How common is otogenic meningitis? A retrospective study in southern Sweden over 18 years.

BACKGROUND: Bacterial meningitis is a rare, but life-threatening disease, which sometimes occurs as a complication to acute otitis media (AOM). The proportion of meningitis cases originating from AOM is not clear. PURPOSE: The aim of this study was to investigate the proportion of meningitis cases caused by AOM, to compare risk factors, bacteriology and outcome between otogenic and non-otogenic meningitis, and to analyse the incidence of bacterial meningitis after the introduction of conjugate pneumococcal vaccines (PCV). METHODS: The medical charts of all patients admitted to hospitals in southern Sweden with bacterial meningitis between 2000 and 2017 were retrieved. Based on otoscopy and/or imaging, the proportion of otogenic meningitis cases was calculated, as were annual incidences. RESULTS: A total of 216 patients were identified, 25 of whom died. The proportion of otogenic meningitis was 31% but varied from 6% among teenagers to 40% among adults. Before PCV, 23% of all meningitis cases were children < 2 years, compared to 1% post-PCV. The average incidence in the adult population, on the other hand, increased post-PCV, though there were large annual variations. S. pneumoniae was the most commonly identified pathogen in everyone but teenagers, in whom N. meningitidis was predominant. CONCLUSION: AOM is an important cause of meningitis in children and adults. Though bacterial meningitis almost disappeared in children < 2 years after the introduction of PCV, the incidence of pneumococcal meningitis in adults seems to have increased.

Panel 1: Epidemiology and global health, including child development, sequelae and complications.

OBJECTIVE: To summarise the published research evidence on the epidemiology of otitis media, including the risk factors and sequelae associated with this condition. DATA SOURCES: Medline (PubMed), Embase, and the Cochrane Library covering the period from 2019 to June 1st, 2023. REVIEW METHODS: We conducted a broad search strategy using otitis [Medical Subject Heading] combined with text words to identify relevant articles on the prevalence, incidence, risk factors, complications, and sequelae for acute otitis media, otitis media with effusion, and chronic suppurative otitis media. At least one review author independently screened titles and abstracts of the retrieved records for each condition to determine whether the research study was eligible for inclusion. Any discrepancies were resolved by reviewing the full text followed by discussion with a second review author. Studies with more than 100 participants were prioritised. RESULTS: Over 2,000 papers on otitis media (OM) have been published since 2019. Our review has highlighted around 100 of these publications. While the amount of otitis media research on the Medline database published each year has not increased, there has been an increase in epidemiological studies using routinely collected data and systematic review methodology. Most of the large incidence studies have addressed acute otitis media (AOM) in children. Several studies have described a decrease in incidence of AOM after the introduction of conjugate PCV vaccines. Similarly, a decrease was noted when rates of coronavirus disease of 2019 (COVID-19) were high and there were major public health efforts to reduce the spread of infection. There have been new studies on OM in adults and OM prevalence in a broader range of countries and population subgroups. CONCLUSION: Overall, the rates of severe and/or suppurative OM appeared to be decreasing. However, there is substantial heterogeneity between populations. While better use of available data is informative, it can be difficult to predict rates of severe disease without accurate examination findings. Most memorably, the COVID-19 pandemic had an enormous impact on the research and clinical services for otitis media for most of the period under review. IMPLICATIONS FOR PRACTICE: The use of routinely collected data for epidemiological studies will lead to greater variability in the definitions and diagnostic criteria used. The impact of new vaccines will continue to be important. Some of the lessons learned during the COVID-19 pandemic concerning behaviours that reduce spread of respiratory viruses can hopefully be used to decrease the burden of otitis media in the future. There are still many countries in the world where the burden of otitis media is not well described. In countries where otitis media has been studied over many years, new potential risk factors continue to be identified. In addition, a better understanding of the disease in specific subgroups has been achieved.

Hearing loss after bacterial meningitis, a retrospective study.

BACKGROUND: Hearing loss is a common sequela after bacterial meningitis, but risk factors for this are poorly studied, particularly in relation to concurrent acute otitis media (AOM). AIMS: The aim of this study was to investigate incidence and risk factors for hearing loss in patients treated for bacterial meningitis. METHODS: In this retrospective study, medical records for patients admitted to hospital with bacterial meningitis in Skåne county, Sweden, between 2000 and 2017 were retrieved. The association between risk factors and hearing loss was estimated using logistic regression. RESULTS: During the 18 years, 187 cases of meningitis were identified. Hearing loss was confirmed in 71 of the 119 patients who had done an audiometry. It was significantly more common in adults. There was also evidence of an association between hearing loss and AOM, and between hearing loss and pneumococcal infection. CONCLUSION: Age, concurrent AOM and pneumococcal infection were risk factors for developing hearing loss. Despite being recommended in the national guidelines, more than a third of the patients had not done a hearing test after recovering from bacterial meningitis. The findings strengthen the demand for prompt ear examination and - if needed - tympanocentesis in meningitis patients.

Pneumococcal vaccination in children at risk of developing recurrent acute otitis media - a randomized study.

AIM: Acute otitis media (AOM) is a common childhood disease, which often becomes recurrent (rAOM). A small reduction in AOM episodes has been noted in unselected child cohorts after vaccination with heptavalent conjugate pneumococcal vaccine (PCV7). The purpose of this study was to investigate how vaccination affects young children at risk of developing rAOM. METHODS: Ninety-six children with an AOM onset before 6 months of age, implying a high risk for rAOM, were closely monitored until the age of 2 years. Forty-six were vaccinated with PCV7 and 50 were not. All episodes of AOM, emergency visits and ventilation tube insertions were registered. RESULTS: A total of 363 AOM episodes were diagnosed. The incidence was reduced by 26% (p = 0.03), the number of emergency visits because of suspected AOM by 36% (p = 0.01) and the proportion of children who received ventilation tubes was halved in the vaccine group (p = 0.02). CONCLUSIONS: During the first 2 years of life, PCV7 significantly reduced AOM episodes, emergency visits and ventilation tube insertions in children with rAOM. Pneumococcal vaccine may be a future route to reduce antibiotic use and health care consumption in otitis-prone children.

Nasopharyngeal cultures in children with AOM - A retrospective study on bacteriological findings and impact on management.

BACKGROUND: Despite a far from perfect correlation with middle ear growth, nasopharyngeal cultures are sometimes used in children with acute otitis media (AOM) in order to have some idea of the causative pathogen. How these cultures are used in clinical practice and to what extent they influence clinical management has not previously been studied. The objective with this study was to investigate in what circumstances nasopharyngeal cultures are performed in children with AOM, what the bacteriological results are and to what extent cultures influence clinical management. METHODS: All nasopharyngeal cultures taken in clinical practice from children with AOM in the county of Skåne, Sweden, during 2017-2018 were retrieved together with details from the medical charts two months prior to and one month after the culture. Information about the reason for culturing, the bacteriological result, and whether this result changed the management of the child, was retrieved from the charts. RESULTS: During the 2 years, 978 nasopharyngeal cultures were taken in children with AOM. The most common reasons for obtaining a culture was a recurrence of AOM (40%) or treatment failure (22%). Many of the children had ongoing or recent antibiotic treatment. M. catarrhalis was the most commonly identified pathogen (53%), followed by H. influenzae (30%) and S. pneumoniae (14%). Resistance rates were low, and the most commonly identified resistant pathogen was betalactamase-negative ampicillin-resistant H. influenzae. One in five cultures led to a change in management, such as a change of antibiotics or an additional check-up. This was most commonly seen in association with H. influenzae, reflecting clinical practice in Sweden, where AOM is primarily treated with penicillin V. CONCLUSION: Despite not having a perfect correlation with middle ear growth, nasopharyngeal cultures can provide clues about suitable alternative antibiotics in cases of treatment failure, and they can help monitoring nasopharyngeal carriage and resistance rates.

Nasopharyngeal cultures in children; when, what and why?

INTRODUCTION: Nasopharyngeal cultures are commonly used to determine the causative bacteria in upper airway infections. However, several bacteria can occupy the nasopharynx simultaneously and most healthy children are asymptomatic carriers of presumptive pathogens. This makes the interpretation of nasopharyngeal cultures difficult. Knowledge about which bacteria reside in the nasopharynx can assist the physician in the choice of antibiotic treatment and might also predict the risk of complications. Today, little is known about how nasopharyngeal cultures are being used in clinical practice. OBJECTIVES: The aim of this study was to explore how nasopharyngeal cultures are used in clinical practice, when and why they are performed, what they show, and what impact they have on the treatment of the patient. METHODS: The results of all nasopharyngeal cultures taken from children aged 0-12 years in the county of Skåne, Sweden, during 2018 were obtained. Medical charts from hospitals and primary care centres were used to determine why the cultures were taken and whether they resulted in a change of treatment. RESULTS: During 2018, 2200 nasopharyngeal cultures were taken, most of them during the winter season. Forty-one percent of children had on-going antibiotic treatment or had been treated with antibiotics in the previous two months. Acute otitis media (AOM) was the most common reason for taking a culture. The most frequently identified bacteria were Moraxella catarrhalis and Haemophilus influenzae. There was a positive correlation between M. catarrhalis on one hand and Streptococcus pneumoniae and H. influenzae on the other. Overall, bacterial resistance was rare. The presence of beta-lactamase negative ampicillin resistant H. influenzae was associated with recent or on-going antibiotics, whereas S. pneumoniae with decreased penicillin susceptibility were found less frequently in the same group of children. A positive culture resulted in a change of treatment in 29% of the cases. CONCLUSION: Apart from playing a confirmatory role and monitoring the incidence of resistant bacteria, almost a third of the nasopharyngeal cultures analysed in this study contributed to decision-making. It therefore appears that bacterial sampling have a role in clinical practice. It would be valuable to study more closely why nasopharyngeal cultures are taken in during AOM and how the result affects the treatment.

Panel 1: Biotechnology, biomedical engineering and new models of otitis media.

OBJECTIVE: To summarize recently published key articles on the topics of biomedical engineering, biotechnology and new models in relation to otitis media (OM). DATA SOURCES: Electronic databases: PubMed, Ovid Medline, Cochrane Library and Clinical Evidence (BMJ Publishing). REVIEW METHODS: Articles on biomedical engineering, biotechnology, material science, mechanical and animal models in OM published between May 2015 and May 2019 were identified and subjected to review. A total of 132 articles were ultimately included. RESULTS: New imaging technologies for the tympanic membrane (TM) and the middle ear cavity are being developed to assess TM thickness, identify biofilms and differentiate types of middle ear effusions. Artificial intelligence (AI) has been applied to train software programs to diagnose OM with a high degree of certainty. Genetically modified mice models for OM have further investigated what predisposes some individuals to OM and consequent hearing loss. New vaccine candidates protecting against major otopathogens are being explored and developed, especially combined vaccines, targeting more than one pathogen. Transcutaneous vaccination against non-typeable Haemophilus influenzae has been successfully tried in a chinchilla model. In terms of treatment, novel technologies for trans-tympanic drug delivery are entering the clinical domain. Various growth factors and grafting materials aimed at improving healing of TM perforations show promising results in animal models. CONCLUSION: New technologies and AI applications to improve the diagnosis of OM have shown promise in pre-clinical models and are gradually entering the clinical domain. So are novel vaccines and drug delivery approaches that may allow local treatment of OM. IMPLICATIONS FOR PRACTICE: New diagnostic methods, potential vaccine candidates and the novel trans-tympanic drug delivery show promising results, but are not yet adapted to clinical use.

Quality of life in Swedish children receiving grommets - An analysis of pre- and postoperative results based on a national quality register.

BACKGROUND: Otitis media with effusion (OME) and recurrent otitis media (rAOM) are two common diagnoses in childhood, both of which are treated with grommets, or ventilation tubes. It is known that affected children have a worse quality of life (QoL), and various questionnaires have been used to evaluate this. The national Swedish quality register for grommet insertions contains some QoL questions that have hitherto never been analysed. METHODS: Data from 2010 to 2016 was extracted from the register and analysed with regards to QoL questions, reasons for surgery, hearing levels and number of AOM episodes. RESULTS: Preoperative QoL data was available for 3835 children. Before surgery, most parents felt that the QoL of their children was negatively affected by the ear disease. Parents of children with OME were more likely to suspect that their child had a hearing loss (ORs 10.1 and 28.2 for suspecting a mild and severe hearing loss, respectively), but less likely to find that the ear disease affected the child's general wellbeing than did parents of children with rAOM (ORs 0.54 and 0.33 for somewhat and much affected, respectively). Many children underwent surgery despite not fulfilling the criteria for surgery as stipulated in the national guidelines. Those who did fulfil criteria, however, had a more severely affected QoL. A significant improvement was seen in individual QoL scores after surgery (p < 0.001). The degree of postoperative improvement in pure tone average correlated with the improvement in QoL (p < 0.001). CONCLUSION: This is the first time that the QoL aspect has been analysed in the Swedish grommet register. Though the validity of the questions has not been proven, they provide valuable information. The relevance of the surgical criteria in national guidelines is illustrated by their correlation with the QoL questions, particularly for OME, and the postoperative improvement in QoL suggests parents find that their children benefit from surgery.

The Swedish grommet register - Hearing results and adherence to guidelines.

OBJECTIVES: The insertion of grommets is one of the most commonly performed surgical procedures in children. The underlying reason might be otitis media with effusion (OME) with concomitant hearing loss, recurrent acute otitis media (rAOM) or a combination of the two. Sweden has a national quality register for children receiving grommets with the purpose of evaluating how treatment guidelines are followed, and if surgery confers good quality health care. The purpose of this study was to investigate the circumstances during which Swedish children receive grommets and to examine how doctors follow the guidelines for grommet surgery. METHODS: Quality register data was extracted from 2010 to 2016, and information on reasons for surgery, audiometry, number of AOM episodes, type of grommet etc was analysed. RESULTS: The dominating reason for surgery was OME (71%). A large proportion (27%) of children with OME had not undergone a preoperative audiometry, despite national guidelines stating that it is hearing impairment that calls for surgery. Furthermore, among those who had done audiometry, 47% did not have a hearing impairment as measured by pure tone average. Nevertheless, a significant hearing improvement (11 dB, p < 0.001) was seen on post-operative follow-ups in those children who underwent audiometry. Forty-four percent of children operated due to rAOM had had fewer episodes of AOM than recommended as an indication for surgery, though this figure should be interpreted with caution as GP diagnosed episodes are not entered in the register. CONCLUSION: Even though grommet insertions are quick and confer a low per-operative risk, it seems many children undergo surgery without a clear indication. This puts them at an unnecessary risk of per-operative as well as long-term complications. Since the procedure is so common, it also means large sums of money are spent on operations that might not be necessary.

Trends in Otitis Media Incidence After Conjugate Pneumococcal Vaccination: A National Observational Study.

BACKGROUND: Pneumococcal conjugate vaccine (PCV) was introduced in 2000. The first 7-valent vaccine (PCV7) was followed by a 13-valent vaccine (PCV13) with the same conjugate, and a 10-valent vaccine (PCV10), conjugated to protein D from Haemophilus influenzae. The vaccines offer some protection against pneumococcal acute otitis media (AOM), and, with PCV10, possibly also some protection against H. influenzae AOM. PCV7 was introduced in Sweden in 2009, but from 2010, Swedish counties were free to use either PCV13 or PCV10. The purpose of this study was to investigate the incidence of AOM-related diagnoses and surgical procedures before and after the introduction of PCV in Sweden, but also to compare the areas using PCV13 and PCV10. METHODS: Data showing the number of AOM diagnoses, ventilation tube insertions, myringotomies, acute mastoiditis cases and mastoidectomies between 2005 and 2014 were extracted from the National Board of Health and Welfare database. Yearly national incidences were calculated, and areas using PCV13 and PCV10 were compared. RESULTS: AOM incidence decreased, both in outpatients (39%) and hospital admissions (42%). Ventilation tube insertions decreased by 18%, and myringotomies by 15%. The decline in outpatient AOM and ventilation tube insertions was more pronounced in areas that used PCV10, but geographical differences were large also before vaccine introduction. CONCLUSION: Otitis media-related diagnoses have decreased in Sweden since the introduction of PCV. Though some decreases were more pronounced in areas where PCV10 were used, figures should be interpreted with great caution, because considerable geographical differences were obvious also before vaccine introduction.

Panel 7: Otitis Media: Treatment and Complications.

Objective We aimed to summarize key articles published between 2011 and 2015 on the treatment of (recurrent) acute otitis media, otitis media with effusion, tympanostomy tube otorrhea, chronic suppurative otitis media and complications of otitis media, and their implications for clinical practice. Data Sources PubMed, Ovid Medline, the Cochrane Library, and Clinical Evidence (BMJ Publishing). Review Methods All types of articles related to otitis media treatment and complications between June 2011 and March 2015 were identified. A total of 1122 potential related articles were reviewed by the panel members; 118 relevant articles were ultimately included in this summary. Conclusions Recent literature and guidelines emphasize accurate diagnosis of acute otitis media and optimal management of ear pain. Watchful waiting is optional in mild to moderate acute otitis media; antibiotics do shorten symptoms and duration of middle ear effusion. The additive benefit of adenoidectomy to tympanostomy tubes in recurrent acute otitis media and otitis media with effusion is controversial and age dependent. Topical antibiotic is the treatment of choice in acute tube otorrhea. Symptomatic hearing loss due to persistent otitis media with effusion is best treated with tympanostomy tubes. Novel molecular and biomaterial treatments as adjuvants to surgical closure of eardrum perforations seem promising. There is insufficient evidence to support the use of complementary and alternative treatments. Implications for Practice Emphasis on accurate diagnosis of otitis media, in its various forms, is important to reduce overdiagnosis, overtreatment, and antibiotic resistance. Children at risk for otitis media and its complications deserve special attention.

Individual-level effects of antibiotics on colonizing otitis pathogens in the nasopharynx.

BACKGROUND: Although there is evidence of an association between antibiotic consumption and resistant bacteria on a population level, the relationship on an individual level has been less well studied, particularly in terms of nasopharyngeal colonization. We have therefore analysed this association, using data from a closely followed cohort of children taking part in a vaccination trial. METHODS: 109 children with early onset of acute otitis media (AOM) were randomised to heptavalent pneumococcal conjugate vaccine (PCV7) or no vaccination. They were followed for three years with scheduled appointments as well as sick visits. Nasopharyngeal cultures were obtained at all visits. Antibiotic treatments were recorded, as were risk factors for AOM, including siblings, short breast-feeding and parental smoking. Data were entered into a Cox regression model, and the findings of Streptococcus pneumoniae and Haemophilus influenzae with reduced susceptibility to the penicillin group were related to the number of previous courses of antibiotics. RESULTS: There was evidence of an association between the amount of previously consumed betalactams and colonization with beta-lactamasenegative ampicillin-resistant (BLNAR) H. influenzae (RR 1.21; 95% CI 1.03-1.43; p = 0.03), and also with the most commonly prescribed drug; amoxicillin (RR 1.39; 95% CI 1.09-1.76; p = 0.01). There was no evidence for an association between antibiotic consumption and betalactamase producing H. influenzae or S. pneumoniae with reduced susceptibility to penicillin. Furthermore, there was no evidence of an association between resistant bacteria and AOM risk factors or PCV7. CONCLUSION: In this subgroup of children, most of whom were given several courses of antibiotics in early childhood, there was evidence of an association between betalactam/amoxicillin consumption and nasopharyngeal colonization with BLNAR strains, bacteria that have increased in prevalence during the last 10-15 years, and that are notoriously difficult to treat with oral antibiotics.

Acute otitis media in children-current treatment and prevention.

Acute otitis media (AOM) is the most common bacterial infection in children and has a very varied clinical spectrum, ranging from spontaneous resolutions to serious complications. The effect of antibiotics in AOM depends on the chosen outcome, but has been shown to reduce pain somewhat, and have a greater beneficial effect in severe cases of AOM. Today, not all episodes of AOM are treated with antibiotics, but most countries have issued guidelines that include an option of watchful waiting in many cases. Prevention of AOM reaches from modification of environmental risk factors to vaccinations and surgery. Conjugate pneumococcal vaccines and influenza vaccines have been shown to somewhat reduce the number of AOM episodes in different groups of children. Grommets, with or without adenoidectomy, are effective at least during the first 6 months after surgery.

Effect of pneumococcal conjugate vaccination on nasopharyngeal carriage in children with early onset of acute otitis media - a randomized controlled trial.

CONCLUSION: Although children vaccinated with heptavalent pneumococcal conjugate vaccine (PCV) had fewer episodes of acute otitis media (AOM), this trial was unable to prove a simultaneous decrease in nasopharyngeal carriage. OBJECTIVE: Carriage rates of AOM pathogens in the nasopharynx are high among children, and colonization is the first step towards infection. The possible impact of PCV on carriage is therefore of interest, particularly in children with recurrent AOM. The aims of this study were to examine the effect of heptavalent PCV on carriage of AOM pathogens in children at high risk of developing recurrent disease, and to monitor carriage of resistant pathogens in vaccinated and unvaccinated children. METHODS: A total of 109 children with an onset of AOM before 6 months of age, 89 of whom developed recurrent disease, were enrolled in a trial. Fifty-two children were vaccinated and all were closely monitored for 3 years. RESULTS: There was no difference statistically between vaccinated children and controls concerning the carriage of any of the major AOM pathogens. There was evidence of within-child clustering for S. pneumoniae (p = 0.002) and H. influenzae (p < 0.001), indicating that children continued to carry either species over time. Resistance rates were generally low and comparable with national levels.

The importance of being specific--a meta-analysis evaluating the effect of antibiotics in acute otitis media.

BACKGROUND: Whether acute otitis media (AOM) should be the cause for antibiotic treatment has been a matter of debate during the last decades. Treatment guidelines are based on less than twenty trials that have found the effect of antibiotics on symptomatic outcomes in AOM, such as pain, to be very modest. Two recent trials found a more substantial effect of antibiotics when they looked at treatment failure as the outcome. That the effect varies with the chosen outcome may not only be because the true effect is different but also because different outcomes are more or less specific for the disease in question. OBJECTIVE: The purpose of this study was to perform a meta-analysis to calculate a composite risk ratio for treatment failure in AOM and also to investigate whether the specificity of treatment failure as an outcome differs from that of symptomatic outcomes, such as pain. METHODS: Trials evaluating the effect of antibiotics in AOM and reporting the number of treatment failures were identified and a fixed-effects meta-analysis was performed. In addition, the literature was searched for articles providing direct or indirect figures on the specificity of different outcomes in AOM trials. A hypothetical study was designed to show how differences in sensitivity/specificity of inclusion/outcome criteria affect the results of a trial. RESULTS: The meta-analysis yielded a composite risk ratio of 0.4 (95% CI 0.35-0.48), p<0.001 for the effect of antibiotics on treatment failure. Based on data from the literature, the specificity of treatment failure was estimated to 92-100%. The hypothetical study showed how a non-specific outcome biases the effect estimate towards the null, whereas other kinds of misclassification only decrease precision. CONCLUSION: Future trials should focus on improving diagnostic criteria to increase precision but primarily, they should focus on choosing a specific outcome in order not to get a biased effect estimate.

Immunologic findings in young children with early onset of acute otitis media.

CONCLUSION: No significant differences in the number of immune aberrations were seen between children with or without severe recurrent acute otitis media (rAOM); however, subnormal values of immunological markers were found more often than expected, and 4 of the 60 children had treatment-requiring immune deficiencies. OBJECTIVE: Minor immunologic aberrations have been reported to be more frequent in children with rAOM. Immune investigation is recommended in children with severe rAOM, defined as six or more AOM episodes per year. The purpose of this study was to describe immunological findings in young children at high risk of developing rAOM, and to relate these to the number of expected aberrations and to the presence of severe rAOM. METHODS: A total of 109 children at risk of developing rAOM were offered immune investigation including complement function, immunoglobulins with subclasses and cellular immunity. RESULTS: Sixty patients were tested, 31 of whom had severe rAOM and 12 of whom did not develop rAOM. Low levels of IgG2 (27%), C1q (31%) and mannan-binding lectin (21%) were found up to eight times as often as expected. Although subnormal values were more frequent among children with severe rAOM, the study was too small to provide reliable evidence of any difference. Four children were diagnosed with immune deficiencies that required treatment.

Risk factors for carriage of AOM pathogens during the first 3 years of life in children with early onset of acute otitis media.

CONCLUSION: Risk factors associated with increased carriage rates are the same in children with recurrent acute otitis media (rAOM) as in healthy children. These are also known to be risk factors for the development of AOM itself. OBJECTIVES: The aim of this study was to describe risk factors for nasopharyngeal carriage in a cohort of young children at high risk of developing rAOM. METHODS: Children with an onset of AOM before 6 months of age, indicating an 80% risk of developing rAOM, were enrolled in a vaccination trial on heptavalent PCV. These children were monitored for 3 years during healthy and AOM periods with nasopharyngeal cultures, physical examinations, and questionnaires. RESULTS: A total of 109 children were included at a mean age of 5 months; 105 were followed for 3 years, 89 (82%) of whom developed rAOM. Risk factors associated with increased carriage of all major AOM pathogens were age <2 years, concurrent AOM, and fulfilment of rAOM criteria. Having siblings in day care was associated with increased carriage of Streptococcus pneumoniae and Haemophilus influenzae, recent antibiotic treatment was associated with H. influenzae and Moraxella catarrhalis carriage, and winter season was associated with M. catarrhalis carriage alone.

The Binax NOW test as a tool for diagnosis of severe acute otitis media and associated complications.

The diagnosis of acute otitis media (AOM) is often difficult, depending heavily on the experience and skills of the examiner. However, it is important to identify episodes of AOM that involve the risk of complications and to treat these episodes appropriately. The present study was performed in order to evaluate the use of a rapid antigen assay for Streptococcus pneumoniae, the Binax NOW test, as a diagnostic tool in patients with severe AOM and associated complications. The study included 70 patients with 74 episodes of AOM, 18 of them with complications. Cultures, Binax NOW tests, and a PCR assay were performed on nasopharyngeal secretions, middle ear fluid, and in some cases mastoid bone, cerebrospinal fluid, and urine. According to culture and PCR of the middle ear fluid, 30 (41%) of the episodes were caused by S. pneumoniae. The Binax NOW test was positive in 24 of these episodes (80%). It identified pneumococcal AOM independent of antibiotic treatment, and it was easily adapted to bone tissue. The test yielded sensitivity, specificity, and positive and negative predictive values for middle ear specimens of 85%, 100%, 100%, and 89%, respectively. The corresponding positive and negative values for predicting the bacterial etiology with nasopharyngeal secretions were 51% and 75%. This study showed that the Binax NOW test is a useful diagnostic tool for patients with severe AOM with or without complications.