Update of the consensus document on the aetiology, diagnosis and treatment of acute otitis media and sinusitis.

Update of the consensus on acute otitis media (AOM) (2012) and sinusitis (2013) following the introduction of pneumococcal vaccines in the immunization schedule, and related changes, such as epidemiological variation, colonization by of nonvaccine serotypes and emerging antimicrobial resistances. A majority of studies show that the introduction of the pneumococcal 13-valent conjugate vaccine has been followed by a reduction in the nasopharyngeal carriage of pneumococcus, with an increase in the proportion of drug-resistant nonvaccine serotypes. The diagnosis of AOM is still clinical, although more stringent criteria are proposed, which are based on the visualization of abnormalities in the tympanic membrane and the findings of pneumatic otoscopy performed by trained clinicians. The routine diagnosis of sinusitis is also clinical, and the use of imaging is restricted to the assessment of complications. Analgesia with acetaminophen or ibuprofen is the cornerstone of AOM management; watchful waiting or delayed antibiotic prescription may be suitable strategies in select patients. The first-line antibiotic drug in children with AOM and sinusitis and moderate to severe disease is still high-dose amoxicillin, or amoxicillin-clavulanic acid in select cases. Short-course regimens lasting 5-7 days are recommended for patients with uncomplicated disease, no risk factors and a mild presentation. In allergic patients, the selection of the antibiotic agent must be individualized based on severity and whether or not the allergy is IgE-mediated. In recurrent AOM, the choice between watchful waiting, antibiotic prophylaxis or surgery must be individualized based on the clinical characteristics of the patient.

La otitis media aguda en la era de la vacunación antineumocócica / Acute otitis media in the era of pneumococcal vaccination

La otitis media aguda (OMA) es una de las enfermedades más frecuentes en el niño y la principal causa de prescripción de antibióticos en países desarrollados. El tratamiento indiscriminado de niños con un diagnóstico dudoso ha favorecido el desarrollo de resistencias, lo que ha conducido a la creación de guías clínicas para el uso racional de antibióticos. La OMA tiene un elevado índice de resolución espontánea y el beneficio antibiótico es mínimo, por lo que en muchos pacientes está justificado un período de observación durante 48-72 h antes de iniciarla antibioterapia. En los últimos años el interés se ha dirigido a la utilización de vacunas frente a los principales patógenos, Streptococcus pneumoniae y Haemophilus influenzae. La vacuna conjugada frente a H. influenzae tipo b tiene muy poco impacto en la OMA, ya que la mayor parte de las cepas son no tipificables. La vacuna neumocócica conjugada heptavalente muestra una eficacia del 55%en la prevención de OMA por serotipos vacunales, perosu reemplazamiento por serotipos no vacunales y H. influenzae no tipificables disminuyen la eficacia globalal 6-8%. Se ha evidenciado una disminución global de la resistencia a penicilina en neumococo en niños vacunados, pero existe una tendencia al incremento de la resistencia antibiótica en los serotipos no vacunales. Aunque el tratamiento de elección de la OMA es amoxicilina en dosis altas, el aumento de H. influenzae en niños vacunados podría modificar esta recomendación en el futuro (AU)

Acute otitis media (AOM) is one of the most common childhood diseases and the main reason for prescribing antibiotics in developed countries. Indiscriminate treatment of children with an inconclusive diagnosis has favored the development of resistance, and this has led to the creation of clinical guidelines to promote judicious antibiotic use. AOM has shown high rates of spontaneous resolution and minimal benefits from antibiotics; hence apolicy of observation for 48-72 hours before initiating treatment is justified in many children. In recent years, attention has been focused on developing effective vaccines against the most common causative pathogens, Streptococcus pneumoniae and Haemophilus influenzae. The H. influenzae type b conjugate vaccine has little impact on AOM since most strains are nontypable. The 7-valent pneumococcal conjugate vaccine has an efficacy of 55% in AOM caused by vaccine serotypes, but replacement with nonvaccine serotypes and nontypable H. influenzae reduce the overall efficacy of the vaccine to6-8%. An overall decrease of pneumococcal resistance to penicillin has been seen in vaccinated children, but there is a trend to an increase in antibiotic resistance in non-vaccine serotypes. High-dose amoxicillin is the treatment of choice for AOM, but the increase of H. influenzae in pneumococcal-vaccinated children may require reconsideration of this recommendation in forthcoming guidelines (AU)