxicillin-clavulanate (p = 0.935), Amoxicillin (p = 0.935), Cephalexin (p = 0.806), Cefixime (p = 0.391) and Azithromycin in both groups. The two groups showed no meaningful difference considering the bacterial flora of nasopharynx and their sensitivity. Bacteria in both groups were sensitive to Amoxicillin and Amoxicillin-clavulanate and resistant to Azithromycin, Cefixime and Cephalexin.

Objective: To compare the efficacy of two treatment regimens among Helicobacter pylori stool antigen positive children suffering from resistant otitis media with effusion., Methods: The study comprised 258 children with bilateral otitis media with effusion; 134 were positive for H pylori stool antigen, and were equally and randomly allocated to the control group or study group. The control group received standard otitis media with effusion therapy (amoxicillin and clavulanate), while the study group received standard H pylori triple therapy (clarithromycin, metronidazole and lansoprazole)., Results: In the control group, there was a marked clinical response to treatment in 33 of the 67 children (49.3 per cent). In the study group, there was a marked response in a significantly higher number of children (46 out of 67, 68.7 per cent). The 124 H pylori stool antigen negative children not included in the 2 aforementioned groups received amoxicillin and clavulanate, and a marked response in symptoms was evident in 98 of these children (79 per cent)., Conclusion: H pylori infection may lead to resistance to traditional otitis media with effusion treatment in some cases. H pylori eradication is associated with a high cure rate.

Introduction: Infectious conditions of the middle ear are a common and significant cause of morbidity and mortality worldwide. Systemic antibiotics are frequently used, but their effectiveness will depend on whether an adequate antibiotic concentration is achieved in the middle ear; this is especially important in biofilm infections such as otitis media with effusion (OME), where high antibiotic concentrations are typically required for effective treatment., Objective: This review examines what antibiotic levels can be reached in the middle ear with oral administration, as a means of guiding rational antibiotic choice in the clinic and future research, and to determine whether levels high enough for biofilm eradication are reached., Methods: A literature search of studies measuring levels of antibiotics in the plasma and in the middle ear after oral administration was conducted. These levels were compared to the minimum inhibitory concentrations (MIC) provided by the European Committee for Antimicrobial Susceptibility Testing (EUCAST) to determine if antibiotic doses were reaching sufficient levels to inhibit planktonic bacteria. The middle ear concentrations were then calculated as a multiple of the MIC to determine if the concentrations were reaching biofilm eradication concentrations (typically up to 1000×MIC)., Results: The highest antibiotic levels against Staphylococcus aureus reach 8.3×MIC, against Moraxella catarrhalis 33.2×MIC, against Haemophilus influenzae 31.2×MIC, and against Streptococcus pneumoniae 46.2×MIC. The macrolide antibiotics reach higher levels in the middle ear than in plasma., Conclusions: Orally administered antibiotics reach levels above the MIC in the middle ear. However, they do not reach levels that would be likely to eradicate biofilms., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Acute otitis media (AOM) microbiology was evaluated in children after 7-valent pneumococcal conjugate vaccine (PCV7) introduction in Costa Rica (private sector, 2004; National Immunization Program, 2009). This was a combined prospective and retrospective study conducted in a routine clinical setting in San José, Costa Rica. In the prospective part of the study, which was conducted post-PCV7 introduction (2010-2012), standard bacteriological procedures were used to evaluate the etiology and serotype distribution of middle ear fluid samples collected by tympanocentesis or otorrhea from children aged 3-59 months diagnosed with AOM. E-tests were used to evaluate antimicrobial susceptibility in culture-positive samples. Retrospective data recorded between 1999 and 2004 were used for comparison of bacterial etiology and serotype distribution before and after PCV7 introduction. Statistical significance was evaluated in bivariate analyses at the P-value < 0.05 level (without multiplicity correction). Post-PCV7 introduction, Haemophilus influenzae was detected in 118/456 and Streptococcus pneumoniae in 87/456 AOM episodes. Most H. influenzae isolates (113/118) were non-typeable. H. influenzae was more (27.4% vs 20.8%) and S. pneumoniae less (17.1% vs 25.5%) frequently observed in vaccinated (≥ 2 PCV7 doses or ≥ 1 PCV7 dose at >1 year of age) versus unvaccinated children. S. pneumoniae non-susceptibility rates were 1.1%, 34.5%, 31.7%, and 50.6% for penicillin, erythromycin, azithromycin, and trimethoprim/sulfamethoxazole (TMP-SMX), respectively. H. influenzae non-susceptibility rate was 66.9% for TMP-SMX. Between pre- and post-PCV7 introduction, H. influenzae became more (20.5% vs 25.9%; P-value < 0.001) and S. pneumoniae less (27.7% vs 19.1%; P-value = 0.002) prevalent, and PCV7 serotype proportions decreased among pneumococcal isolates (65.8% vs 43.7%; P-value = 0.0005). Frequently identified pneumococcal serotypes were 19F (34.2%), 3 (9.7%), 6B (9.7%), and 14 (9.7%) pre-PCV7 introduction, and 19F (27.6%), 14 (8.0%), and 35B (8.0%) post-PCV7 introduction. Following PCV7 introduction, a change in the distribution of AOM episodes caused by H. influenzae and pneumococcal serotypes included in PCV7 was observed in Costa Rican children. Pneumococcal vaccines impact should be further evaluated following broader vaccination coverage.

Tebipenem pivoxil, an oral carbapenem antibiotic for pediatric use, exhibits excellent clinical effects on acute otitis media (AOM). The present study was conducted to assess the pharmacokinetic profile of tebipenem in middle ear effusion and to examine the clinical efficacy of tebipenem pivoxil by calculating the values of the pharmacokinetic-pharmacodynamic parameters (AUC/MIC, C max/MIC, and T > MIC) of tebipenem at the site of action. Twenty-three pediatric outpatients diagnosed with AOM were enrolled. Ear discharge or nasopharyngeal swabs collected before the onset of oral administration were used to conduct bacteriological examinations, and subjects were then treated by twice-a-day oral administration of tebipenem pivoxil 6 mg/kg. The clinical isolates of Streptococcus pneumoniae and Haemophilus influenzae were obtained from 10 and 19 pediatric patients (8 overlapped), respectively. On day 2 of administration, blood and middle ear effusion were collected from 20 pediatric patients to measure plasma and middle ear concentrations of tebipenem. Consequently, the C max and the AUC0-∞ in plasma were 5.3 ± 1.6 μg/ml (mean ± SD) and 7.9 ± 0.2 μg h/ml, respectively. The C max in middle ear effusion of tebipenem was 1.2 ± 0.1 μg/ml, exceeding its MIC for these pathogens. The ratio of AUC0-∞ in middle ear effusion to AUC0-∞ in plasma was 0.36, showing the good transfer of tebipenem into the effusion; this result corroborated the known high rate of clinical efficacy of tebipenem pivoxil for patients with AOM and the low incidence of recurrence in them as manifested by the healing rate of 94.1 % (16/17).

Background: Otitis media with effusion (OME) is characterised by an accumulation of fluid in the middle ear behind an intact tympanic membrane, without the symptoms or signs of acute infection. In approximately one in three children with OME, however, a bacterial pathogen is identified in the middle ear fluid. In most cases, OME causes mild hearing impairment of short duration. When experienced in early life and when episodes of (bilateral) OME persist or recur, the associated hearing loss may be significant and have a negative impact on speech development and behaviour. Since most cases of OME will resolve spontaneously, only children with persistent middle ear effusion and associated hearing loss potentially require treatment. Previous Cochrane reviews have focused on the effectiveness of ventilation tube insertion, adenoidectomy, autoinflation, antihistamines, decongestants, and oral and topical intranasal steroids in OME. This review focuses on the effectiveness of antibiotics in children with OME., Objectives: To assess the effects of antibiotics in children up to 18 years with OME., Search Methods: We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the search was 22 February 2012., Selection Criteria: Randomised controlled trials comparing oral antibiotics with placebo, no treatment or therapy of unproven effectiveness. Our primary outcome was complete resolution of OME at two to three months. Secondary outcomes included resolution of OME at other time points, hearing, language and speech, ventilation tube insertion and adverse effects., Data Collection and Analysis: Two authors independently extracted data using standardised data extraction forms and assessed the quality of the included studies using the Cochrane 'Risk of bias' tool. We presented dichotomous results as risk differences as well as risk ratios, with their 95% confidence intervals. If heterogeneity was greater than 75% we did not pool data., Main Results: We included 23 studies (3027 children) covering a range of antibiotics, participants, outcome measures and time points of evaluation. Overall, we assessed the studies as generally being at low risk of bias.Our primary outcome was complete resolution of OME at two to three months. The differences (improvement) in the proportion of children having such resolution (risk difference (RD)) in the five individual included studies ranged from 1% (RD 0.01, 95% CI -0.11 to 0.12; not significant) to 45% (RD 0.45, 95% CI 0.25 to 0.65). Results from these studies could not be pooled due to clinical and statistical heterogeneity.Pooled analysis of data for complete resolution at more than six months was possible, with an increase in resolution of 13% (RD 0.13, 95% CI 0.06 to 0.19).Pooled analysis was also possible for complete resolution at the end of treatment, with the following increases in resolution rates: 17% (RD 0.17, 95% CI 0.09 to 0.24) for treatment for 10 days to two weeks, 34% (RD 0.34, 95% CI 0.19 to 0.50) for treatment for four weeks, 32% (RD 0.32, 95% CI 0.17 to 0.47) for treatment for three months, and 14% (RD 0.14, 95% CI 0.03 to 0.24) for treatment continuously for at least six months.We were unable to find evidence of a substantial improvement in hearing as a result of the use of antibiotics for otitis media with effusion; nor did we find an effect on the rate of ventilation tube insertion. We did not identify any trials that looked at speech, language and cognitive development or quality of life. Data on the adverse effects of antibiotic treatment reported in six studies could not be pooled due to high heterogeneity. Increases in the occurrence of adverse events varied from 3% (RD 0.03, 95% CI -0.01 to 0.07; not significant) to 33% (RD 0.33, 95% CI 0.22 to 0.44) in the individual studies., Authors' Conclusions: The results of our review do not support the routine use of antibiotics for children up to 18 years with otitis media with effusion. The largest effects of antibiotics were seen in children treated continuously for four weeks and three months. Even when clear and relevant benefits of antibiotics have been demonstrated, these must be balanced against the potential adverse effects when making treatment decisions. Immediate adverse effects of antibiotics are common and the emergence of bacterial resistance has been causally linked to the widespread use of antibiotics for common conditions such as otitis media.

This paper is focused on the topical otorhinolaryngological problem of Eustachian tube dysfunction, a pathological condition preceding or accompanying exudative otitis media. Based on the results of modern fundamental research, the author considers for the first time the role of endotoxins of Gram-negative microorganisms and endothelial dysfunction in etiology and pathogenesis of tubal disorders, exudative otitis media, and the related complications of sensorineural impairment of hearing.

Background: Conjugate vaccines, such as the 7-valent conjugate vaccine (PCV7), alter serotype nasopharyngeal carriage, potentially increasing cases of otitis media by non-vaccine serotypes., Methods: All paediatric middle ear fluid (MEF) isolates received in the Spanish Reference Laboratory for Pneumococci through a passive, laboratory-based surveillance system from January 1997 to June 2009 were analysed. Data from 1997 to 2000 were pooled as pre-vaccination period. Trends over time were explored by linear regression analysis., Results: A total of 2,077 isolates were analysed: 855 belonging to PCV7 serotypes, 466 to serotype 19A, 215 to serotype 3, 89 to serotype 6A and 452 to other serotypes (< 40 isolates each). Over time, there has been a decreasing trend for PCV7 serotypes (R(2) = 0.944; p < 0.001, with significant decreasing trends for serotypes 19F, 14, 23F and 9V), and increasing trends for serotype 19A (R(2) = 0.901; p < 0.001), serotype 3 (R(2) = 0.463; p = 0.030) and other non-PCV7 serotypes (R(2) = 0.877; p < 0.001), but not for serotype 6A (R(2) = 0.311; p = 0.094). Considering all isolates, amoxicillin non-susceptibility showed an increasing trend (R(2) = 0.528; p = 0.017). Regarding serotype 19A, increasing trends in non-susceptibility to penicillin (R(2) = 0.726; p = 0.001), amoxicillin (R(2) = 0.804; p < 0.001), cefotaxime (R(2) = 0.546; p = 0.005) and erythromycin (R(2) = 0.546; p = 0.009) were found, with amoxicillin non-susceptibility firstly detected in 2003 (7.4%) and increasing up to 38.0% in 2009. In PCV7 serotypes (which prevalence decreased from 70.7% during 1997-2000 to 10.6% in 2009) amoxicillin non-susceptibility rates showed an increasing trend (R(2) = 0.702; p = 0.002). However, overall, amoxicillin non-susceptibility (≈25% in 2008-9) could be mainly attributed to serotype 19A (> 35% isolates) since PCV7 strains represented < 11% of total clinical isolates., Conclusions: In contrast to reports on invasive pneumococcal strains, in MEF isolates the reduction in the prevalence of PCV7 serotypes was not associated with decreases in penicillin/erythromycin non-susceptibility. The high prevalence of serotype 19A among paediatric MEF isolates and the amoxicillin non-susceptibility found in this serotype are worrisome since amoxicillin is the most common antibiotic used in the treatment of acute otitis media. These data suggest that non-PCV7 serotypes (mainly serotype 19A followed by serotypes 3 and 6A) are important etiological agents of acute otitis media and support the added value of the broader coverage of the new 13-valent conjugate vaccine.

Background: The treatment of MRSA (methocillin resistant staphylococcus aureus) colonized middle ear is difficult. According to the guidelines, a MRSA colonized Patient is not to be treated with systemic antibiotics. The topical treatment shows the problem of the ototoxicity of most of the used antiseptic as well as antibiotic substances., Method: Selective literature review and consideration of the author's own clinical experience., Results and Conclusions: Antibiotic treatment options include aequeous Tetracyclin drops, aequeous chloramphenicol drops and quinolon ear drops (unfortunately the MRSA is resistent mostly). Antiseptics without ototoxic effects are the Burow's solution, Povidone-iode, acetic acid solutions and aequeous dequalinium solutions.

Objectives: The aim of this study is to examine the internalization of nontypeable Haemophilus influenzae (NTHi) into human epithelial cells., Methods: Bactericidal assay was applied to examine the effects of antibiotics against cell-adherent NTHi using HEp-2 cells. A trans-well chamber assay was applied to examine the internalization and penetration of NTHi using Detroit562 cells., Results: The adherence of NTHi to HEp-2 cells was noted after 2h of incubation. Azithromycin had a strong bactericidal effect against both cell-associated and non-adherent NTHi, while ceftriaxone did not show bactericidal effects on NTHi adhered to the HEp-2 cells. Three (60.0%) out of five NTHi isolates from the nasopharynx of children with intractable acute otitis media (AOM) internalized into and subsequently penetrated through the epithelial cells at various degrees. Azithromycin had a strong bactericidal effect against the cell-internalized NTHi, while ceftriaxone was bactericidal only against extracellular NTHi., Conclusion: The potential of NTHi as the intracellular pathogen may contribute to the persistent existence of this pathogen that result in the prolonged and intractable clinical course of AOM. Azithromycin may be a therapeutically significant antibiotic for patients with prolonged respiratory tract infections due to NTHi., (Copyright (c) 2009. Published by Elsevier Ireland Ltd.)

Background: National Institute for Health and Clinical Excellence (NICE) guidance to treat otitis media in older children immediately with antibiotics only if they have ear discharge is based on limited evidence., Aim: To determine the clinical significance and outcome of ear discharge in children with acute otitis media, in routine clinical practice., Design of Study: Observational cohort study of children with acute otitis media comparing those with and without ear discharge at presentation., Setting: Primary care in East Somerset., Method: Two hundred and fifty-six children aged 6 months to 10 years were recruited from primary care. Clinical features and other characteristics were recorded at presentation. Follow-up was undertaken at 2 weeks and 3 months., Results: Children with otitis media who present with ear discharge are much more likely to be treated with antibiotics irrespective of age (adjusted odds ratio 15, 95% confidence interval [CI] = 3 to 66). Most with discharge have proven bacterial infection (58%, 95% CI = 42 to 72%). They have a more severe systemic illness, with higher axillary temperature (80% increase in odds of ear discharge for each additional degree centigrade, P = 0.02), pulse rate (9% increase in odds for each extra beat, P<0.001), and Yale score (mean 10.5 versus 9.0, P = 0.003). They may also have an increased likelihood of adverse outcome (adjusted odds ratio of pain at 1 week 2.9; further episodes of acute otitis media 3.3; hearing difficulty at 3 months 4.7; all P<0.10)., Conclusion: Ear discharge defines a group of children with otitis media who are sicker and may be at higher risk of adverse outcome. NICE guidance to treat them with antibiotics is supported.

Objectives: Otitis media with effusion is a common disease entity in children, which is frequently managed surgically by insertion of a tympanostomy tube. Children who develop posttympanostomy tube otorrhea (PTTO) can be treated by administration of antibiotics. The abuse and misuse of antibiotics, however, has led to the emergence of resistant bacterial strains. We therefore examined the antibiotic sensitivity of bacterial strains collected from middle ear effusion fluid (MEEF) and PTTO. We also evaluated treatment outcomes in these patients., Methods: This study was conducted in 289 patients who underwent tympanostomy tube insertion for chronic otitis media with effusion between March 2004 and February 2008., Results: Bacterial culture tests during the insertion of tympanostomy tubes showed a high frequency of coagulase(-) Staphylococcus (CNS), followed by Pseudomonas, methicillin resistant Staphylococcus aureus (MRSA) and methicillin-susceptible S. aureus (MSSA). Patients with PTTO had a high frequency of CNS and MRSA, followed by MSSA and Streptococcus pneumoniae. Overall antibiotic sensitivity was lower in postoperatively collected than in intraoperatively collected bacterial strains., Conclusions: The bacterial strains detected in MEEF, and their antibiotic sensitivity profiles, differed somewhat from those of PTTO. Antibiotic sensitivity was decreased in bacteria from PTTO compared with those in MEEF.

Antibiotic-resistant Streptococcus pneumoniae (Sp) are described around the world. The present national surveillance study report analyzes more than 6000 Sp strains, isolated from adults across France in 2001 and 2003, from blood cultures (3086 in 2001 and 3164 in 2003), cerebrospinal fluid (respectively, 238 and 240), or middle ear fluid (respectively, 110 and 100). The proportion of isolates with reduced susceptibility to penicillin fell significantly between 2001 and 2003 from 46.5% to 43.9%. The proportion of high-level resistant strains to penicillin minimal inhibitory concentrations (MIC > 1 mg/L), amoxicillin, and cefotaxime (MIC > 2 mg/L) slightly decreased but remained low: 10.6%, 1.2%, and 0.2% in 2003. Resistance to other antibiotics (erythromycin, cotrimoxazole, tetracycline, and chloramphenicol) also decreased. Decrease in prevalence of penicillin-resistant Sp varied according to specimen source. The proportion of penicillin nonsusceptible pneumococci decreased in blood cultures and middle ear fluids between 2001 and 2003 but increased in cerebrospinal fluid (43.4% and 46.5%, respectively). Serotypes covered by the heptavalent vaccine accounted for 42.4% of all isolates recovered in 2001 and 46.1% in 2003. Prevalence of antibiotic-resistant Sp decreased in 2003 in France.

Unlabelled: Acute otitis media is one of the most common diseases in children aged 0-24 months and Streptococcus pneumoniae is the most frequently isolated bacterial pathogen of acute otitis media. It is well established and documented that the heptavalent pneumococcal conjugate vaccine reduces the frequency of otitis media, especially caused by vaccine-serotype pneumococcus (4, 6B, 9, 14, 18C, 19F, 23F). However, this effect depends on the serotype distribution of isolated otopathogenic pneumococcal strains., Objective: Aim of this study was to determine the serotype distribution and antimicrobial resistance of pneumococcal strains causing acute otitis media in children aged 0-24 months., Patients and Methods: Between year 2002 and 2005 we investigated 73 pneumoccocal strains isolated from middle ear fluids of children aged 0-24 months in 10 pediatric centers in Budapest, Hungary. After bacteriological identification, pneumococcal serotyping was performed through Quellung reaction in the Microbiological Laboratory of Szent Lászlo Hospital Budapest, Hungary. Antimicrobial resistance was determined according to the international standards accepted by the Hungarian Society for Microbiology., Results: The 73 strains represented 14 different serotypes. The most common were serotypes 14 (13.7 %), 19F (13.7 %), 6B (13.7 %), 23A (11 %) and 3 (9.6 %). Coverage ratio of the heptavalent pneumococcal conjugated vaccine was 63 %. Intermediate penicillin susceptibility was 41 % among all serotypes and 90 % among vaccine-serotypes. No high level penicillin resistant strains were found. Among intermediate penicillin susceptible strains serotype 9V, 14 and 19F were the most frequent., Conclusion: Serotype distribution of otopathogenic pneumococcal strains and coverage ratio of heptavalent conjugated pneumococcal vaccine in Hungary are similar to the result found in other geographic regions. In conclusion, we suppose that use of the pneumococcal conjugated vaccines in Hungary would provide same effectiveness against acute otitis media showed in previous multinational efficacy trials.

Objective: To establish if otorrhea associated to tympanostomy tubes in infants suffering from recurrent acute otitis media is similar to acute otitis media, and if topical treatment alone is sufficient or if addition of systemic antibiotics is required., Methods: Children under 3 years of age with tympanostomy tubes due to recurrent acute otitis media were recruited to the study. The study design was open label randomized and prospective. Fifty patients were allocated to either of two treatment groups and were monitored for 6 months. Group I received only topical treatment (commercially available ear drops and saline solution) in case of otorrhea. Group II was treated with topical treatment together with systemic antibiotics. All episodes of acute otorrhea were registered. Main outcome measure was duration of otorrhea in days. Bacterial samples from the ear discharge were taken., Results: Forty-one episodes were treated according to protocol. The bacteriological testing mainly showed bacteria typical of acute otitis media. A majority of episodes were cured within 7 days in both groups, and statistical analysis showed no significant difference between the treatment groups in duration of otorrhea. In Group I systemic antibiotics were added in one-third (7/21) of the episodes due to signs of affected general condition such as high fever and severe earache., Conclusions: The otorrhea episodes in the study were similar to acute otitis media based on the bacteriological results. Topical treatment alone might be used as first treatment of choice. Although systemic antibiotics were added in several cases in the topical treatment group, the findings of the study do not support use of systemic antibiotics for tube associated otorrhea in RAOM children in general.

Background: For children at high risk of chronic suppurative otitis media (CSOM), strategies to prevent acute otitis media with perforation (AOMwiP) may reduce progression to CSOM., Methods: In a double blind study in northern Australia, 103 Aboriginal infants with first detection of OME were randomised to receive either amoxicillin (50 mg/kg/d BD) or placebo for 24 weeks, or until bilateral aerated middle ears were diagnosed at two successive monthly examinations (success). Standardised clinical assessments and international standards for microbiology were used., Results: Five of 52 infants in the amoxicillin group and none of 51 infants in the placebo group achieved success at the end of therapy (Risk Difference = 9.6% [95% confidence interval 1.6,17.6]). Amoxicillin significantly reduced the proportion of children with i) perforation at the end of therapy (27% to 12% RD = -16% [-31,-1]), ii) recurrent perforation during therapy (18% to 4% RD = -14% [-25,-2]), and iii) reduced the proportion of examinations with a diagnosis of perforation during therapy (20% to 8% adjusted risk ratio 0.36 [0.15,0.83] p = 0.017). During therapy, the proportion of examinations with penicillin non-susceptible (MIC > 0.1 microg/ml) pneumococci was not significantly different between the amoxicillin group (34%) and the placebo group (40%). Beta-lactamase positive non-capsular H. influenzae (NCHi) were uncommon during therapy but more frequent in the amoxicillin group (10%) than placebo (5%)., Conclusion: Aboriginal infants receiving continuous amoxicillin had more normal ears, fewer perforations, and less pneumococcal carriage. There was no statistically significant increase in resistant pneumococci or NCHi in amoxicillin children compared to placebo children who received regular paediatric care and antibiotic treatment for symptomatic illnesses.

Children who had acute otitis media and were treated with levofloxacin were assessed for the emergence of fluoroquinolone-resistant Streptococcus pneumoniae. Nasopharynx cultures were obtained from patients at the entry to and during levofloxacin therapy. All nasopharynx isolates (n = 59) from 12 children were levofloxacin susceptible without parC/E or gyrA/B mutations. Pneumococcal nasopharynx persistence was not associated with levofloxacin resistance.

Various topical preparations are widely used for treating external otitis, acute otitis media with perforation, post-tympanostomy tube otorrhea, and chronic suppurative otitis media. Solutions and suspensions that enter the middle ear through a perforated tympanic membrane can reach the inner ear by crossing through the round window membrane. The safety of various components of otic solutions used in this way, particularly aminoglycosides, corticosteroids, solvents, and preservatives, has been questioned in light of their ototoxic potential. The authors' objective is to review the literature discussing the safety of commonly used classes of otic preparations in settings in which the constituents can access the middle and inner ear in high concentrations and discuss their clinical experience with ototoxicity and experience with medical-legal issues.

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.

Faropenem was tested against 1,188 middle ear fluid pathogens from children in Israel and Costa Rica. Against Streptococcus pneumoniae and Haemophilus influenzae, faropenem was the most active beta-lactam, with activity that was similar to or greater than of the other oral antimicrobial classes studied. Faropenem was also active against Moraxella catarrhalis and Streptococcus pyogenes.

Objectives: Honey has had a valued place in traditional medicine for centuries. Renewed interest in honey for various therapeutic purposes, including treatment of infected wounds, has led to the search for different types of honey with antibacterial activity. In this study, we have assessed the antibacterial activity of different types of honey (manuka honey from Australia, heather honey from the United Kingdom, and locally marketed Indian honey)., Methods: The agar dilution method was used to assess the antibacterial activity of honey against 152 isolates of Pseudomonas aeruginosa by determining minimum inhibitory concentrations., Results and Conclusions: The locally available (khadikraft) honey produced the best activity against Pseudomonas aeruginosa and was found to be better than all of the imported varieties of therapeutic honey.

Conclusion: A high prevalence of penicillin-binding protein gene-mutated (PGM) strains of Haemophilus influenzae should be taken into account when treating otitis media in children., Objective: To evaluate the prevalence of beta-lactamase-non-producing ampicillin-resistant strains of H. influenzae with mutations in the ftsI gene encoding penicillin-binding protein 3 (PBP3) among children with otitis media., Material and Methods: A total of 644 nasopharyngeal isolates of H. influenzae were collected from pediatric acute otitis media patients with or without otitis media with effusion at the clinics of the Department of Otolaryngology-Head and Neck Surgery, Wakayama Medical University Hospital and 6 affiliated hospitals in Wakayama Prefecture between January 1999 and December 2003. MICs to ampicillin (AMP), cefdinir (CFD), cefaclor (CCL), cefpodoxime (CPD) and cefcapene (CFPN) were determined by a microbroth dilution method according to the recommendations of the National Committee for Clinical Laboratory Standards. Types of mutations in the PBP3 gene (ftsI) were evaluated by means of a polymerase chain reaction (PCR)-based genotyping method. The beta-lactamase gene (bla) was also identified by means of PCR., Results: Beta-lactamase-producing (BLP) strains having the bla gene were identified in 16 isolates (2.5%). PGM strains were identified in 279 isolates (43.3%). There were 242 PGM1-non-BLP strains (37.6%) with mutations in the variable mutated locus of ftsI, 35 PGM2-non-BLP strains (5.4%) with mutations in the highly mutated locus of ftsI and 2 BLP-PGM strains (0.3%) with mutations in ftsI that produced beta-lactamase. BLP-non-PGM strains producing beta-lactamase without mutations in ftsI were identified in 14 isolates (2.2%). MICs of PGM1-non-BLP strains to AMP were 0.5-2.0 microg/ml. The MIC90 of CDN to the PGM1-non-BLP strains was the lowest (0.06 microg/ml). The proportion of PGM1-non-BLP strains increased rapidly during 1999-2002 and then decreased in 2003. In contrast, the proportion of PGM2-non-BLP strains increased in 2003.

Infection with methicillin-resistant Staphylococcus aureus (MRSA) is increasing. It may be community or hospital acquired and is characteristically difficult to eradicate. Here we report a case of a two-year-old girl who sustained a traumatic tympanic membrane perforation following a minor burns injury. She was seen as an out-patient in a burns unit and subsequently developed MRSA otorrhoea. This was treated with a two-week course of fusidic acid topical drops. At three-week follow up the tympanic membrane had healed and the infection had healed completely. Fusidic acid is safe and effective in the treatment of MRSA otorrhoea. We need to maintain vigilance in the treatment of otorrhoea, as MRSA may become an increasingly common pathogen in the future.

Acute otitis media (AOM) is treated with antibiotics in the United States, but the changing distribution of bacterial pathogens that cause the disorder can present physicians with several challenges. Most physicians treat AOM empirically, and their treatment choice should target Streptococcus pneumonia, nontypeable Haemophilus influenzae, and Moraxella catarrhalis, as those bacteria are most often isolated in AOM. First-line treatment for new onset AOM remains amoxicillin (80-90 mg/kg/d, divided twice daily). For persistent or recurrent AOM, guidelines recommend high-dose amoxicillin-clavulanate, cefdinir, cefprozil, cefpodoxime, cefuroxime, or ceftriaxone. Improved diagnosis and optimizing the choice of therapy by considering in vitro and in vivo efficacy of the different antibiotics will improve patient outcomes. Improved patient outcomes will result in fewer AOM episodes, decreased antibiotic resistance, and reduced direct and indirect health care costs.

Objective: To further understand the roles of bacteria and antibiotics in the development of otitis media with effusion (OME)., Methods: Samples of middle-ear effusion (MEE) were collected during the placement of ventilation tubes to treat chronic OME. Children with acute otitis media within the past three months were excluded from this study. We used polymerase chain reaction (PCR) to detect pathogens and to test the susceptibility of Streptococcus pneumoniae to penicillin., Results: Among MEE samples from 52 children, PCR detected bacterial DNA in 32 per cent (24/75) of them. S. pneumoniae was detected more frequently in middle ears that required ventilation tube insertion at least twice compared with those requiring ventilation tube insertion only once (5/15 versus 4/60; p = 0.013). Higher levels of S. pneumoniae were detected in MEE from children with, than without, a long history of antibiotic administration (7/10 versus 2/14; p = 0.0187). The pbp genes of all isolated S. pneumoniae contained mutations., Conclusions: Long exposure to antibiotics might significantly influence the bacterial genome in MEE.

This study analyzes the in vitro activities of levofloxacin and other commonly used antimicrobials against middle ear fluid, nasopharyngeal, and oropharyngeal pathogens obtained from children with otitis media at risk of having a resistant pathogen. Levofloxacin proved to be very active against these pathogens and had intermediate activity against Streptococcus pyogenes.

We investigated the association between prescribing antimicrobial agents and antimicrobial resistance of Streptococcus pneumoniae among children with acute otitis media in southern Israel. During a 6-year period, all prescriptions of a sample of approximately 20% of Jewish and Bedouin children <5 years of age were recorded and all pneumococcal isolates from middle ear fluid were collected. Although antimicrobial drug use was significantly higher in Bedouin children, the proportion of S. pneumoniae isolates with penicillin MIC = or > 1.0 microg/mL was significantly higher in Jewish children. In both populations, antimicrobial prescriptions were markedly reduced over time, especially for penicillins and erythromycin. In contrast, azithromycin prescriptions increased from 1998 to 2001 with a parallel increase in macrolide and multidrug resistance. Penicillin resistance was associated with macrolide resistance. These findings strongly suggest that azithromycin affects increased antimicrobial resistance, including multidrug resistance, in S. pneumoniae.

Otic exudate was obtained from 33 dogs with otitis externa for cytopathology and culture. Two samples were taken from the same location in the external ear canal, for a total of 100 samples. Thirty-six (36%) samples isolated only a single organism, of which 21 (21%) were Malassezia spp. Two organisms were present in 23 (23%) of the samples. Cultures of the two samples agreed in 40 (80%) of the 50 pairs. Cytopathology agreed with culture results only 68% of the time. Cytopathology and culture may not be as definitive as previously assumed because of apparent variability of the microbial population within the external canal.

Background: Because of the increasing number of resistant middle ear pathogens and the impact of the new conjugate Streptococcus pneumoniae vaccine, an active surveillance of the microbiology and susceptibility pattern of middle ear pathogens is required., Objective: To study the microbiology and susceptibility pattern of middle ear pathogens obtained from Costa Rican children with acute otitis media (AOM), recurrent otitis media (ROM) and therapeutic failure otitis media (FOM)., Methods: Between 1999 and 2001 middle ear fluid (MEF) was collected from 276 Costa Rican patients. S. pneumoniae serotyping and pulsed field gel electrophoresis analysis was done on available strains., Results: Among the total study population, 102 were AOM patients, 98 were ROM patients and 76 were FOM patients. Overall S. pneumoniae (88 strains) was the most common pathogen isolated followed by Haemophilus influenzae (41 strains) and Streptococcus pyogenes (10 strains). H. influenzae was the most common agent in FOM patients (P = 0.015). Beta-lactamase production was observed in 3 of 41 (7%) H. influenzae strains and 3 of 3 (100%) Moraxella catarrhalis strains. Penicillin-nonsusceptible S. pneumoniae strains were more common in FOM (64%) and ROM (63%) patients than in AOM (42%) patients (P = 0.05). S. pneumoniae serotype 19F was the most prevalent serotype, mainly within one distinct clone., Conclusions: Overall S. pneumoniae serotype 19F was the most common isolate from the middle ear fluid of Costa Rican children. Beta-lactamase-negative H. influenzae was the most prevalent in the subpopulation of patients with FOM. S. pyogenes was the third most common isolate and M. catarrhalis was uncommon.

The efficacy of amoxycillin-clavulanic acid (10 and 15 mg/kg amoxycillin) and erythromycin (20 and 50 mg/kg) was assessed in a gerbil model of otitis media with effusion induced by beta-lactamase-producing Haemophilus influenzae. Animals were divided into groups receiving acetaminophen concomitantly or not receiving it. Treatment started 2 h post-middle ear inoculation and continued t.i.d. for up to three doses. Middle ear samples were obtained on day 2 post-inoculation. Amoxycillin-clavulanic acid showed significantly higher efficacy than erythromycin, regardless of acetaminophen administration (P<0.05). Amoxycillin-clavulanic acid middle ear concentrations exceeded the amoxycillin MIC (1/0.5 microg/ml) by 1.88-fold, whereas erythromycin concentrations were below MIC level of 4 microg/ml. Animals receiving acetaminophen showed significantly fewer polymorphonuclear cells and more Haemophilus organisms in the middle ear exudate.

Objectives: (1) To determine the relationship between acute otitis media (AOM) pathogens isolated in cases of early clinical recurrence of AOM (occurring within 1 month from completion of therapy) to the original pathogens causing the initial AOM episode; and (2) To determine whether shorter time intervals between completion of antibiotic therapy and clinical recurrences of AOM are associated with higher rates of true bacteriologic relapse., Patients and Methods: From 1995 through 2000, 1077 infants and young children ages 3 to 36 months with AOM were enrolled in double tympanocentesis (performed on Day 1 in all patients and Days 4 to 6 in those initially culture-positive) studies. Of these, 834 (77%) completed successfully the antibiotic treatment [pathogen eradication on Days 4 to 6 of therapy or no pathogen on middle ear fluid (MEF) culture on Day 1 and clinical improvement at end of therapy]. Patients were followed for 3 to 4 weeks after completion of therapy, and additional MEF cultures were obtained if clinical recurrence occurred. True bacteriologic relapse was defined as the presence of a pathogen identical with that isolated before therapy by serotype and pulsed field gel electrophoresis for and by pulsed field gel electrophoresis for Streptococcus pneumoniae and beta-lactamase production for Haemophilus influenzae., Results: MEF cultures were performed in 108 consecutive patients with early recurrent AOM. One hundred pathogens were isolated at recurrence in 88 of 108 (81%) patients: 54 H. influenzae; 45 S. pneumoniae; and 1 Moraxella catarrhalis. Most recurrent AOM episodes developed during the first 2 weeks of follow-up; 39 (36%), 38 (35%), 21 (19%) and 10 (9%) recurrent AOM episodes occurred on Days 1 to 7, 8 to 14, 15 to 21 and 22 to 28 after completion of therapy, respectively. In most patients these episodes were caused by a new pathogen. True bacteriologic relapses were found in 30 (28%) of 108 patients whose MEF cultures were positive for 35 pathogens: 13 of 108 (12%) S. pneumoniae; 12 of 108 (11%) H. influenzae; and 5 of 108 (5%) both. When timing of recurrent AOM after completion of therapy was analyzed, true bacteriologic relapses were found in 16 of 39 (41%), 10 of 38 (26%), 3 of 21 (14%) and 1 of 10 (10%) of all episodes on Days 1 to 7, 8 to 14, 15 to 21 and 22 to 28 after completion of therapy, respectively (P = 0.01). The respective rates for were 11 of 17 (65%), 3 of 10 (30%), 3 of 13 (23%) and 1 of 5 (20%) (P = 0.02). For H. influenzae the respective rates were 8 of 19 (42%), 9 of 23 (39%), 0 of 8 (0%) and 0 of 4 (0%) (P = 0.02)., Conclusions: Most recurrent AOM episodes occurring within 1 month from completion of antibiotic therapy are in fact new infections. Most of the true bacteriologic AOM relapses occur within 14 days after completion of therapy, but even during this time interval most of the recurrences are caused by new pathogens. H. influenzae is very unlikely to cause true bacteriologic AOM relapses 14 days or later after completion of therapy.

Context: There is limited information on the identity and antibiotic susceptibility of bacterial pathogens in children with chronic otitis media whose repeated antibiotic use may place them at increased risk of antibiotic-resistant bacteria., Objective: To determine, at myringotomy for tympanostomy tube placement, (1) the prevalence of bacteria, (2) the extent and patterns of antibiotic resistance, and (3) the risk factors associated with the presence and resistant status of pathogens., Design: Prospective, multi-site, cohort study., Setting and Patients: Children undergoing myringotomy for tympanostomy tube placement between November 1, 1999 and March 31, 2000 in seven hospitals in Toronto, Ontario, were identified. If fluid was present, aspirates were submitted for bacteriologic testing. A follow-up telephone questionnaire was administered to patient caregivers in order to identify risk factors for the presence of (1) culturable pathogens and (2) resistant pathogens., Main Outcome Measures: The identification and prevalence of bacteria cultured from the middle ears of subjects, and the degree of nonsusceptibility to commonly prescribed antibiotics., Results: Among 601 patients (mean age 3.9 years, 60.7% male), both a telephone interview (n=544) and an ear specimen (n=527) were obtained for 478. Pathogens were found in middle ear effusions of 37% of the children in the study; including at least one 'definite' pathogen in 189 children (31.4%), and a further 32 children (5.3%) with at least one 'possible' pathogen. Definite pathogens included Haemophilus influenzae in 17% of the children, followed by Moraxella catarrhalis (9%) and Streptococcus pneumoniae (6%); ampicillin nonsusceptibility was found in 40, 100 and 24%, respectively. Overall, 123 children (20.5%) were found to have definite pathogens with resistance to ampicillin/penicillin, trimethoprim-sulfamethoxazole, or clarithromycin/erythromycin. Patient characteristics included premature birth and/or long length of stay in the nursery (23%), first infection before the age of 6 months (26%), put to bed with a bottle (28%), household smoker (34%), in out-of-home child care (38%), history of eczema, bronchiolitis and/or asthma (39%), and use of pacifiers (40%). Household characteristics were smoking (34%), married/common law parents (85%), and 60% had completed college or university; in 26% both parents were born outside of Canada; 73% of children were Caucasian. Of the 75% who responded to the question regarding income, 42% had household income over $60,000 (CAN). Risk factors for the presence of a pathogen and for a resistant pathogen in multivariate analysis included younger age, lower maternal education, day care centre attendance, no previous adenoidectomy and bilateral, primarily winter infections as well as amoxicillin use in the previous 6 months., Conclusion: Modifiable risk factors for otitis media including household smoking and pacifier use are present in many children undergoing tympanostomy tube placement; child care centre attendees are over-represented. Multiple antibiotic courses were commonly prescribed prior to surgery. H. influenzae and M. catarrhalis are important pathogens and therapy in clinical failures should be directed against them. The 7-valent protein conjugate polysaccharide vaccine (Prevnar) would have covered 73% of the serotypes of S. pneumoniae isolated in this study.

We compared the outcomes of two different regimens--azithromycin and pseudoephedrine hydrochloride (PHCl)--for the treatment of otitis media with effusion (OME) in children. In a double-blind randomized clinical study, a total of 90 children aged between 2 and 13 years with persistent OME were randomly assigned to one of 3 treatment groups. The first group received azithromycin at a dose of 10 mg/kg once daily for 3 days and this regimen was repeated weekly for up to 12 weeks according to the results of tympanometry and pneumatic otoscopy. The second group received azithromycin at a dose of 10 mg/kg once daily for 3 days for the first week, and this regimen was repeated for 1 day a week for the following 11 weeks. The third group received PHCl, 4 mg/kg, 3 times daily for up to 12 weeks. Each patient underwent pneumatic otoscopic and tympanometric investigations at baseline and at Weeks 4, 8 and 12. The outcomes in the azithromycin-treated groups were superior to that in the decongestant group. However, the difference between the outcomes in the azithromycin groups according to the treatment protocol was not statistically significant. Azithromycin therapy, particularly a once-weekly regimen, helps patients to comply with treatment and also helps us to achieve good results with minimal therapy.

Objective: We studied the microbiological epidemiology of tympanostomy tube otorrhea, rifamycin and ofloxacin sensitivity of pathogens isolated from these otorrheas, and the bactericidal power of the rifamycine-ofloxacin combination., Material and Methods: A prospective study was conducted in 1997 with cultures of otorrhea aspirates, in vitro study of pathogen resistance to rifamycin and ofloxacin, bacteriocidal study of the rifamycin-ofloxacin combination., Results: One hundred eight aspirates were obtained from 98 children (mean age 5 years). Ten aspirates were sterile, 32 had more than one pathogen. The more frequent pathogens were Pseudomonas aeruginosa (Pa) (n=35), Staphylococcus aureus (Sa) (n=27), Haemophilus influenae (Hi) (n=12) and Streptococcus pneumoniae (Sp) (n=9). All Hi, all Sp, 86.3% of the Sa (MIC(90) 0.25 mg/l) and none of the Pa were rifamycin sensitive. All Hi, 97.7% of the Pa (MIC(90) 0.5 mg/l), 73,1% of the Sa (MIC(90) 0.24 mg/l) and none of the Sp were ofloxacin sensitive. The rifamycin-ofloxacin combination led to a 4 log CFU/ml decrease in 6 hours for Sp, and in 24 hours for Pa, Hi and Sa., Conclusion: The rifamycin-ofloxacin combination is bactericidal for bacteria causing tympanostomy tube otorrhea. Otic drops with this combination should be considered as the first line treatment for such otorrhea.

Acute otitis media (AOM) is the most common disease for which pediatricians prescribe antimicrobial agents. Middle ear fluid were collected from 243 children with AOM that failed to respond to a previous course of antimicrobial therapy and who had then received myringotomy from September 1997 through August 1999. Bacterial cultures were done and antimicrobial susceptibilities were analyzed. Streptococcus pneumoniae (21.8%) was the most common causative organism, followed by Haemophilus influenzae (10.2%), Staphylococcus aureus (7%), and Pseudomonas aeruginosa (1.8%), while Moraxella catarrhalis (0.7%) and group A beta-hemolytic streptococcus (0.2%) were rarely isolated. In patients whose condition failed to improve after a course of antibiotic treatment, drug resistance became a serious problem. Fourteen percent of the patients in this series had complications, which included recurrent AOM, persistent middle ear effusion necessitating ventilation tube insertion, hearing impairment, mastoiditis, meningitis, chronic otitis media, brain abscess, and sepsis. Possible risk factors such as young age, male sex, underlying diseases, and a culture of S. pneumoniae or H. influenzae were not significantly associated with an increased incidence of complications. More stringent diagnosis and the correct choice of antibiotic treatment combined with the introduction of potential virus and bacterial vaccines are promising ways to reduce the morbidity of AOM in children.

Otitis media is currently the most common diagnosis made by clinicians, which has a major impact on managed care. The emergence of resistant bacterial pathogens has caused controversy over the use of antibiotics when acute otitis media (AOM) is diagnosed. All infants with AOM and all older children with severe AOM should be treated with antibiotics, despite concerns about rising rates of resistant bacterial pathogens. Some older children with nonsevere AOM may be candidates for initial observation, although this is not confirmed by clinical trials. Antimicrobial agents are not required for otitis media with effusion of recent onset but may be considered if this effusion becomes chronic; in these cases, tympanostomy tube placement may be indicated. Antimicrobial prophylaxis for prevention of recurrent AOM should be reserved for selected patients because of the possible emergence of resistant organisms. Tympanostomy tube placement is a more reasonable option today.

Objective: To compare 5-, 7- and 10-day duration of antibiotic therapy for acute otitis media (AOM) in children., Study Design and Setting: Prospective nonrandomized 1-year evaluation of 3 treatment durations for AOM in a private pediatric setting. Outcomes assessed at 14 +/- 4 days after start of therapy with clinical response categorized as cure, improvement, or failure., Results: A total of 2172 children were studied; 46.4% were < or =2-years-old. Antibiotics used were amoxicillin (61.9% of patients), trimethoprim/sulfamethoxazole (11.7%), cephalosporins (14.2%), amoxicillin/clavulanate (5.2%), and macrolides/azalides (4.8%). No overall difference in outcome was observed comparing the 5-day (n = 707), 7-day (n = 423), or 10-day (n = 1042) treatments, including children < or =2-years-old. However, in the subset who had an episode of AOM in the preceding month, outcome differed; 5-day treatment was followed by more frequent failure than 10-day treatment (P < 0.001). In logistic regression analysis, variables identified as contributing to a cure were: >2-years-old (P < 0.0001), no AOM in the preceding month (P = 0.07), or preceding 12 months (P = 0.03)., Conclusions: Our study supports the transition from 10 to 5 days for standard AOM antibiotic treatment duration in most patients. A 10-day regimen may be superior in children who have experienced an episode of AOM within the preceding month, a known risk factor for resistant bacterial infection in the otitis-prone patient.