Impact of the 13-valent pneumococcal conjugate vaccine (PCV13) on acute mastoiditis in children in southern Israel: A 12-year retrospective comparative study (2005-2016).

OBJECTIVES: To define the trends in acute mastoiditis (AM) incidence, microbiology, complications and management in children, before and after the 13-valent pneumococcal conjugate vaccine (PVC13) introduction. METHODS: Medical records of all AM patients <15 years of age diagnosed during 2005-2016 were reviewed. The study years were divided into three periods: pre-vaccination (2005-2008), interim (2009-2011) and post-PCV13 vaccination (2012-2016). RESULTS: 238 patients (53.4% males) were enrolled, 81, 56 and 101 in the 3 time periods, respectively. Overall, 177/238 (75.2%) of children were <5 years of age. Mean AM incidence in the whole population was 10.32/100,000, with no changes during the study years. Ninety-three (45.6%) of 204 evaluable patients had positive middle ear fluid/mastoid cultures; S. pneumoniae (SP) was isolated in 47/93 (50.5%) cases. Mean incidence of SP-AM during the study years was 2.49 cases/100,000. A trend for decrease in mean incidence of SP-AM was recorded between the pre and the post-vaccination periods (3.05/100,000 vs. 1.82/100,000, P = 0.069). Among patients <5 years, SP-AM rates decreased from pre to post-vaccination period (19/50, 38% vs. 15/73, 20.6%, P = 0.034). No changes were reported in percentages of culture negative-AM and of AM complications in the post-PCV13 period compared with the pre-vaccine period. A significant decrease in distribution of PCV13 serotypes was recorded (17/19, 89.5% vs. 8/12, 66.6% and vs. 7/16, 43.75% during the 3 study periods, P = 0.015) accompanied by a complementary increase in non-vaccine serotypes. CONCLUSIONS: The introduction of PCV13 was accompanied by a significant decrease in SP-AM cases among children <5 years of age. PCV13 serotypes decreased significantly as etiologic agents of SP-AM while non-vaccine serotypes and culture negative-AM became more common in the postvaccination period.

Antibiotic use and serious complications following acute otitis media and acute sinusitis: a retrospective cohort study.

BACKGROUND: Most people with acute otitis media (AOM) and acute sinusitis (AS) do not benefit from antibiotics, and GPs are under increasing pressure to reduce antibiotic prescribing. Concern about the risk of complications can drive unnecessary prescribing. AIM: To describe the incidence of serious complications following AOM and AS, and to determine whether antibiotics are protective. DESIGN AND SETTING: This was a retrospective cohort study using the Clinical Practice Research Datalink database to identify patients diagnosed in general practice with AOM or AS between 1 January 1982 and 31 December 2012. METHOD: The incidence of brain abscess and acute mastoiditis following AOM, and of brain abscess and orbital cellulitis following AS, were calculated, as was the association between antibiotics and the development of these complications and numbers needed to treat (NNT). RESULTS: The incidence of brain abscess and acute mastoiditis following AOM were 0.03 (95% confidence interval [CI] = 0.01 to 0.20) and 5.62 (95% CI = 4.81 to 6.56) per 10 000 AOM episodes, respectively. The incidence of brain abscess and orbital cellulitis following AS was 0.11 (95% CI = 0.05 to 0.26) and 1.50 (95% CI = 1.17 to 1.90) per 10 000 AS episodes, respectively. Antibiotic prescription for AOM was associated with lower odds of developing acute mastoiditis (odds ratio [OR] 0.54; 95% CI = 0.37 to 0.79); NNT to prevent one case was 2181 (95% CI = 1196 to 5709). Antibiotic prescribing for AS was associated with lower odds of subsequent brain abscess (OR 0.12; 95% CI = 0.02 to 0.70); NNT to prevent one case was 19 988 (95% CI = 4951 to 167 099). No significant association between antibiotic prescription and development of orbital cellulitis following AS were found (OR 0.56; 95% CI = 0.27 to 1.12). CONCLUSION: Serious complications following AOM and AS are rare. Antibiotics are associated with lower odds of developing complications, but the NNT are large.

The impact of the Italian guidelines on antibiotic prescription practices for acute otitis media in a paediatric emergency setting.

BACKGROUND: Acute otitis media (AOM) is one of the most common childhood infectious diseases. The recent Italian Pediatric Guidelines for the treatment of AOM constitutes a step forward in the management of children with uncomplicated AOM. The aim of this study was to evaluate antibiotic prescription patterns for AOM in a Pediatric Emergency Department (PED) after those guidelines were introduced and to assess the relationship between implementation of the "watchful waiting" strategy and the incidence of acute mastoiditis in the PED. METHODS: This retrospective study was conducted between 1st January 2007 to 31st December 2013 at the PED of the University of Modena and Reggio Emilia in Modena (Italy). All children between 0 and 14 years who were examined because of symptoms and/or signs of AOM and acute mastoiditis were enrolled. Pearson's chi-squared test was used to evaluate if introduction of the Italian Paediatric Guidelines was associated with a reduction in the antibiotic prescription pattern in children with AOM and/or with an increase in mastoiditis frequency. RESULTS: 4,573 (89.4%) patients were included in our analysis, antibiotics were prescribed to 81% cases of the children diagnosed with AOM. The frequency of antibiotic prescribing continued to be stable after the Italian guidelines were introduced (82% versus 81%). Forty children were admitted to hospital with a diagnosis of acute mastoiditis. Our study did not find any association between the number of cases of acute mastoiditis and the percentage of patients treated with antibiotics; the annual incidence of mastoiditis before and after the new guidelines were published was, in fact, stable. CONCLUSIONS: Despite the diffusion of clinical guidelines recommending a "watchful waiting" approach for children with AOM, the antibiotic prescription rate continues to be high. It appears to be more difficult to impact the percentage of cases for which antibiotics are prescribed than the type of antibiotic that is utilized. In view of these findings, a close follow-up control by the primary care paediatrician or a scheduled follow-up appointment at the PED and incisive campaigns to promote parents' awareness of proper antibiotic use appear to be warranted.

Acute mastoiditis in the pneumococcal conjugate vaccine era.

Following the introduction of the 7- and 13-valent pneumococcal conjugate vaccines, we observed an inverse relationship between the increasing rate of immunized children and the proportion of middle ear fluid cultures collected during acute mastoiditis episodes that tested positive for Streptococcus pneumoniae among a subset of children 0 to 6 years old who had initially presented with severe acute otitis media and had bacterial cultures collected during tympanocentesis or from spontaneous otorrhea.

Microbiology of acute mastoiditis and complicated or refractory acute otitis media among hospitalized children in the postvaccination era.

In the post-heptavalent pneumococcal conjugate vaccine era, Streptococcus pneumoniae remains the leading cause of acute mastoiditis and other complicated or refractory acute otitis media among hospitalized children in our settings. Serotype 19A is predominant, invasive and multidrug resistant causing more than half of all mastoiditis cases, two-thirds of cases with subperiosteal abscess and all those requiring mastoidectomy. Continuous surveillance is required.

[Acute otitis media in children: antibiotic therapy or watchful waiting?]. / Akute Otitis media bei Kindern: Antibiose oder "watchful waiting"?

Acute otitis media is one of the most common infections in childhood and the options of therapy have been examined in numerous studies. Nevertheless, there are controversial opinions regarding the question whether antibiotic therapy makes sense. This is proved through the many different ways that the primary treatment of the middle ear infection is handled throughout the international community. This work gives an overview of the current knowledge and based on these results gives practical recommendations to assist with the diagnosis and treatment of the individual patients.

What effect has pneumococcal vaccination had on acute mastoiditis?

BACKGROUND: Streptococcus pneumoniae is a frequent cause of acute mastoiditis. Despite the recent (2005) introduction of pneumococcal vaccination, mastoiditis incidence and severity may be increasing. This study aimed to assess the incidence, severity and microbiology of acute mastoiditis over an 11-year period. METHODS: Retrospective review of paediatric acute mastoiditis cases seen at our institution (2000-2010), comparing patients seen prior to vaccination introduction (period one, 2000-2004), around the time of vaccine introduction (period two, 2005-2007) and post-vaccination (period three, 2008-2010). RESULTS: We reviewed 84 children. In periods one, two and three, respectively: mean annual case load was 8.4, 5 and 9 children; pneumococcal isolates were seen in 40.5, 6.7 and 29.6 per cent of cases; highest recorded fever was 38.6, 38.9 and 38.2°C and highest leukocyte count 18.9, 15.0 and 15.6 × 109/l; incidence of intracranial complications was 11.9, 0 and 7.4 per cent; mean duration of intravenous antibiotics was 6.0, 4.1 and 4.2 days; proportion treated surgically was 71.4, 60.0 and 48.1 per cent; and mean length of in-patient stay shortened. CONCLUSION: Pneumococcal mastoiditis admission rates appeared to fall when vaccination was introduced, with concomitant reduction in overall mastoiditis incidence and intracranial complications; subsequently, however, admission rates rapidly returned to pre-vaccination levels.

Bilateral, simultaneous cochlear implantation in children: surgical considerations.

PROBLEM: The advantages of bilateral, simultaneous cochlear implantation include: the possibility to pre-empt cochlear calcification following meningitis; reduction of the intervention to only one procedure, general anaesthetic and course of clinical care (with obvious benefits for the patient); and greater cost-effectiveness. The disadvantages of such a procedure include: doubling the risk of associated complications; placing the patient on the implanted side during contralateral implantation; the possibility of vestibular alteration simultaneously in both ears; the need for precise planning of symmetrical incisions and implant sites; and longer surgery time. METHODS: The study cohort included 10 children who underwent bilateral, simultaneous cochlear implantation using the suprameatal approach. RESULTS: The overall operation time, inclusive of anaesthesia, was approximately three hours in all cases. None of the children had any intra- or post-operative complications. CONCLUSIONS: From a surgical perspective, bilateral, simultaneous cochlear implantation is a safe procedure. The use of a non-mastoidectomy approach is recommended.

Effect of antibiotics for otitis media on mastoiditis in children: a retrospective cohort study using the United kingdom general practice research database.

BACKGROUND: Information is needed on whether mastoiditis has increased in association with the decline in antibiotics prescribed to children by primary care physicians in the United Kingdom. OBJECTIVE: To determine time trends in mastoiditis incidence, the frequency of antecedent otitis media, and the effect of antibiotics for otitis media on the risk of mastoiditis in children. PATIENTS AND METHODS: We conducted a retrospective cohort study by using the UK General Practice Research Database. Children aged 3 months to 15 years between 1990 and 2006 were included. Risk of mastoiditis within 3 months after otitis media diagnosis and the protective effect of antibiotics were determined. RESULTS: There were 2 622 348 children within the General Practice Research Database; 854 had mastoiditis, only one third of whom (35.7%) had antecedent otitis media. Mastoiditis incidence remained stable between 1990 and 2006 ( approximately 1.2 per 10 000 child-years). Risk of mastoiditis, after otitis media, was 1.8 per 10 000 episodes (139 of 792 623) after antibiotics compared with 3.8 per 10 000 (149 of 389 649) without antibiotics, and increased with age. Antibiotics halved the risk of mastoiditis. General practitioners would need to treat 4831 otitis media episodes with antibiotics to prevent 1 child from developing mastoiditis. If antibiotics were no longer prescribed for otitis media, an extra 255 cases of childhood mastoiditis would occur, but there would be 738 775 fewer antibiotic prescriptions per year in the United Kingdom. CONCLUSIONS: Most children with mastoiditis have not seen their general practitioner for otitis media. Antibiotics halve the risk of mastoiditis, but the high number of episodes needing treatment to prevent 1 case precludes the treatment of otitis media as a strategy for preventing mastoiditis. Although mastoiditis is a serious disease, most children make an uncomplicated recovery after mastoidectomy or intravenous antibiotics. Treating these additional otitis media episodes could pose a larger public health problem in terms of antibiotic resistance.

Mastoiditis aguda: estudio epidemiológico de una década / Acute mastoiditis: one-decade long epidemiological study

Objetivos: Describir las características clínicas de los pacientes ingresados por mastoiditis aguda en nuestro hospital. Material y métodos: Estudio descriptivo retrospectivo de niños con mastoiditis aguda ingresados en el Hospitalde Cabueñes (Gijón), entre enero de 1997 y diciembre de2007.Resultados: Se incluyeron 28 pacientes (54% varones)con edad media de 35,5 meses. Siete casos (25%) ocurrieron en 2007. El 28% de pacientes refería antecedente de otitis recurrentes. El 61% de los niños recibía tratamiento antibiótico en el momento del diagnóstico. Los síntomas más frecuentes fueron tumefacción, eritema y/o despegamiento en la región retroauricular (96%), fiebre (86%), otalgia(64%) y otorrea (36%). El recuento leucocitario fue superior a 15.000/mm3 en el 79% de los casos y el valor medio de laPCR fue 79,3 mg/L. Se realizó estudio microbiológico en 21niños (75%). S. pneumoniae y P. aeruginosa (3 casos cada uno)fueron los patógenos hallados con más frecuencia. La estancia media hospitalaria fue de 8 días. Se realizó miringotomía en 15 pacientes (53,6%). Siete pacientes precisaron cirugía. Las complicaciones registradas fueron: una cofosis (enun paciente con laberintitis por S. aureus), una parálisis facial transitoria, un absceso subperióstico temporal y un colesteatoma. Conclusiones: La mastoiditis aguda continúa siendo una complicación relativamente frecuente de la otitis media aguda, responsable de una considerable morbilidad, qu erequiere un adecuado manejo por parte de los diversos especialistas implicados, con el fin de realizar un diagnóstico y tratamiento tempranos que eviten complicaciones. Es necesaria una adecuada observación epidemiológica para determinar si existe realmente una incidencia creciente en nuestro medio (AU)

Objective: To describe clinical characteristics of children admitted to our hospital with a diagnosis of acute mastoiditis. Material and methods: Retrospective study on cases of children admitted to Hospital Cabueñes (Gijón) with a diagnosis of acute mastoiditis from 1997 to 2007 .Results: Twenty-eight patients (54% males) with a mean age of 35.5 months were included. Seven cases (25%) occurred in 2007. Eight patients had a history of recurrentotitis media. Sixty-one percent of children received antibiotics before diagnosis of mastoiditis. Swelling, erythema and postauricular inflammation (96%), fever (86%), pain(64%) and othorrea (36%) were the most frequent symptoms and signs. The white blood cell count was greater than15,000/mm3 in 79% of the cases and the CRP mean value was 79.3 mg/L. Cultures were obtained from 21 children(75%). S. pneumoniae and P. aeruginosa (3 cases each) were the most common etiological agents. Mean hospital stay was8 days. Miringotomy was performed in 15 patients (53.6%).Seven patients needed surgery. Complications included one case each of deafness (a patient with S. aureus labyrinthitis),transitory facial palsy, temporal subperiostic abscess and cholesteatoma. Conclusions: Acute mastoiditis remains a relatively frequent complication of acute otitis media, responsible for considerable morbidity. Epidemiological surveillance is required to confirm a real amount of incidence in our population (AU)

[Mastoiditis in children in Iceland]. / Stikilbólga hjá börnum á Islandi.

INTRODUCTION: Mastoiditis is an infection in the mastoid process and is a complication of otitis media. Studies have revealed that the incidence might be increasing with altered antibiotic usage. The aim of the current study was to describe the epidemiology, clinical symptoms and treatment of mastoiditis in Iceland during the last two decades with special emphasis on children and to study possible correlations between antibiotic use and incidence of mastoiditis. PATIENTS AND METHODS: Information on patients diagnosed with mastoiditis during the period 1984-2002 at The Children's Hospital Iceland, The Department of Paediatrics, Landakoti and Landspitali--University Hospital Iceland was gathered and clinical data were recorded from patients records of children diagnosed with mastoiditis during 1999-2002. Information on antibiotic use during the years 1989-2002 was obtained from the Ministry of Health in Iceland. RESULTS: Eighty-four patients were diagnosed with mastoiditis during the period 1984-2002. Of those, 52 (62%) were children less than 18 years of age. The mean age of those children was 2 years and 8 months. Boys were 58%. Twenty six (50%) of the children were less than three years old. During the years 1999-2002, a total of 28 children were diagnosed; the mean age was 2 years and 2 months. Fifteen children (54%) sought medical attention within a week prior to admission to hospital and had been diagnosed with otitis media. Eleven children (73%) were appropriately treated with antibiotics prior to the diagnosis of mastoiditis but four (27%) received no antibiotics. During the period 1989-2002, a statistically significant correlation was detected between decreased antibiotic use among children and increasing incidence of mastoiditis (r=-0.68; p=0.007). DISCUSSION: Following changes in guidelines for antibiotic prescriptions for otitis media in Iceland during the nineties, antibiotic use in children decreased at the same time as the incidence for mastoiditis increased. It is uncertain, however, if a causal relationship exists. It is important to diagnose and appropriately treat otitis media, while staying alert for serious complications, especially in young children.

Mastoiditis aguda: revisión casuística / Acute mastoiditis: review of a single center experience

Fundamento. La incidencia de mastoiditis aguda y la necesidad de tratamiento quirúrgico disminuyeron con la introducción del tratamiento antibiótico. Posteriormente se ha mantenido estable o podría haber aumentado por cambios de la sensibilidad microbiana. Objetivo. Conocer la presentación clínica y evolución de las mastoiditis agudas tratadas en nuestro centro. Método. Revisión retrospectiva de 19 mastoiditis agudas ingresadas entre enero de 1998 y enero de 2002. Resultados. La edad media fue de 35 meses. Todos iban a guarderia o colegio. 7 (36.8%) tenían otitis medias agudas recurrentes. 13 (68.4%) recibieron antibióticos el mes anterior. 17 (89.5%) presentaban otitis aguda. 13 (68.4%) manifestaban fiebre, 18 (94.7%) otalgia o irritabilidad, 9 (47.4%) supuración, todos tímpano alterado y eritema postauricular, 15 (78.9%) tumefacción postauricular y 17 (89.5%) pabellón desplazado. El recuento fue superior a 15000 leucocitos/mm3 en 4, la proteína C reactiva superior a 60 mg/L en 7 y el hemocultivo negativo en 15 de 17. La tomografía computerizada confirmó el diagnóstico, 2 con osteitis y 2 con absceso retroauricular. El antibiótico más utilizado fue la cefotaxima. 2 requirieron punción timpánica (10.5%), 8 drenaje transtimpánico (42.1%), 2 mastoidectomía (10.5%) y 9 (47.4%) ningun abordaje. Conclusiones. La mastoiditis aguda se da sobre todo en menores de 6 años, no siempre con otitis media aguda recurrente, que han recibido antibióticos el mes previo. Habitualmente es complicación de una otitis media aguda. El diagnóstico es clínico. La tomografía computerizada determina la extensión. El tratamiento es antibiótico endovenoso y drenaje de la colección purulenta (AU)

Background. The incidence of acute mastoiditis and the need for surgical treatment declined significantly after the introduction of antibiotics and stabilized subsequently. However, given the changes in bacterial sensitivities, the incidence of acute mastoiditis may be rising. Objective. To describe the clinical characteristics, treatment, and outcome of patients diagnosed with acute mastoiditis in our institution. Method. Retrospective review of 19 patients with acute mastoiditis seen in our institution between January 1998 and January 2002. Results. Mean age at diagnosis was 35 months. All patients were attending either daycare or school. Seven patients (36.8%) had recurrent acute otitis media. Thirteen patients (68.4%) had received an antibiotic during the previous month. Seventeen patients (89.5%) had concomitant acute otitis media, 13 (68.4%) had fever, 18 (94.7%) had otalgia or irritability, 9 (47.4%) had otorrhea, 15 (78.9%) had retroauricular swelling, 17 (89.5%) had auricular displacement, and ll patients had abnormal tympanic membrane and retroauricular erythema. White blood cell count was greater than 15,000/cumm in 4 patients, C-Reactive protein was greater than 60 mg/L in 7 patients, and blood culture was negative in 15 of 17 patients in whom blood culture was obtained. Computorized tomography confirmed the diagnosis of mastoiditis in all patients. In two patients, there was evidence of osteitis, and in 2 patients a retroauricular abscess was noted. The most frequent antibiotic prescribed was cefotaxime. Two patients (10.5%) required myringotomy, 8 patients (42.1%) required the placement of tympanic drainage tubes, 2 patients (10.5%) required mastoidectomy, and 9 patients (47.4%) did not require any surgical intervention. Conclusions. Acute mastoiditis is diagnosed typically in young children (< 6 years) that have a recent history of antibiotic administration, as a complication of acute otitis media. However, it is not always associated with recurrent acute otitis media.The diagnosis is usually clinical, and computorized tomography may help in the definition of the extension of the infection. The treatment is with intravenous antibiotics and surgical drainage of any abscesses (AU)

Prevention of acute mastoiditis: fact or fiction?

Acute mastoiditis is the most common complication of acute otitis media (AOM). In recent years routine antibiotic treatment for acute middle ear infections was questioned and even abandoned in some countries. The goal of our study was to investigate the influence of antibiotic treatment on the occurrence and clinical outcome of acute mastoiditis and to analyze the bacteriological findings. A retrospective case record study of 48 patients with 50 episodes of acute mastoiditis hospitalized at our tertiary-care center between 1992 and 1999 was performed. Twenty-three patients (48%) received antibiotic treatment before admission whereas 25 (52%) did not. The group of patients without antibiotic pretreatment were younger (mean, 6 years) than patients with antibiotics (mean, 18 years) and their referral was delayed. The most common isolated single pathogen was Streptococcus pneumoniae. All pneumococci were sensitive to penicillin. Acute mastoiditis may be the first clinical sign of a middle ear infection, especially in very young children. Adequate antibiotic pretreatment cannot invariably prevent the development of acute mastoiditis even in the absence of penicillin resistant pathogens.

[Attempt at prevention of chronic otitis media in childhood]. / Törekvéseink az otitis media chronica prevenciójára gyermekkorban.

Two diseases are considered by the author as fundamental ones in the development of chronic otitis media. These are the mastoiditis and the tube auditory dysfunction. Both diseases occur the most frequently in age-groups which can be determined well. The mastoiditis occurs most frequently in infancy and in baby-age, while the auditory tube dysfunction occurs between the age of 3 and 7. Main trend of the prevention should be focused on these two diseases. By recovering from mastoiditis in time, recognition of the tube dysfunction and providing the ventilation of the middle ear, the definitive destroy of the tympanic membrane, the auditory ossicle and the development of chronic otitis media can be prevented.