Nonsusceptible Streptococcus pneumoniae in children with chronic otitis media with effusion and recurrent otitis media undergoing ventilating tube placement

Evaluation of serotypes of Streptococcus pneumoniae isolated from otitis media patients by multiplex polymerase chain reaction

The increasing difficulty in the management of pneumococcal acute otitis media in parallel with increases in antimicrobial-resistant strains has led to much interest in pneumococcal capsular types for the adoption of effective prevention by vaccines. This study shows that multiplex polymerase chain reaction is a valuable and expeditious method for the capsular typing of pneumococci. The multiplex polymerase chain reaction method accurately detects the majority of serotypes and serogroups frequently isolated from pediatric patients with acute otitis media, allowing the characterization of the colonization patterns for further implications of pneumococcal vaccines.

Effect of pneumococcal vaccination on quality of life in children with recurrent acute otitis media: a randomized, controlled trial

BACKGROUND

Limited effectiveness of current treatment strategies for recurrent acute otitis media (RAOM) and increasing antibiotic resistance have diverted attention to prevention of AOM by vaccination. Pneumococcal vaccination for AOM seems to have only modest clinical efficacy. Thus far, the effects on health-related quality of life (HRQoL) or functional health status (FHS) have not been studied.

OBJECTIVE

To assess the effect of vaccination on HRQoL or FHS.

METHODS

In a double-blind, randomized, controlled trial, 383 children 1 to 7 years old with RAOM were vaccinated with either heptavalent pneumococcal conjugate vaccine followed by pneumococcal polysaccharide vaccine (pneumococcal group: n = 190) or with hepatitis A or B vaccines (control group: n = 193). Parents completed validated Dutch versions of 8 HRQoL and FHS instruments assessing generic FHS (Rand, Functional Status Questionnaire specific, and Functional Status Questionnaire generic), otitis media-specific FHS (OM-6), otitis media-specific child HRQoL (Numerical Rating Scale for Child), family functioning (Family Functioning Questionnaire), and otitis media-specific caregiver HRQoL (Numerical Rating Scale for Caregiver). Scores were compared at baseline and at 14 and 26 months' follow-up.

RESULTS

At baseline, the average AOM incidence in the pneumococcal and control group was 5.0 (SD: 2.8) and 4.9 (SD: 2.6) episodes per year, respectively, with 38.4% and 36.8% having suffered from > or =6 episodes per year. AOM frequency decreased 4.4 episodes per year in both groups, with a considerable and comparable improvement in HRQoL and FHS. No substantial differences in HRQoL or FHS were found between the pneumococcal and the control group at baseline or at 14 or 26 months' follow-up.

CONCLUSION

Pneumococcal vaccination has no beneficial effect compared with control vaccination on either HRQoL or FHS in children 1 to 7 years old with RAOM.

Effect of myringotomy on prognosis in pediatric acute otitis media

OBJECTIVE

In children with acute otitis media (AOM), we compared clinical outcomes between groups with and without myringotomy to elucidate the effect of this procedure on long-term clinical course and prognosis.

METHODS

Fifty-nine children (29 male, 30 female) with tympanic membrane bulging or middle ear fluid (MEF) at initial presentation were assigned to one of two treatment groups. Group A received oral antibiotics and also underwent myringotomy at initial enrollment (36 cases), while group B received oral antibiotics without myringotomy (23 cases). Clinical outcomes were evaluated by otolaryngologic specialists using pneumatic otoscopy and tympanometry at 5, 10, 15, 30 days and 12 weeks and then every 2 weeks after the initial treatment. Otitis media with effusion (OME), early recurrence and recurrent AOM were used as the evaluation criteria for the prognosis.

RESULTS

In group A, 6 children (16.7%) showed transition to OME, 11 (30.6%) showed early recurrence of AOM, and 9 (25.0%) developed recurrent AOM. In group B 10, 8, and 3 (43.5%, 34.8%, and 13.0%) showed these respective adverse outcomes. While early recurrence rates and recurrent AOM rates did not differ significantly between groups, progression of OME was significantly less frequent in group A than group B (P = 0.036).

CONCLUSIONS

Lower rates of progression to OME in the group undergoing myringotomy suggested that myringotomy might be effective in preventing this outcome.

Differences in nasopharyngeal bacterial flora in children with nonsevere recurrent acute otitis media and chronic otitis media with effusion: implications for management

BACKGROUND

The interactions between nasopharyngeal flora and the individual entities covered by the broad term otitis media have not been completely elucidated. We investigated in infants and children ages 6 months to 7 years with nonsevere recurrent acute otitis media (rAOM) or with chronic otitis media with effusion (cOME): (1) the nasopharyngeal carriage rate and bacterial density of respiratory pathogens and alpha-hemolytic streptococci in comparison with healthy children; (2) the resistance pattern of respiratory pathogens; and (3) the relationship between the type of nasopharyngeal colonization and long term outcome.

METHODS

Nasopharyngeal cultures were obtained from 85 children with rAOM,113 children with cOME and 55 controls. A semiquantitative analysis was used in the reading of cultures. A 12-week follow-up without treatment was planned.

RESULTS

The carrier rate of respiratory pathogens was significantly greater in cOME (70%) than in rAOM (45%) (P = 0.0006) or controls (31%) (P < 0.0001). Similarly colonization density was significantly greater in cOME than in rAOM. The carriage rate and the colonization density of alpha-hemolytic streptococci were significantly lower in rAOM than in cOME or controls. The incidence of resistant (R) strains was greater in rAOM (Streptococcus pneumoniae penicillin-R, 24%; macrolide-R, 64%; Haemophilus influenzae amoxicillin-R, 24%) compared with cOME (S. pneumoniae penicillin-R,18%; macrolide-R, 44%; H. influenzae amoxicillin-R, 5%) or controls (S. pneumoniae penicillin-R, 8%; macrolide-R, 23%; H. influenzae amoxicillin-R, 10%). During the follow-up period persistence of OME and occurrence of AOM were greater among carriers of respiratory pathogens at baseline.

CONCLUSIONS

There are substantial differences in nasopharyngeal flora between children with nonsevere rAOM and children with cOME. The results of nasopharyngeal cultures should be taken into account to avoid treatment with drugs that are ineffective and likely to select resistant organisms.

Microbiologic findings and risk factors for antimicrobial resistance at myringotomy for tympanostomy tube placement--a prospective study of 601 children in Toronto

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.

beta-Lactamase-producing Moraxella catarrhalis may prevent the emergence of penicillin-resistant Streptococcus pneumoniae in children with recurrent acute otitis media

We studied the effect of concomitant nasopharyngeal carriage of beta-lactamase producing Moraxella catarrhalis and Haemophilus influenzae on the occurrence of penicillin resistance of Streptococcus pneumoniae. We took nasopharyngeal samples from 306 children with recurrent otitis media and a history of several antibiotic treatments. We could isolate at least one of the pathogens in 89 subjects. Of these children 13% carried more than one pathogen. Of the isolated M. catarrhalis and H. influenzae strains 93% and 43% produced beta-lactamase, respectively. Of the S. pneumoniae strains 25% were non-susceptible (I/R) to penicillin. However, in patients carrying beta-lactamase-producing M. catarrhalis together with pneumococci all strains were susceptible to penicillin (P=0.0353). This finding suggests that beta-lactamase producing M. catarrhalis may hinder the emergence of penicillin resistance of S. pneumoniae in children with recurrent acute otitis media.