Epidemiologic and microbiologic characteristics of culture-positive spontaneous otorrhea in children with acute otitis media.

OBJECTIVES: We aimed to describe the epidemiologic and microbiologic characteristics of acute otitis media (AOM) with spontaneous otorrhea in children and compare it with AOM with intact tympanic membrane in children who underwent tympanocentesis. PATIENTS AND METHODS: All infants and young children aged <3 years with culture-positive AOM of < or =7 days duration diagnosed during 1999 to 2006 and in whom epidemiologic and microbiologic data were available, were analyzed. Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and Streptococcus pyogenes were considered true AOM pathogens. Multivariable regression analysis models adjusting for age, gender, ethnicity, seasonality, previous antibiotics, AOM history, tympanocentesis history, and pathogens isolated, were used. RESULTS: Of 12,617 AOM patients from whom a middle ear fluid was obtained, 5247 (42%) culture-positive patients were enrolled; spontaneous otorrhea was observed in 822 (15%) patients. Patients with spontaneous otorrhea were older than patients with AOM who underwent tympanocentesis (15.8 +/- 8.2 vs. 9.7 +/- 6.7 months, respectively, P < 0.01; 36.9% vs. 69.1%, respectively, were <12 months, P < 0.01). S. pyogenes was found in a higher proportion (47/822, 5.7% vs. 44/4425, 1%, P < 0.01) and H. influenzae in a lower proportion (264/822, 32.1% vs. 1805/4425, 40.8%, P < 0.01) among patients with spontaneous otorrhea than in patients with AOM and tympanocentesis. In the multivariate model, Bedouin ethnicity (OR: 1.5, 95% CI: 1.2-1.7, P < 0.001), age (OR: 1.1, 95% CI: 1.0-1.11, P < 0.001) for each consecutive month, lack of antibiotic treatment for the 48 hours preceding diagnosis (OR: 2.1, 95% CI: 1.7-2.6, P < 0.001), > or =1 previous AOM episode (OR: 3.2, 95% CI: 2.6-4.0, P < 0.001), >1 previous tympanocentesis (OR: 1.4, 95% CI: 1.4-1.7, P = 0.001), and infection with S. pyogenes (OR: 8.2, 95% CI: 5.4-12.3, P < 0.001) were independent risk factors for AOM presenting as spontaneous otorrhea. CONCLUSIONS: AOM presenting as spontaneous otorrhea in patients less than 3 years of age is characterized by older age, previous repeated tympanocenteses, > or =1 previous AOM episodes, lack of recent antibiotic treatment, and infection with S. pyogene.

[Obstructive sleep apnea syndrome in young infants].

UNLABELLED: Obstructive sleep apnea syndrome (OSAS) has been reported among children aged 3-6 years. Adenotonsillar hypertrophy is the most common cause of OSAS. The upper airway obstruction results in repeated obstructive apneas and hypopneas, associated with oxygen desaturations and sleep fragmentation. OSAS in children is associated with higher respiratory morbidity as well as significant clinical consequences, mainly neurocognitive and behavioral problems, impaired growth and cardiac dysfunction. The objectives of the present study were to determine the clinical and sleep characteristics of OSAS in children younger than 2 years, and to evaluate morbidity and health care utilization of infants with OSAS. This retrospective study included 35 children younger than 2 years of age, referred for polysomnography because of suspected OSAS. The controL group included healthy children, matched by age, gender and pediatrician. RESULTS: A total of 33 infants were diagnosed with OSAS. Mean apnea/hypopnea index [AHI) was 18.7 +/- 18.1 events/ hour [range 1.3-90.2]. In 10 infants a pattern of intermittent hypoxemia was observed. Infants with OSAS demonstrated a higher number of primary care clinic visits (20.8 +/- 14 vs. 12.1 +/- 6.6, P < 0.02). A higher percentage of children with OSAS visited the emergency room (60.6% vs. 32.2%, P < 0.03), and was hospitalized (36.3% vs. 12.9%, P < 0.03). Duration of hospitalization was also higher in the OSAS group [23.2 +/- 14.1% vs. 3 +/- 2.1%, P < 0.05). The number of drug prescriptions was higher among the study group [25.9 +/- 21.8% vs. 13.6 +/- 10.1, P < 0.03). Thirteen patients underwent adenoidectomy with or without tonsillectomy, resulting in improvement of AHI, decreasing from 26.4 +/- 24 before to 3.6 +/- 4.5 events per hour after surgery (p < 0.01). CONCLUSIONS: OSAS can be found in infants younger than 2 years of age. OSAS at this young age is characterized by a higher morbidity in comparison to healthy children. Early diagnosis and treatment may prevent morbidity in young children with OSAS.

Rates of tympanic membrane closure in double-tympanocentesis studies.

BACKGROUND: Data on the outcome of tympanic membrane (TM) closure after tympanocentesis in acute otitis media (AOM) patients is limited. OBJECTIVES: To analyze the dynamics of TM perforation closure after 1 or 2 tympanocentesis procedures performed at diagnosis and during AOM treatment. PATIENTS AND METHODS: Study population included 113 children enrolled in 4 double-tympanocentesis studies. Only the files of patients whose first and second examination were performed by the same 2 otorhinolaryngologists were analyzed. Middle ear fluid (MEF) was cultured on day 1 and days 4-6, the latter only in initially culture-positive patients. Patients were also examined on days 11-14 and followed until days 22-28. RESULTS: Ninety-three (82%) patients underwent tympanocentesis on days 4-6; 103 (91%) and 95 (84%) were evaluable on days 11-14 and 22-28, respectively. One hundred seventy-three ears underwent tympanocentesis on day 1 and 139 on days 4-6. Ninety-seven (86%) patients had positive MEF cultures. One hundred fifty-three (88%) tympanocentesis procedures performed at enrollment were closed on days 4-6. No differences were recorded in the closure rates as function of patient age, previous AOM history, MEF culture positivity, pathogens isolated at enrollment, and pathogen eradication on days 4-6. The 20 eardrums still open on days 4-6 were closed on days 11-14. Eleven (9%) of the evaluable ears tapped on days 4-6 were not closed on days 11-14 and 9 of 10 were closed on days 22-28. CONCLUSIONS: TM perforation closed in most cases within a few days regardless of patient and disease characteristics, and 2 consecutive tympanocentesis procedures performed at short-time intervals are associated with good TM closure rates.

Persistence of pathogens despite clinical improvement in antibiotic-treated acute otitis media is associated with clinical and bacteriologic relapse.

BACKGROUND: Pathogen eradication in patients with acute otitis media (AOM) is associated with a reduced risk of clinical failures, but most children in whom middle ear fluid (MEF) culture remains positive show clinical improvement or clinical cure. We investigated the relationship between MEF culture-positivity during treatment in patients with clinical improvement/cure, and the occurrence of subsequent AOM. METHODS: A total of 673 patients with culture-positive MEF were enrolled in double-tympanocentesis studies and followed for 3 weeks after completion of treatment. RESULTS: On day 4-6, 189/673 (28%) patients had culture-positive MEFs. Patients with clinical improvement/cure on day 11-14 (end of treatment) despite having culture-positive MEF on day 4-6 more often had recurrent AOM episodes (53/151, 35%) than those with culture-negative MEF (114/476, 24%; P = 0.007). 41/53 (77%) culture-positive patients with clinical improvement/cure on day 11-14 underwent tympanocentesis when AOM recurred and 29/41 (71%) were culture-positive. Pulsed field gel electrophoresis identity between pathogens at recurrence and those persisting on day 4-6 was found in 19/29 (66%) compared with 31/86 (36%) of the evaluable patients with recurrence and culture-negative MEF on day 4-6 (P = 0.005). CONCLUSIONS: (1) Failure to eradicate MEF pathogens during antibiotic treatment is associated with clinical recurrences, even in patients showing clinical improvement/cure at end of treatment; (2) these recurrences are mostly caused by pathogens initially present in MEF and persisting during treatment.

Failure to achieve early bacterial eradication increases clinical failure rate in acute otitis media in young children.

BACKGROUND: The objective of this study was to determine the association between early bacteriologic failure and clinical failure in acute otitis media (AOM). METHODS: Children with AOM aged 3-35 months enrolled in studies documenting both bacteriologic outcomes by tympanocentesis on day 4-6 and clinical outcomes on day 11-16 (immediate posttreatment visit) constituted our study group. Bacteriologic outcomes were studied for children with AOM caused by Streptococcus pneumoniae, nontypeable Haemophilus influenzae or both. The relative risk (RR) for clinical failure of children with bacteriologic failure compared with children with bacteriologic eradication was the main outcome measure. RESULTS: Nine hundred seven episodes were analyzed. Clinical failure occurred in 7.3% of 660 patients with bacterial eradication versus 32.8% of 247 patients with bacteriologic failures. The overall RR (95% confidence interval) for clinical failure was 4.41 (95% CI: 3.19-6.11), with little variation between pathogens. After correction for age, gender, ethnic origin, previous otitis history, and previous antibiotic treatment, the rate was 6.52 (95% CI: 4.26-9.99). Across clinical studies with 8 antibiotic drug regimens for AOM, the rate of clinical failure correlated with bacteriologic failure (r = 0.8967; P = 0.003). CONCLUSIONS: In young children with culture-positive AOM, failure to eradicate the pathogen from middle ear fluid within the first few days of treatment leads to a significant risk for clinical failure.

A prospective randomized double-blind trial of fibrin glue for reducing pain and bleeding after tonsillectomy.

OBJECTIVES: Varying surgical techniques as well as a large selection of analgesics and other medications have been evaluated over the years in the hopes of reducing post-tonsillectomy pain. Several publications in recent years have demonstrated the efficacy of fibrin glue in reducing post-tonsillectomy bleeding and pain. The objectives of this study were to evaluate the effect of fibrin glue on pain and bleeding after tonsillectomy. STUDY DESIGN: A prospective randomized double-blind study was performed on 168 consecutive patients undergoing tonsillectomy for obstructive sleep apnea and chronic tonsillitis. METHODS: Patients were randomly assigned to the treatment protocol. In the study group, the tonsillar beds were coated with fibrin glue (Quixil, OMRIX biopharmaceuticals) at the end of the operation. Patients in the controlled group underwent tonsillectomy without the use of fibrin glue. The patients were then monitored for postoperative bleeding, and a patient-based pain assessment instrument was used to evaluate pain, ability to eat and analgesics consumption for 10 days after surgery. RESULTS: Ninety-six patients returned for postoperative follow up and filled in the questionnaire. As our medical center is the only hospital in the southern district of Israel and we hospitalize every person who presents with post-tonsillectomy bleeding, we can assume that any patient from either group who presented with post-tonsillectomy bleeding would be familiar to us. Analysis showed that no statistically significant differences relating to postoperative pain, bleeding, use of analgesics and postoperative eating resumption were detected between the patients treated with fibrin glue and controls. CONCLUSIONS: We cannot substantiate a significant beneficial effect of fibrin glue in post-tonsillectomy pain control, prevention of bleeding or facilitating eating and thus find no indication for the routine use of fibrin glue in tonsillectomy.

Is bilateral acute otitis media clinically different than unilateral acute otitis media?

BACKGROUND: Information regarding the specific characteristics of bilateral acute otitis media (BAOM) versus unilateral acute otitis media (UAOM) is lacking. OBJECTIVES: To compare the epidemiologic, microbiologic, and clinical characteristics of BAOM with UAOM in children. PATIENTS AND METHODS: 1026 children aged 3-36 months (61%, <1 year of age) with AOM were enrolled during 1995-2003. All patients had tympanocentesis and middle ear fluid (MEF) culture at enrollment. Clinical status was determined by a clinical/otologic score evaluating severity (0 = absent to 3 = severe, maximal score 12) of patient's fever and irritability and tympanic membrane redness and bulging. Multivariate logistic regression models were used to estimate the risk of BAOM and UAOM presenting with a high severity score (> or =8). RESULTS: Six-hundred twenty-three (61%) patients had BAOM. Positive MEF cultures were recorded in 786 (77%) patients. More patients with BAOM had positive MEF cultures than patients with UAOM (517 of 623, 83% versus 269 of 403, 67%; P < 0.01). Nontypable Haemophilus influenzae was more common in BAOM than in UAOM (390 of 623, 63% versus 170 of 430, 42%; P < 0.01). Overall, the clinical/otologic score showed higher severity in culture-positive than in culture-negative patients (8.2 +/- 2.0 versus 7.7 +/- 2.2; P < 0.001) and in BAOM than in UAOM (8.3 +/- 2.1 versus 7.8 +/- 2.1; P = 0.001). Clinical/otologic score of > or =8 was more frequent in BAOM than in UAOM patients (371, 61.8% versus 200, 51.3%; P = 0.001). The estimated risk for BAOM patients (compared with UAOM patients) to present with a score > or =8 was 1.5. The association between BAOM and clinical/otologic score > or = 8 was maintained after adjustment for age, previous AOM history, and culture results at enrollment. CONCLUSIONS: (1) BAOM is frequent; (2) Nontypable H. influenzae is more frequently involved in the etiology of BAOM than of UAOM; (3) The clinical picture of BAOM is frequently more severe than that of UAOM, but overlap of clinical symptoms is common.

The effect of adenotonsillectomy on children suffering from obstructive sleep apnea syndrome (OSAS): the Negev perspective.

OBJECTIVE: To present the Negev perspective in recent decades as to the effect of adenotonsillectomy regarding clinical and polysomnographic features, cardiopulmonary morbidity, growth, neurocognitive function, health care services utilization, and enuresis by reviewing current related literature. METHODS: All relevant published data by the Soroka University Medical Center and related community medical services were reviewed and compared to MEDLINE linked literature regarding aspects of childhood obstructive sleep apnea published through November 2005. RESULTS: Published data support a significant effect of adenotonsillectomy on the associated co morbidities: adenotonsillectomy resulted in the reduction of pulmonary hypertension, improved growth as a result of an increase in growth hormone secretion, improvement of neurocognitive function to the normal range, reduction in nocturnal enuresis, as well as reducing general morbidities, as reflected by the reduction in health care utilization. However, there are still uncertainties relating to major aspects. There is no specific definition for OSAS grading, or for generating a guideline for surgical treatment and refinement of the indications of T&A. CONCLUSIONS: Adenotonsillectomy has a beneficial effect on children with OSAS, however, further research is required before recommendations for the treatment of OSAS in children can be formulated.

Adenotonsilectomy improves enuresis in children with obstructive sleep apnea syndrome.

OBJECTIVES: To evaluate the prevalence of nocturnal enuresis (NE) in children diagnosed with obstructive sleep apnea syndrome (OSAS) and the effect of tonsillectomy and adenoidectomy on enuresis. DESIGN, SETTING, AND PARTICIPANTS: All children 4-18 years of age who underwent polysomnography (PSG) between January 2003 and May 2004 were included (n=161). The evaluation was based on a retrospective review of a standard sleep questionnaire and a full overnight PSG, followed by an additional structured telephone questionnaire performed 9 months after adenotonsillectomy (T&A) (range 5-14). RESULTS: We identified 144 (89%) children with an apnea hypopnea index >1. Of these 144 children, 42 [29.2% (95% CI, 21.8-36.6)] were reported to have enuresis, 27 of these 42 underwent T&A. Among the 27 enuretic children who had undergone adenotonsillectomy, 74.1% had 3 or more wet nights per week before the procedure compared to 37%, 1 month after [n=27 (chi2=3.308, McNemar pv<0.0001)]. Of the 27 children who underwent adenotonsillectomy, any decrease in enuresis severity was reported by 70.4% (95% CI 53.2-87.62), while in 56% of these 27 (95% CI 41.96-70.06) it occurred 1 month postoperatively. In 11/27 children (41%), enuresis totally disappeared within 1 month, while in 3/27 (11%) enuresis disappeared throughout the remaining time of follow-up. CONCLUSIONS: Obstructive sleep apnea in children is frequently associated with nocturnal enuresis. Adenotonsillectomy has a favorable therapeutic effect on enuresis in children with obstructive sleep apnea presenting this symptom.

Acute otitis media caused by Streptococcus pyogenes in children.

BACKGROUND: Streptococcus pyogenes, or group A beta -hemolytic Streptococcus (GAS), is an important causative agent of bacterial pharyngotonsillititis and skin, soft-tissue, and invasive infections. Although it is also an important pathogen in acute otitis media (AOM), its exact role has not been determined. METHODS: Patients aged 0-18 years with AOM, from whom a specimen of middle-ear fluid was obtained and cultured during 1999-2003, were enrolled. Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and GAS were considered pathogens. Information collected included demographic characteristics, clinical history, and signs and symptoms. RESULTS: GAS otitis was observed in 350 (3.1%) of 11,311 episodes (of which 117 were also culture-positive for other pathogens). The other 10,961 episodes involved H. influenzae only (n = 2507), S. pneumoniae only (n = 2131), dual infection with H. influenzae and S. pneumoniae (n = 1290), M. catarrhalis only (n = 129), and other combinations of pathogens (n = 271). Increased age and Jewish ethnicity were independent, significant, positive risk factors for GAS AOM, and fall season was a negative risk factor. Episodes of GAS infection were less frequently bilateral, febrile, and accompanied by other systemic findings than were other episodes of other types of infection. Most patients with GAS AOM presented with acute drainage from the ears. A lower proportion of cases of AOM were due to GAS in children with recurrent AOM and in patients recently treated with antibiotics, compared with patients with AOM who did not have these factors. The risk for mastoiditis was highest among patients with GAS AOM, compared with patients infected with other pathogens: 11.6 episodes per 1000 episodes of GAS AOM, compared with 2.2, 0.3, and 0 episodes of mastoiditis per 1000 episodes of AOM due to S. pneumoniae, H. influenzae, and M. catarrhalis, respectively. CONCLUSION: Compared with AOM caused by pathogens other than GAS, GAS AOM is characterized by older age and higher local aggressiveness manifested by lower rates of fever and respiratory symptoms and higher rates of tympanic perforation and mastoiditis.

Gelfoam plug tympanoplasty concomitant with removal of retained ventilation tubes.

OBJECTIVE: To review the charts of patients treated using a gelfoam plug and to determine the efficacy of its use as a grafting material for prevention of perforation when removing retained ventilation tubes. METHOD: Following removal of the retained tube, excision and debridement of the rim of the perforation, the perforation was plugged with gelfoam material. Between February 1998 and July 2002, we used this procedure in 27 patients aged 15 years and younger, on a total of 36 ears. RESULTS: In all 27 cases, complete healing of the perforation was attained. CONCLUSION: A minimal tympanoplastic procedure using gelfoam graft concomitantly with tube removal is effective in prevention of perforation resulting from delayed spontaneous extrusion.

Acute otitis media-diagnosis and treatment in the era of antibiotic resistant organisms: updated clinical practice guidelines.

The treatment of children with AOM has to rely on an accurate diagnosis and a clear discrimination between AOM and serous otitis media. The last decade has seen major changes in the epidemiology of AOM with an earlier onset of disease and a greater proportion of children with recurrent/complicated AOM. The processes of changing susceptibility of bacterial pathogens added a major problem in treatment selection. Tastier, more efficient, safe and conveniently-dosing as well as cost effective drugs are required to achieve adherence to therapy. The recent published guidelines for the treatment of AOM in the present era of pneumoccocal resistance represent a major step forward in the approach to the management of this disease by establishing a clear hierarchy among the various therapeutic agents. A 48-72 h observation option without use of antibacterial therapy in selected children with uncomplicated AOM should be promoted. Immunization against S. pneumoniae with the heptavalent pneumococcal conjugated vaccines was showed to result in a decrease in the frequency of AOM caused by this pathogen, including AOM caused by antibiotic-resistant S. pneumoniae.

Adenotonsillectomy improves neurocognitive function in children with obstructive sleep apnea syndrome.

OBJECTIVE: To evaluate neurocognitive functions of children with obstructive sleep apnea syndrome (OSAS), before and after adenotonsillectomy, compared with healthy controls. DESIGN: Prospective study. PATIENTS AND METHODS: Thirty-nine children with OSAS aged 5 to 9 years (mean age, 6.8 +/- 0.2 years) and 20 healthy children (mean age, 7.4 +/- 1.4 years) who served as controls, underwent a battery of neurocognitive tests containing process-oriented intelligence scales. Twenty-seven children in the OSAS group underwent follow-up neurocognitive testing 6 to 10 months after adenotonsillectomy. Fourteen children in the control group were also reevaluated 6 to 10 months after the first evaluation. RESULTS: Children with OSAS had lower scores compared with healthy children in some Kaufman Assessment Battery for Children (K-ABC) subtests and in the general scale Mental Processing Composite, indicating impaired neurocognitive function. No correlation was found between neurocognitive performance and OSAS severity. Six to 10 months after adenotonsillectomy, the children with OSAS demonstrated significant improvement in sleep characteristics, as well as in daytime behavior. Their neurocognitive performance improved considerably, reaching the level of the control group in the subtests Gestalt Closure, Triangles, Word Order, and the Matrix analogies, as well as in the K-ABC general scales, Sequential and Simultaneous Processing scales, and the Mental Processing Composite scale. The magnitude of the change expressed as effect sizes showed medium and large improvements in all 3 general scales of the K-ABC tests. CONCLUSIONS: Neurocognitive function is impaired in otherwise healthy children with OSAS. Most functions improve to the level of the control group, indicating that the impaired neurocognitive functions are mostly reversible, at least 3 to 10 months following adenotonsillectomy.

Sleep characteristics following adenotonsillectomy in children with obstructive sleep apnea syndrome.

OBJECTIVE: To compare the effect of adenotonsillectomy on rapid eye movement (REM)- and non-REM-related respiratory and sleep architecture characteristics in children with obstructive sleep apnea syndrome (OSAS). STUDY DESIGN: This prospective study evaluated 36 children (median age, 6.9 years; range, 1.8 to 12.6 years) with OSAS using polysomnography before and a few months after adenotonsillectomy. Primary outcomes included the number of obstructive apnea and hypopnea and arousals per hour of sleep. RESULTS: At 4.6 months (range, 1 to 16 months) after adenotonsillectomy, there was a significant improvement of all respiratory parameters. The median respiratory disturbance index (RDI) decreased from 4.1/h (range, 0 to 85/h) to 0.9/h (range, 0 to 13/h) after adenotonsillectomy (p < 0.0001). The median non-REM RDI decreased from 3.0/h (range, 0 to 89/h) to 0.4/h (range, 0 to 13/h) [p < 0.001] as compared with REM RDI, which decreased from 7.8/h (range, 0 to 69/h) to 2.3/h (range, 0 to 54/h) after adenotonsillectomy (p < 0.01). Median arousal index decreased following adenotonsillectomy from 17.5/h (range, 7 to 57/h) to 14.0/h (range, 6 to 47/h) [p < 0.03]. CONCLUSIONS: Adenotonsillectomy resulted in a greater improvement in non-REM RDI as compared with REM-RDI, and a decrease in the number of arousals.

Recurrent acute otitis media occurring within one month from completion of antibiotic therapy: relationship to the original pathogen.

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.

Can acute otitis media caused by Haemophilus influenzae be distinguished from that caused by Streptococcus pneumoniae?

BACKGROUND: Previous limited data suggest that acute otitis media (AOM) caused by Streptococcus pneumoniae can present as a more severe disease than that caused by Haemophilus influenzae or Moraxella catarrhalis, as expressed by both tympanic membrane and systemic findings. OBJECTIVES: To evaluate the severity of disease and impact of various pathogens, age, disease history and previous antibiotic therapy in children with AOM by using a comprehensive clinical/otologic score. PATIENTS AND METHODS: The study group consisted of 372 children ages 3 to 36 months with AOM seen at the pediatric emergency room during 1996 through 2001. All patients had tympanocentesis and middle ear fluid culture performed at enrollment. Clinical status was determined by a clinical/otologic score evaluating severity (0 = absent to 3 = severe) of tympanic membrane findings (redness and bulging) and patient's fever, irritability and ear tugging. Maximal severity score was 15. RESULTS: There were 138 (37%) H. influenzae, 76 (21%) S. pneumoniae, 64 (17%) mixed infections (H. influenzae + S. pneumoniae) and 94 (25%) culture-negative cases. The overall clinical/otologic score was higher in culture-positive than in culture-negative patients (9.27 +/- 2.75 vs.8.38 +/- 3.08, P = 0.01). When analyzed by age groups, this difference was significant only for the youngest age group (3 to 6 months, P = 0.05). The severity scores for AOM caused by H. influenzae and S. pneumoniae were significantly higher than in the culture-negative AOM when tympanic membrane redness and bulging were analyzed separately. No differences were recorded in clinical/otologic scores between different pathogens (9.49 +/- 2.86, 9.03 +/- 2.72 and 9.09 +/- 2.54 for H. influenzae, S. pneumoniae and H. influenzae + S. pneumoniae, respectively). The mean clinical/otologic score was higher in culture-positive than in culture-negative patients without relationship to previous antibiotic treatment or number of previous AOM episodes. CONCLUSIONS: (1) The clinical/otologic score of culture-positive young infants was higher than that of culture-negative infants; (2) the severity of tympanic membrane redness and bulging were the most indicative factors discriminating between a bacterial and nonbacterial etiology of AOM; and (3) the use of a clinical/otologic score could not discriminate among various bacterial etiologies of AOM.

Relationship among peripheral leukocyte counts, etiologic agents and clinical manifestations in acute otitis media.

OBJECTIVES: To analyze the peripheral leukocyte counts of children with acute otitis media (AOM) in relation to etiology, age, clinical symptoms and signs, prior antibiotic treatment, previous AOM history and pathogen eradication during antibiotic therapy. PATIENTS AND METHODS: Leukocyte counts were determined at diagnosis and on days 4 to 6 of therapy in patients age 3 to 36 months with AOM enrolled in double tympanocentesis studies. Clinical status was determined by a clinical score evaluating severity of fever, irritability and tympanic membrane redness and bulging. RESULTS: Of 771 enrolled patients, culture-positive middle ear fluid was reported in 590 (77%): 294 (50%) Haemophilus influenzae; 150 (25%) Streptococcus pneumoniae; 127 (21%) H. influenzae and S. pneumoniae together; 9 (2%) Moraxella catarrhalis; and 10 (2%) others. Mean leukocyte count +/- sd in patients with AOM caused by S. pneumoniae (15.7 +/- 6.7 cells x 10/mm) was significantly higher than those of patients with AOM caused by H. influenzae (13.7 +/- 5.8 cells x 10/mm) and patients with culture-negative AOM (13.8 +/- 5.6 cells x 10/mm), P < 0.01 for each comparison. Mean absolute neutrophil count (ANC) +/- sd was higher in patients with AOM caused by S. pneumoniae (8.6 +/- 5.1 cells x 10/mm) than in patients with AOM caused by H. influenzae (6.5 +/- 4.0 cells x 10/mm) or culture-negative patients (6.5 +/- 4.4 cells x 10/mm), P < 0.05 for each comparison. When multivariant regression analysis was used, S. pneumoniae etiology and fever (body temperature > or = 38 degrees Celsius) were independent factors, each significantly associated with leukocyte and ANCs. A significant correlation was found between leukocyte and ANCs and higher clinical scores in patients with pneumococcal AOM (P = 0.01, r = 0.21 and P < 0.01, r = 0.27, respectively). The mean leukocyte count on Days 4 to 6 was lower than on Day 1 (11.5 +/- 4.1 compared with 14.2 +/- 6.0 cells x 10/mm, P < 0.01). When paired (Day 1 and Days 4 to 6) examinations were analyzed, the leukocyte counts were lower on Days 4 to 6 irrespective of bacterial eradication or persistence. CONCLUSIONS: Significantly higher leukocyte counts and ANCs were found in pneumococcal AOM than in AOM caused by H. influenzae or in culture-negative AOM. A significant decrease in leukocyte counts was found during antibiotic therapy for AOM, regardless of etiology and bacteriologic outcome. Isolation of S. pneumoniae and fever were each significantly associated with increased peripheral leukocyte and ANCs.

Acute mastoiditis in Southern Israel: a twelve year retrospective study (1990 through 2001).

BACKGROUND: Acute mastoiditis is a serious complication of acute otitis media (AOM) and has been increasingly reported in the last decade. OBJECTIVES: To report the experience accumulated with acute mastoiditis at the Soroka University Medical Center, Beer-Sheva, Israel, in a period of increasing antimicrobial resistance with Streptococcus pneumoniae. PATIENTS AND METHODS: We reviewed the records of all children with acute mastoiditis hospitalized from 1990 through 2001. Acute mastoiditis was diagnosed when one or more of the physical signs of mastoiditis (swelling, erythema, tenderness of the retroauricular area and anteroinferior displacement of the auricle) were diagnosed in the presence of concomitant or recent (< or =4 weeks) AOM. RESULTS: One hundred sixteen episodes of acute mastoiditis occurred in 101 children age 2 months to 14 years (median, 25 months; 19% <1 year old). The average yearly incidence was 6.1 cases per 100 000 population <14 years old, with a significant increase in the number of cases during the study period. Acute mastoiditis was the first evidence of AOM in 10 (10%) patients. Fever >38 degrees C and >15,000 WBC/mm3 were present in 67 and 43% of cases, respectively. Irritability, retroauricular swelling, redness and protrusion of the auricle occurred more commonly in patients <3 years old (79, 90, 84 and 76% vs. 28, 42, 45 and 30%, respectively, in patients > or =3 years old; P < 0.002). Computed tomography scans were performed in 54 of 116 (47%) cases and revealed bone destruction in 38 (70%). Periosteal abscess and lateral sinus vein thrombosis were diagnosed in 8 and 2 patients, respectively. Simple mastoidectomy was done in 32 of 116 (28%) cases, after no response to intravenous antibiotics was observed; ventilation tubes were inserted in 12 patients. Cultures were obtained at admission in 83 (72%) episodes (71 by tympanocentesis and 12 from ear discharges). Overall 43 pathogens were isolated: 34 at admission; 14 at surgery; and 5 at both occasions. The most commonly isolated organisms were S. pneumoniae (14 of 43, 33%; 4 penicillin-nonsusceptible), Streptococcus pyogenes (11 of 43, 26%), nontypable Haemophilus influenzae (6 of 43, 14%), Pseudomonas aeruginosa (5 of 43, 12%) and Escherichia coli (4 of 43, 9%). All S. pneumoniae organisms were isolated between 1996 and 2001. CONCLUSIONS: (1) The incidence of acute mastoiditis in children in Southern Israel is greater than that reported in the literature; (2) a significant increase in the number of cases was recorded during the study period; (3) the clinical picture of acute mastoiditis was more severe in infants and young children; (4) the pathogen distribution in acute mastoiditis differs from that of AOM with significantly higher rates of S. pyogenes and lower rates of nontypable H. influenzae recovery; (5) penicillin-nonsusceptible S. pneumoniae played only a minor role in the etiology of acute mastoiditis in Southern Israel.

Bacteriologic and clinical efficacy of high dose amoxicillin for therapy of acute otitis media in children.

BACKGROUND: High dose (70 to 90 mg/kg/day) amoxicillin is recommended as first line therapy of acute otitis media (AOM) in geographic areas where drug-resistant Streptococcus pneumoniae is prevalent. Information on the bacteriologic efficacy of high dose amoxicillin treatment for AOM is limited. OBJECTIVES: To evaluate the bacteriologic and clinical efficacy of high dose amoxicillin as first line therapy in AOM. METHODS: In a prospective study 50 culture-positive patients ages 3 to 22 months (median, 9 months; 77% <1 year) were treated with high dose amoxicillin (80 mg/kg/day three times a day for 10 days) No antibiotics were administered 72 h before enrollment. Twenty-four (48%) patients presented with their first episode of AOM. Middle ear fluid was cultured by tympanocentesis at enrollment and on Days 4 to 6 of therapy. Additional middle ear fluid cultures were obtained if clinical relapse occurred. Bacteriologic failure was defined by positive cultures on Days 4 to 6 and clinical failure by no change or worsening of AOM signs and symptoms and requirement for additional antibiotics during therapy and/or at end of therapy. Patients were followed until Day 28 +/- 2. Susceptibility to penicillin and amoxicillin was measured by E-test. RESULTS: Sixty-five organisms were recovered at enrollment: Haemophilus influenzae (38), Streptococcus pneumoniae (24), Streptococcus pyogenes (2) and Moraxella catarrhalis (1). Eighteen (75%) S. pneumoniae were nonsusceptible to penicillin (MIC > 0.1 microg/ml). All 24 S. pneumoniae isolates had amoxicillin MIC < or = 2.0 microg/ml. Thirteen (34%) of the 38 H. influenzae were beta-lactamase producers. Eradication was achieved in 41 (82%) patients for 54 of 65 (83%) pathogens: 22 of 24 (92%) S. pneumoniae, 21 of 25 (84%) beta-lactamase-negative H. influenzae, 8 of 13 (62%) beta-lactamase-positive H. influenzae, 2 of 2 S. pyogenes and 1 of 1 M. catarrhalis. Seven organisms not initially present were isolated on Days 4 to 6 in 5 patients: 3 beta-lactamase-positive H. influenzae; 1 beta-lactamase-negative H. influenzae; 2 S. pneumoniae; and 1 M. catarrhalis. In total 14 of 50 (28%) patients failed bacteriologically on Days 4 to 6 (persistence + new infection), of whom 9 (64%) had beta-lactamase-positive H. influenzae. Three (33%) of the 9 patients with bacteriologic failure (2 beta-lactamase-positive H. influenzae, 1 S. pneumoniae) failed also clinically on Days 4 to 6. CONCLUSIONS: The predominant pathogens isolated from children with AOM failing high dose amoxicillin therapy were beta-lactamase-producing organisms. Because its overall clinical efficacy is good, high dose amoxicillin is still an appropriate choice as first line empiric therapy for AOM, followed by a beta-lactamase-stable drug in the event of failure.

Dynamics of pneumococcal nasopharyngeal carriage in children with nonresponsive acute otitis media treated with two regimens of intramuscular ceftriaxone.

BACKGROUND: A 3-day intramuscular ceftriaxone regimen was superior to a 1-day regimen in the treatment of nonresponsive acute otitis media caused by resistant Streptococcus pneumoniae. However, the effect of various regimens of intramuscular cefriaxone on the nasopharyngeal carriage of S. pneumoniae and especially that of resistant strains during and after therapy has not been thoughtfully studied. OBJECTIVES: To compare the effect of one dose and three dose intramuscular ceftriaxone regimens on the nasopharyngeal carriage of S. pneumoniae in patients with nonresponsive acute otitis media treated with these two regimens and to document the dynamics of nasopharyngeal colonization with S. pneumoniae during and after completion of these two therapeutic regimens. PATIENTS AND METHODS: In a prospective study performed during January, 1998, through September, 1999, 170 evaluable patients ages 3 to 36 months with nonresponsive acute otitis media were randomized to receive the 1 (n = 83)- or 3 (n = 87)-day intramuscular ceftriaxone regimen (50 mg/kg/day), respectively. Nasopharyngeal cultures for S. pneumoniae were obtained on Days 1, 4 to 5, 11 to 14 and 28 to 30. Susceptibility of S. pneumoniae to penicillin and ceftriaxone was determined by E-test. RESULTS: On Day 1 nasopharyngeal S. pneumoniae carriage was found in 108 (64%) patients, 54 in each treatment group. Forty-seven of 54 (87%) and 9 of 54 (17%) S. pneumoniae isolates from the one dose group were nonsusceptible to penicillin and ceftriaxone, respectively; the respective values in the three dose group were 49 of 54 (91%) and 8 of 54 (15%). On Days 4 and 5 negative nasopharyngeal cultures were achieved in 43 of 83 (52%) and 70 of 87 (80%) cases from the one dose and three dose group, respectively (P < 0.001). Eradication of penicillin-nonsusceptible S. pneumoniae was achieved on Day 4 to 5 in 18 of 49 (37%) and 39 of 49 (80%) organisms isolated from the one dose and three dose groups, respectively (P < 0.001). Nasopharyngeal S. pneumoniae carriage among evaluable patients on Days 11 to 14 and Days 28 to 30 was 43 of 69 (62%) and 31 of 45 (69%) for the one dose group and 42 of 73 (58%) and 31 of 50 (62%) for the three dose group, respectively (P not significant). A decrease was observed during the study period in the proportion of highly penicillin-resistant S. pneumoniae isolated in the three dose group compared with the one dose group (30, 24, 17 and 13% vs. 30, 27, 19 and 26% at Days 1, 4 to 5, 11 to 14 and 28 to 30, respectively; P = 0.05). CONCLUSIONS: A marked reduction in the carriage of penicillin-nonsusceptible S. pneumoniae (including highly penicillin-resistant organisms) was achieved on Days 4 to 5 of therapy with both ceftriaxone regimens. The 3-day intramuscular ceftriaxone regimen was significantly superior to the 1-day regimen in the reduction of carriage during the treatment period. The reduction of overall S. pneumoniae nasopharyngeal carriage by both ceftriaxone regimens was a short-lived phenomenon followed by rapid recolonization of the nasopharynx.