Chronic Otitis Media Home Remedies

Natures Amazing Ear Infection Cures By Naturopath Elizabeth Noble

Little Known Secrets To Cure An Ear Infection Fast! Here's A Taste Of What's Revealed In The Nature's Amazing Ear Infection Cures e-book: What type of ear infection do you or your loved one have? The 9 ear infection symptoms you can't afford to ignore. Danger at the drugstore what drugs you should never buy. Why antibiotics are useless and possibly dangerous for most ear infections. The problems with surgery. The causes and triggers of an ear infection everything from viruses, bacteria and fungi to allergies, biomechanical obstruction, environmental irritants, nutrient deficiencies, poor infant feeding practices and more. How to relieve even the most excruciating ear ache with a hot onion poultice. An ancient Ayurvedic recipe to control an ear infection. The herbal ear drops you can make in your own kitchen that are renowned for soothing ear pain. The wonderful essential oil ear rubs you can make to ease ear congestion and discomfort. The simplicity of homeopathy for treating an ear infection great for babies and young children. User-friendly acupressure, massage and chiropractic to relieve ear pain, enco. How to relieve problem ears with air travel.

Natures Amazing Ear Infection Cures By Naturopath Elizabeth Noble Overview

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Otitis Media Middle Ear Infections

In children (in whom otitis media is most common), pneumococci (33 of cases) and Haemophilus influenzae (20 ) are the usual etiologic agents in acute disease. Group A streptococci (Streptococcus pyogenes) are the third most frequendy encountered agents, found in 8 of cases. Other organisms, encountered in 1 to 6 of cases, include Moraxella catarrhalis, Staphylococcus aureus, gram-negative enteric bacilli, and anaerobes in one recent study, M. catarrhalis, S. pneumoniae, and H. influenzae were the most common bacterial pathogens.9 Viruses, chiefly respiratory syncytial virus (RSV) and influenza virus, have been recovered from the middle ear fluid of 4 of children with acute or chronic otitis media. Chlamydia trachomatis and Mycoplasma pneumoniae have occasionally been isolated from middle ear aspirates. Otitis media with effusion (fluid) is considered a chronic sequela of acute otitis media. A slowly growing organism, Alloiococcus otitidis is a potential pathogen that is found solely...

Acute Otitis Media Microbiology

Other organisms that less frequently cause AOM include group A beta-hemolytic streptococci (GABHS), Staphylococcus aureus, Turicella otitidis, Alloiococcus otitis Chlamydia spp., and Staphylococcus epidermidis, and various aerobic and faculatative gram-negative bacilli (7) including Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Proteus spp. Gram-negative bacilli and staphylococci are implicated as dominant etiologic agents in otitis media of the neonate. However, even among very young infants, S. pneumoniae and H. influenzae constitute the most common etiologic agents. Viruses were recovered in the middle-ear fluid of 14.3 of children (8). TABLE 1 Bacteria Isolated from 186 Cases of Acute Otitis Media TABLE 1 Bacteria Isolated from 186 Cases of Acute Otitis Media

Otitis Externa External Ear Infections

Otitis externa is similar to skin and soft tissue infections elsewhere. Two major types of external otitis exist acute or chronic. Acute external otitis may be localized or diffuse. Acute localized disease occurs in the form of a pustule or furunde and typically results from Staphylococcus aureus. Erysipelas caused by group A strepto-cocd may involve the external ear canal and the soft tissue of the ear itself. Acute diffuse otitis externa (swimmer's ear) is related to maceration (softening of tissue) of the ear from swimming and or hot, humid weather. Gram-negative bacilli, particularly Pseudomonas aeruginosa, play an important role. A severe, hemorrhagic external otitis caused by P. aeruginosa is difficult to treat and has occasionally been related to hot tub use. Chronic otitis externa results from the irritation of drainage from the middle ear in patients with chronic, suppurative otitis media and a perforated eardrum. Ma- lignant otitis externa is a necrotizing infection that...

Acute Otitis Externa Swimmers

External otitis is defined as a varying degree of an inflammation of the auricle, external ear canal, or outer surface of the tympanic membrane (67). The etiology of the inflammation can be an infection, inflammatory dermatoses, trauma, or a combination of these. Sudden onset of diffuse infection involving the external auditory canal is termed acute otitis externa (68). The most predominant cause of the acute infection is P. aeruginosa. The diffuse infection needs to be differentiated from a localized furunculosis of the hair follicles that is caused by aerobic gram-positive bacteria. Chronic otitis externa results from persistence of the infection that causes thickening of the canal skin. Extension of the infection that encompasses the bone and cartilage is termed necrotizing otitis externa (69,70).

Ear Infections

Otitis media is one of the most common diseases of early childhood. The incidence is highest between 6 and 18 months. There are four defined types of otitis media (1) (z) acute otitis media (AOM) is characterized by a rapid onset of signs and symptoms of middle-ear inflammation. Earache, bulging of the tympanic membrane, and purulent exudate characterize the early phase of infection. Even though clinical signs and symptoms resolve rapidly, the effusion can persist (ii) otitis media with effusion (OME) refers to the presence of asymptomatic effusion. It may follow acute otitis media with effusion (AOME) or appear as silent or secretory otitis media (iii) chronic otitis media with effusion (COME) denotes a persistence of fluid for three months or longer. The fluid is more mucoid, so-called glue ear and (iv) chronic suppurative otitis media (CSOM) signifies chronic drainage through a perforation of the tympanic membrane.

Microbiology and Pathogenesis

Meningitis caused by F. necrophorum has been associated with chronic otitis media and an episode of upper respiratory infection (4,5). C. perfringens is a cause of meningitis following head injuries or surgery (2,6), that is fatal in about a third of patients despite therapy. Contamination of these wounds with environmental or endogenous flora would explain the entry of C. perfringens into the CNS.

The Socioeconomic Perspective

Social constraints exert a strong effect on the use of antibiotic agents. This influence can be best illustrated by otitis media, the leading reason for excessive antimicrobial use in young children. Attendance at a child-care center outside the home correlates with an increased risk of otitis media and antibiotic use.8 Therefore, differences in availability of and attendance to nonparental day-care facilities between countries lead to differing antibiotic prescription rates in young children. The need of parents to return to work and bring their children back to day care is an often underestimated pressure on antibiotic demand.

Lateral Pharyngeal Space

The lateral pharyngeal space is continuous with the carotid sheath. Involvement of this space may follow pharyngitis, tonsillitis, otitis, parotitis, and odontogenic infections. Anterior compartment involvement is characterized by fever, chills, pain, tremors, and swelling below the angle of the jaw. Posterior compartment infection is characterized by septicemia, often with few local signs. Other complications include edema of the larynx, asphyxiation, internal carotid artery, and erosion internal jugular vein thrombosis. Close observation is mandatory and tracheostomy may be required. Surgical drainage and parenteral antibiotic therapy are needed.

Trends in Outpatient Antimicrobial Utilization

May be due to a combination of reduced health care-seeking behavior (self care for illnesses recognized to be viral or limited access to care for those without medical insurance) and reduced prescribing by physicians when a visit does occur. Similar trends have been observed using claims data from 9 large health plans. From 1996 to 2000, prescribing rates for children aged between 3 months and less than 6 years declined approximately 25 , and reduced prescribing for otitis media accounted for nearly two-thirds of the total decrease 32 . Inappropriate use of broad-spectrum antimicrobials continues to be a problem, generating additional selection pressure for antimicrobial resistance in community-acquired pathogens. From 1996 to 2000, pediatric use of second-generation macrolide drugs (azithromycin, clarithromycin) increased dramatically in 9 large health plans, although they accounted for less than 10 of all antimicrobials dispensed 33 . From 1995 to 2002, fluoroquinolone prescribing...

Pkpd Characteristicsbetalactams

For example, the relationship between the beta-lactam T> MIC and efficacy has been evaluated in patients with acute otitis media caused by S. pneumoniae and Haemophilus influenzae (12,35-37). Bacteriologic cure rates of 80 to 85 were observed when the T> MIC for various beta-lactams were greater than 40 to 50 of the dosing interval. Similarly, in hospitalized patients with community-acquired pneumonia, no differences in clinical outcome were observed between patients receiving the cephalosporin cefuroxime as a 1,500-mg per day continuous infusion (T> MIC 100 ) compared with 750 mg administered three times daily (estimated T> MIC 50 to 60 ), suggesting a T> MIC target of 50 is adequate (42).

Microbiology Acute Mastoiditis

Streptococcus pneumoniae, Streptococcus pyogenes, Staphylococcus aureus, Haemophilus influenzae are the most common organisms recovered (4-8). Rare organisms are Pseudomonas aeruginosa and other gram-negative aerobic bacilli, and anaerobes (6-12). Several studies demonstrated the predominance of P. aeruginosa in acute M. This organism is a known pathogen in chronic otitis media and chronic M (13). Since this organism is a common colonizer of the ear canal (14) it is possible that some of these isolates recovered from pus collected from the ear canal do not represent a true infection. Mastoiditis is rarely caused by tuberculosis.

Chronic Mastoiditis

Chronic suppurative otitis media that often acompanies chronic M is treated with topical antimicrobial therapy and thorough aural toilet and system antimicrobials are given if this approach fails. The empirical choice of systemic antimicrobials for chronic M is directed at the eradication of both aerobic and anaerobic bacteria. Some of the anaerobic organisms, such as B. fragilis, and many pigmented Prevotella and Porphyromonas and Fusobacterium spp. are resistant to penicillins through the production of the enzyme beta-lactamase.

Alternative Therapies

In a study from Brazil, 59 patients with MDR P. aeruginosa and Acinetobacter strains were treated using intravenous colistin (103). In patients with normal renal function, initial doses were 2.5 to 5mg kg day, divided into two or three doses, up to a maximum of 300 mg daily. A range of infections were treated, including pneumonia, urinary tract infections, bacteremias, central nervous system infections, peritonitis, catheter-related infections, and otitis media. Overall, colistin treatment resulted in a positive clinical outcome in 58 of patients, although pneumonias had a poorer response rate (25 ).

Symptoms And Signs

Pharyngoconjunctival fever often occurs in children and presents with pharyngitis, conjunctivitis and fever, often accompanied by rhinitis, otitis media and or diarrhoea. Exudate may be present on the tonsils and posterior pharyngeal wall. Cervical lymphadenopathy is common. Ocular disease (without respiratory symptoms). A follicular conjunctivitis is seen with oedema of periorbital tissue, redness of the conjunctivae and serous exudation. Recovery is usually complete.

Drug Selection And Dosing

Different classes of antibacterial drugs. Exposure parameters such as maximum drug concentration minimum inhibitory concentration (Cmax MIC) ratio are useful for many drugs, including aminoglycosides and fluoroquinolones. Here, the population Cmax may be used with the MIC90 (MlC for 90 ) of the species or with the individualized pathogen MIC. In the original description, the agent with the highest Cmax MIC would be selected (23). In reality, there may be several agents that have Cmax MIC ratios that are sufficient for optimal response, and other factors (cost, dosing convenience, safety) can be used to select between the agents. For aminoglycosides and fluoroquinolones, Cmax MIC ratios of 8 to 10 or greater are considered optimal for most infections (24,25). Generally the serum Cmax can be used except when the site of infection involves a barrier to drug penetration. For example, cerebrospinal fluid (CSF) concentration should be used with meningeal infection and middle ear fluid...

Pathogensesis And Pathology

Actinomyces species are agents of low pathogenicity and require disruption of the mucosal barrier to cause disease. Actinomycosis usually occurs in immunocompetent persons but may afflict persons with diminished host defenses. Oral and cervicofacial diseases commonly are associated with dental caries and extractions, gingivitis and gingival trauma, infection in erupting secondary teeth, chronic tonsillitis, otitis or mastoiditis, diabetes mellitus, immunosuppression, malnutrition, and local tissue damage caused by surgery, neoplastic disease, or irradiation. Pulmonary infections usually arise after aspiration of oropharyngeal or gastrointestinal secretions. Gastrointestinal infection frequently follows loss of mucosal integrity, such as with surgery, appendicitis, diverticulitis, trauma, or foreign bodies (1). The use of intrauterine contraceptive devices (IUDs) was linked to the development of actinomycosis of the female genital tract. The presence of a foreign body in this setting...

Discussion Of Results And Implications For Practice

In the studies of the use of delayed antibiotic prescriptions for URIs and otitis media, significant patient morbidity was not observed (Arroll et al., 2002 Dowell et al., 2001 Little et al., 2001). As the outcome of viral respiratory tract infections is not altered by antibiotics, these are not unexpected results for the studies of URIs. It is important, however, to have data that demonstrates this lack of morbidity for illnesses such as acute bronchitis and purulent rhinitis where the etiologic agent, while usually viral, is often thought to be bacterial by many practitioners. The demonstration that there is no benefit to immediate use of antibiotics may serve to convince many physicians and patients that antibiotics are not needed for these conditions. Delayed prescriptions for acute otitis media in children are frequently used in many European countries but have not gained popularity in North America. This pragmatic study (Little et al., 2001) demonstrates that waiting a few days...

Indications For Antibiotic Prescriptions

Available population-based studies which describe antibacterial use by indication use physician surveys or prescription databases as the data collection mechanism. In most studies the most common indication for an antimicrobial prescription is a respiratory tract infection (RTI) (60-70 ) followed by urinary tract infections (UTI) (10-15 ), and skin and soft tissue infections (10 ). In children, more than 90 of infectious episodes are respiratory tract infections (including otitis media) and children also receive antimicrobial treatment more often than adults. In the elderly urinary tract infections becomes more prevalent as a diagnosis and increasing utilisation of antimicrobials are observed in the veteran population.

Possible Causes For Observed Variations In Antibiotic

The large variations in antibiotic use in DID or numbers of prescriptions per 1,000 inhabitants and year comparing countries are difficult to explain by medical reasons alone. There is no comprehensive review on guidelines for the treatment of infectious diseases comparing different countries. But differences in antibiotic use may to some extent reflect differences in national guidelines or recommendations, for example, choice of antibiotics, dosage, and length of treatment. In addition, there are different recommendation on antibiotic use for identical indications. For example, antibiotics are recommended for uncomplicated otitis media in children in most countries but not for children older than 6 months in the Netherlands. In addition, different dosage may explain some of the differences in DID for p-lactam antibiotics, since higher dosage may be needed in areas with high prevalence of resistance. But this does not explain the difference in number of prescriptions per 1000...

Antibiotic Consumption

It is a very difficult task to explain or to speculate as to why antibiotic use in the French community is so high. Despite clear guidelines on antibiotic use for presumed viral respiratory tract infection (PVRTI) over the last 10 years, the proportion of patients with PVRTI for whom antibiotics were prescribed remained high. Furthermore, antibiotic use tended to increase between 1984 and 1995, to treat acute media otitis and bronchitis, but remained almost stable for rhinopharyngitis or tonsillitis (Observatoire National des Prescriptions et Consommations des M dicaments, 1998) In contrast to certain northern European countries, in France, acute otitis media is considered as a pathology requiring antibiotic therapy. No element explaining the increased prescription of antibiotics for bronchitis has been clearly identified. The frequency of antibiotic prescriptions in sore throats reached 90 in 1984. Obviously, no increase would be expected but no spontaneous decrease occurred despite...

Guidelines For Rti The Value of Guidelines

Behavior, such as promoting the appropriate use of antibiotics. Effective clinical guidelines should improve patient care while enhancing cost savings. However, cost savings should not be the primary motivating factor. A recent example reported by Beilby et al. described a government intervention in Australia intended to decrease costs by reducing the use of amoxicillin-clavulanate (38). As a result, costs increased through the occurrence of adverse outcomes in patients with acute otitis media (AOM), sinusitis, lower RTI, and acute exacerbations of chronic bronchitis (AECB).

The FDA Has to Level the Playing Field with Generic Antibiotics

The FDA cannot continue to allow Americans to use generic drugs that would not meet FDA's modern standards. All drugs have to meet the same standard of efficacy and safety. Specifically, I'm speaking about all the antibiotics that have ever been approved by the FDA for otitis, sinusitis, bronchitis and pneumonia. If the FDA has decided that the trials that were previously carried out do not show benefit, than by definition the risk to benefit ratio for those drugs is zero. Their marketing approval for those indications should be withdrawn. This is especially important since the use of the older generic drugs tends to be much greater than the use of the new antibiotics which is so closely monitored for approval. With the greater use of the older drugs comes the potential for greater danger.

Production of BL by Anaerobic Gram Negative Bacilli in Clinical Infections

One-hundred and eleven of 387 (29 ) pigmented Prevotella and Porphyromonas spp., which accounted for 12 of BLPB, were isolated in 15 of the patients with BLPB. The highest frequency of recovery of BL-producing pigmented Prevotella and Porphyromonas spp. isolates was found in URTI (38 of all pigmented Prevotella and Porphyromonas spp. isolates) the isolates were recovered in 28 of patients with URTI, mostly in those with recurrent tonsillitis and chronic otitis media. In pulmonary infections, 22 of the pigmented Prevotella and Porphyromonas spp. isolates produced BL and they were isolated in 16 of the patients. Although 22 of the isolates of the pigmented Prevotella and Porphyromonas spp. produced BL in skin and soft tissue infections, these organisms were isolated only in 7 of patients with these infections, mostly in those that were in close proximity or originated from the oral cavity.

Therapeutic Implications of Indirect Pathogenicity

A similar study evaluated the effects of AMX-C and AMX therapy on the nasopharyngeal flora of 50 children with acute otitis media (248). After therapy, 16 (64 ) of the 25 patients treated with AMX and 23 (92 ) of the 25 patients treated with AMX-C were considered clinically cured. A significant reduction in the number of both aerobic and anaerobic isolates occurred after therapy in those treated with either agent. The number of all isolates recovered after therapy in those treated with AMX-C was significantly lower (60 isolates) than in those treated with AMX (133 isolates, p < 0.001). The recovery of known aerobic pathogens (e.g., S. pneumoniae, S. aureus, GABHS, Haemophilus spp., and M. catarrhalis) and penicillin-resistant bacteria after therapy was lower in the AMX-C group than in the AMX group (p < 0.005).

Importance for Resistance at the Individual Level

This enormous level of antimicrobial drug use in the community has implications at the individual level, especially for Streptococcus pneumoniae, the leading cause of community-acquired bacterial pneumonia, meningitis, sinusitis, and otitis media in the United States (3-5). Prior antibiotic use is a risk factor for carriage of, and infection with, antimicrobial-resistant S. pneumoniae (1,6-9). The very high rate of pediatric antibiotic use is especially important, particularly for individuals in childcare. As young children are the age group most likely to be pneumococcal carriers and most likely to be exposed to antimicrobial drugs, they are not surprisingly major carriers of resistant organisms (1,10) and at high risk of resistant infections (8). Colonized individuals in close quarters with symptoms of upper respiratory infection are at increased risk of spreading resistant organisms to other individuals (1). The transmission of drug-resistant pneumococci is of clinical importance,...

Importance for Resistance at the Community Level

In Iceland, the first penicillin-resistant S. pneumoniae (PRSP) was isolated in 1988. By 1993, PRSP accounted for nearly 20 of pneumococcal infections. PRSP surveillance among healthy day care children was instituted, and children found to be carrying PRSP were asked not to attend day care while they had symptoms of upper respiratory infection. Educational messages regarding appropriate antibiotic use were targeted to the public through the media, and the medical community through professional meetings and journals. The focus was on more selective diagnosis and antimicrobial treatment of otitis media, the most frequent reason for pediatric antimicrobial treatment. Propitiously, government outpatient antibiotic subsidies ended in 1991, making families responsible for the full cost

Carbenicillin Ticarcillin Piperacillin and Mezlocillin

Carbenicillin was effective in the treatment of pulmonary and intra-abdominal anaerobic infections in adults (26,27) and active alone or in combination with an aminoglycoside in treatment of aspiration pneumonia (28) and chronic otitis media (29) in children. Carbenicillin has a particular advantage in these infections because of its synergistic quality with aminoglycosides against Pseudomonas aeruginosa, which was also present in these infections.

Lincomycin and Clindamycin

Not be administered in CNS infections (61,62). Because of the effectiveness of its activity against anaerobes, it is frequently used in combination with aminoglycosides for the treatment of mixed aerobic-anaerobic infection of the abdominal cavity and obstetric infection (63). The side effect of most concern with clindamycin is colitis (64). It should be noted that colitis has been associated with a number of other antimicrobial agents, and has been described in seriously ill patients in the absence of previous antimicrobial therapy. Colitis following clindamycin therapy was associated with recovery of C. difficile strains in adults and children (65). The occurrence of colitis in pediatric patients is very rare, however (66). Clinical studies using clindamycin in a pediatric population showed it to be effective in the treatment of intraabdominal infections (67), aspiration pneumonia (68), chronic otitis media (69), and chronic sinutis (70). Clindamycin has also an important role in...

Medical Provider Interventions

Centers for Disease Control and Prevention (CDC) has recently completed a series of practice guidelines regarding appropriate antibiotic use for adult acute respiratory infection, including bronchitis (71), exacerbations of chronic obstructive pulmonary disease (72), pharyngitis (73), sinusitis (74), and nonspecific upper respiratory tract infections (75), and publishes regular guideline updates for influenza (76). The Infectious Diseases Society of America (3) and the American Thoracic Society (77) published recommendations for the management of adult community-acquired pneumonia. The American Academy of Pediatrics published guidelines for the diagnosis and antibiotic treatment of pediatric acute otitis media, the most common outpatient diagnosis for which an antibiotic is prescribed for children (78,79), and pediatric sinusitis (79).

Healthcare System Interventions

Delayed prescriptions Delayed prescription for antibiotics have been evaluated in terms of antibiotic use and patient parent satisfaction. Siegel et al. evaluated watchful waiting in 194 children (mean age 5 years) with nonsevere acute otitis media. Parents were given a safety net antibiotic prescription to fill if symptoms either worsened or did not improve in 48 hr. All subjects received comfort measures and analgesics. Thirty-one percent of the 175 contacted for follow-up had filled the antibiotic prescription. Sixty-three percent of parents reported they would be willing to follow a watchful waiting strategy for acute otitis media in the future (91). McCormick et al. evaluated watchful waiting without antibiotics for children aged 6 months to 12 years with nonsevere otitis media. All unimproved untreated subjects received antibiotic. Over all age groups combined, 5 and 21 of subjects in the immediate-antibiotic group and watchful waiting group, respectively, failed treatment,...

Examples Of Successful Interventions To Reduce Inappropriate Antibiotic

Finkelstein et al. tested the impact of a family and physician educational outreach intervention on pediatric antibiotic use in Massachusetts and Washington State managed care practices. They randomized 12 practices to either intervention or control groups. The physician intervention consisted of two small-group practice meetings with a physician peer leader. At the first meeting, leaders reviewed six one-page CDC-endorsed summaries of prescribing guidelines, focusing on differentiating pediatric bacterial acute otitis media from chronic otitis with effusion, which does not require antibiotics. Four months later, leaders at the second meeting reinforced the recommendations, and presented practitioner- and practice-level feedback regarding antibiotic prescribing rates for the previous year. Parents in intervention practices were mailed the CDC pamphlet Your Child and Antibiotics, with a cover letter signed by their own pediatricians. CDC waiting room posters and pamphlets reinforced...

Virulence of Anaerobic Bacteria and the Role of Capsule

Bacterial Encapsulation

Clinical and animal studies showed bacterial synergy between anaerobic and aerobic or other anaerobic bacteria (12,13). Data derived from therapy of mixed infection also provided support for the importance of anaerobic bacteria. Polymicrobial infection involving aerobic and anaerobic bacteria responded to therapy directed at the eradication of only the anaerobic component of the infection with either metronidazole or clindamycin (14). However, for complete eradication of the infection, animal and patient studies have demonstrated that unless therapy is directed against both aerobic and anaerobic bacteria, the untreated organisms will survive (15-18). Bartlett et al. (15) demonstrated in an intra-abdominal abscess model in rats that combined therapy of clindamycin and gentamicin was needed to prevent mortality caused by Escherichia coli sepsis and abscesses caused by B. fragilis. Thadepalli et al. (16) showed that in patients with intra-abdominal trauma, clindamycin and kanamycin were...

Clinical Clues to Diagnosis of Anaerobic Infections

Anaerobes belonging to the indigenous flora of the oral cavity can be recovered from various infections adjacent to that area such as cervical lymphadenitis (7,8) subcutaneous abscesses (9) and burns (10) in proximity to the oral cavity human and animal bites (11) paronychia (12) tonsillar and retropharyngeal abscesses (13) chronic sinusitis (14) chronic otitis media (15) periodontal abscess (16) thyroiditis (17) aspiration pneumonia (18) empyema (19), and bacteremia associated with one of the above infections (20). The predominant anaerobes recovered in these infections are species of anaerobic gram-negative bacilli including pigmented Prevotella and Porphyromonas, Prevotella oralis, Fusobacterium, and gram-positive anaerobic cocci (Peptostreptococcus spp.) which are all part of the normal flora, the mucous surfaces of the oral, pharyngeal, and sinus flora (Table 3). 15. Brook I. Microbiology and management of chronic suppurative otitis media in children. J Trop Pediatr 2003 49 196-9.

Laboratory Diagnosis

Aspergillus 400x

Aspergillus fumigatus is the most commonly recovered species from immunocompromised patients moreover, it is the spedes most often seen in the clinical laboratory. In addition, Aspergillus flavus is sometimes recovered from immunocompromised patients and represents a frequent isolate in the clinical microbiology laboratory. The recovery of A. fumigatus or A.flavus from surveillance (nasal) cultures has been correlated with subsequent invasive aspergillosis.141 The absence of a positive nasal culture does not preclude infection, however. Aspergillus niger is seen commonly in the clinical laboratory, but its association with clinical disease is somewhat limited this organism is a cause of fungus ball and otitis externa. Aspergillus terreus is a significant cause of infection in immunocompromised patients, but its frequency of recovery is much lower than the previously mentioned species. It is, however, important to correcdy identify this species, because it is innately resistant to...

Collection Transportation and Processing of Specimens for Culture

Portacul Bacteria Collection

Earlier studies of chronic otitis media (1) and human and animal bites (2), which did not employ methods for anaerobes found these organisms in a small number of cases. However, when better techniques were used, anaerobes were recovered in the majority of the cases (3,4). Because anaerobes may invade any body site, and they have been recovered in a variety of infections in children, anaerobes' potential role in an infectious site should be assessed individually. The prevalence of anaerobic bacteria in an infection is a major factor in deciding which clinical specimens should be processed for anaerobes. Because anaerobic bacteria frequently can be involved in various infections, ideally, all properly collected specimens should be cultured for these organisms. The physician should make special efforts to isolate anaerobic organisms in infections in which these organisms are frequently recovered, such as abscesses, wounds in and around the oral and anal cavities, chronic otitis media and...

Bacteroides fragilis Group

Although B. fragilis group is the most common species found in clinical specimens, it is the least common Bacteroides present in fecal flora, comprising only 0.5 of the bacteria present in stool. The pathogenicity of this group of organisms probably results from its ability to produce capsular material, which is protective against phagocytosis (57). Because of its presence in normal flora of the gastrointestinal tract, this organism is predominant in bacteremia associated with intra-abdominal infections (2,32), peritonitis and abscesses following rupture of viscus (18,19), and subcutaneous abscesses or burns near the anus (58,59). Although B. fragilis is not generally found as part of the normal oral flora, it can colonize the oral cavity of patients with poor oral hygiene or of those who previously received antimicrobial therapy, especially penicillin. Following the colonization of the oropharyngeal cavity, these organisms also can be recovered from infections that originate in this...

Guidol Ma English 1st Sem Result 2015

J., Hedrick, J. A. et al., 1995, Penicillin-resistant Streptococcus pneumoniae in acute otitis media Risk factors, susceptibility patterns and antimicrobial management. Pediatr. Infect. Dis. J., 14, 751-759. Brook, I. and Gober, A. E., 1996, Prophylaxis with amoxicillin or sulfisoxazole for otitis media Effect on the recovery of penicillin-resistant bacteria from children. Clin. Infect. Dis., 22, 143-145. Christakis, D. A., Zimmerman, F. J., Wright, J. A., Garrison, M. M., Rivara, F. P., Davis, R. L., 2001, A randomized controlled trial of point-of-care evidence to improve the antibiotic prescribing practices for otitis media in children. Pediatrics, 107, e15. Dolovich, L., Levine, M., Tarajos, R., and Duku, E., 1999, Promoting optimal antibiotic therapy for otitis media using commercially sponsored evidence-based detailing A prospective controlled trial. Drug Inform. J., 33, 1067-1077. Little, P., Gould, C., Williamson, I., Moore, M., Warner, G., and...

Fusobacterium Species

The infectious sites where anaerobic cocci predominate are in descending order of frequency ear, bone, cysts, obstetric and gynecologic, abscesses, and sinuses. These organisms are part of the normal flora of the mouth, upper respiratory tract, intestinal tract, vagina, and skin (7). Their presence has been documented in adults in a variety of syndromes, including endocarditis, brain abscesses, puerperal sepsis, traumatic wounds, and postoperative necro-tizing fasciitis (2,3). They have been recovered in children in subcutaneous abscesses and burns around the oral and anal areas, intra-abdominal infections (18), decubitus ulcers (80), and also have been isolated as causes of bacteremia (11), and brain abscesses (37,81). These organisms are predominant isolates also in all types of respiratory infections in children and adults including chronic sinusitis (15), mastoiditis (16), acute (82,83) and chronic (14) otitis media, aspiration pneumonia (38,60), and lung abscess (60,61). They...

Antibacterial Treatment of Community Acquired Respiratory Tract Infections

Introduction - Community-acquired respiratory tract infections (CARTIs) represent one of the most globally prevalent classes of infection. Acute RTIs account for approximately 75 of all antibiotic prescriptions and 20 of all medical consultations (1). Community-acquired upper respiratory tract infections (CAURTI) (pharyngitis tonsillitis, laryngitis, otitis media and sinusitis) and viral RTIs (rhinorrhea the common cold, influenza A B, adenovirus, parainfluenza and syncytial virus) are typically not life-threatening unless complicated by a coinfection or an immunocompromised host (e.g. meningitis, HIV, etc.). Generally, CAURTIs respond well to front-line antibiotics such as penicillins, erythromycin, azithromycin, amoxicillin clavulanate or cefpodoxime. Viral RTIs are usually self-limiting and only require symptomatic support (2,3). Of greater concern are lower respiratory tract infections (LRTI) which include community-acquired pneumonia (CAP) and acute exacerbations of chronic...

Azithromycin And Clarithromycin Update

Several clinical studies on macrolides have been reported. Due to their safety profile, macrolides represent one of the few potential therapeutic options for pregnant women and children infected with Orientia tsutsugamushi, the etiologic agent of scrub typhus. Azithromycin administered to two pregnant women infected with drug-resistant strains of 0. tsutsugamushi in northern Thailand rapidly abated the symptoms, signs and fever in these patients (73). A comparative trial between azithromycin and ciprofloxacin for treatment of uncomplicated typhoid fever in Egypt on 123 adults infected with or without multidrug resistance strains of Salmonella typhi showed that both azithromycin and ciprofloxacin were similarly effective, clinically and bacteriologically (74). A prospective, open-label, randomized study of azithromycin in acute otitis media in children was conducted. Bacteriologic failure after 3 to 4 days of treatment occurred in high proportion (53 ) of culture-positive patients,...

The FDA Increases Clinical Trial Design Stringency and Costs Companies Abandon Antibiotic Research

With their advisory committee and in public, the FDA began to examine the issue of antibiotics used for mild infections like sinusitis, bronchitis and otitis (middle ear infections). The issue for these infections is that they frequently are caused by viruses and not bacteria and therefore would not respond to antibiotics in any case. This leads to much of the unnecessary use of antibiotics which in turn probably leads to antibiotic resistance. The other question is that even when bacteria cause these types of infections, will they get better without treatment Will serious complications arise without antibiotic treatment How do we know that antibiotics even work The scientific literature is very conflicted on this subject. The area of mild infections is directly related to the agency's basic concern about comparative trials where a placebo is not used. How do we know that the standard or comparator antibiotic is better than no antibiotic

Acute Bacterial Rhinosinusitis ABRS

TABLE 3 Criteria for Initial Antibacterial Treatment or Observation in Children with Acute Otitis Media TABLE 3 Criteria for Initial Antibacterial Treatment or Observation in Children with Acute Otitis Media TABLE 4 Recommended Antibacterial Agents for Acute Otitis Media TABLE 4 Recommended Antibacterial Agents for Acute Otitis Media

Pseudomonas Spp And Brevundimonas

In patients with cystic fibrosis, P. aeruginosa has a predilection for infecting the respiratory tract. Although organisms rarely invade through respiratory tissue and into the bloodstream of these patients, the consequences of respiratory involvement alone are serious and life-threatening. hi other patients, P. aeruginosa is a notable cause of nosocomial infections of the respiratory and urinary tracts, wounds, bloodstream, and even the central nervous system. For immunocompromised patients, such infections are often severe and frequentiy ' '-threatening. In some cases of bacteremia, the organism may invade and destroy walls of subcutaneous blood vessels, resulting in formation of cutaneous Papules that become black and necrotic. This condition is known as ecthyma gangrenosum. Similarly, Patients with diabetes may suffer a severe infection of the external ear canal (malignant otitis externa), Vhich can progress to involve the underlying nerves id bones of the skull.

Bacterial Interactions With Mucosal Surfaces

S. pneumoniae is responsible for several localized and systemic infections such as otitis media, meningitis, sepsis, and pneumonia. There is a well-established relationship between pneumococcal bacteremia associated with pneumonia and mortality of aging subjects (38). Among patients with bacteremia, the fatality rate has been related to age as follows 17-18 among

Introduction to Anaerobes

Neck infections Shunt infections (cardiac, intracranial) Chronic otitis media, cervical lymphadenitis Clostridia strains (C. perfringens, C. butyricum, and C. difficile) have been recovered from blood and peritoneal cultures of necrotizing enterocolitis and from infants with sudden death syndrome (8-10). Strains of Clostridium were recovered from children with bacteremia of gastrointestinal origin (11) and with sickle cell disease (12). Clostridial strains have been recovered from specimens obtained from patients with acute (13) and chronic (14) otitis media, chronic sinusitis and mastoiditis (15,16), peritonsillar abscesses (17), peritonitis (18,19), liver and spleen abscesses (20), abdominal abscesses (21), and neonatal conjunctivitis (22,23). Eubacterium spp. are part of the flora of the mouth and the bowel. They have been recognized as pathogens in chronic periodontal disease (29) and in infections associated with intra-uterine devices (30), and have been isolated from patients...

Educational outreachacademic detailing

Increased prescribing of first-line agents (amoxicillin) for acute otitis media Increase prescribing of first-line agents for UTI, bacterial tonsillitis, otitis media, bacterial bronchitis, mild pneumonia Mean difference from controls between pre and post intervention periods 382 (mean number of units prescribed) (p 0.0006). Significant increase in prescribing of amoxicillin from median 293 prescriptions per physician to 594 (p < 0.05) and doxycycline from median 235 prescriptions per physician to 865 (p < 0.05) (within group comparison only). Both recommended first-line agents for otitis media and pneumonia, respectively. randomized by geographic region, examined changes in the prescribing of first-line agents for acute otitis media (Dolovich et al., 1999) and tonsillitis (De Santis et al., 1994) in response to academic detailing by a pharmacist. Three of the physician randomized RCTs examined the effectiveness of academic detailing on reducing the use of particular antibiotics,...

Do We Want New Antibiotics for Mild Infections Is Bacterial Bronchitis in the Setting of Chronic Lung Disease a Mild

The FDA and Europe could make an enormous difference immediately. First, for mild, acute infections like otitis, sinusitis and bronchitis, they need to reconsider their entire approach. For example, for otitis, where most authorities agree that expectant therapy is a reasonable approach, placebo-controlled trials remain difficult to accomplish, especially in the US. Guidelines from the American Society of Pediatrics suggest that patients with severe symptoms, those age 2 or less and those where the diagnosis is certain that it is otitis media, be treated with antibiotics immediately. This leaves older children, those with milder disease and those where the diagnosis is less certain (the majority of patients) available for expectant therapy. Nevertheless, recent surveys have shown that only 15 of children in the US are treated expectantly. The most common reason is parental concern (85 of parents) about not using antibiotics. One solution is based on a recent study reviewing many...

Medical Professionals

A major factor is imperfect knowledge of the prescriber. This lack of knowledge has to do with insufficient knowledge of infectious diseases, the potential causative microorganisms and their susceptibility to antimicrobials, and expertise on antimicrobial drugs. With regard to the latter, there is probably too little emphasis in most medical curricula on the relevance of prudent antibiotic prescribing. Imperfect knowledge of infectious diseases leads to insecurity about the diagnosis and difficulties of distinguishing in the clinic between bacterial and viral infections. Apparently, many physicians do not know (or ignore) that antibiotics do not influence the outcome in most cases of common infections such as otitis media, sinusitis, acute bronchitis, and chronic obstructive pulmonary disease.5-9 In a series of elegant studies Holmes et al. showed that antibiotics do not alter the natural course of cough.10 Poor case definition also in the hospital setting will lead to indiscriminate...

Tcell And Combined Disorders

Primary disorders of T-cell function and combined T-cell defects come in many forms. One combined immunodeficiency, Wiskott-Aldrich syndrome (WAS), results from defects in the gene for the WAS protein (WASP), encoded on the X chromosome. WASP is a complex protein that functions in phagocytosis of microorganisms and apoptotic cells and regulation of cytoskeletal architecture in T-cells and platelets. WAS results in to profound humoral and cellular deficiency hallmarked by eczema, excessive bleeding, and thrombocytopenia. Patients usually have elevated levels of IgE and IgA accompanied by low levels of IgM. Atopic dermatitis and recurrent infections, including otitis media, pneumonia, sinusitis, meningitis, or sepsis, with pneumococci or other encapsulated bacteria present during the first 12 mo. BMT from HLA-identical siblings or HLA-matched unrelated donors have resulted in complete correction of both platelet and immunological abnormalities. Severe combined immunodeficiency (SCID)...

Evolution Of Antibiotic Resistance

However, highly penicillin-resistant isolates are invariably cross resistant to a range of P-lactam antibiotics including cefotaxime and ceftriaxone 20 , posing reduced therapeutic options. In countries such as Spain, Hungary, and South Africa lack of susceptibility to penicillin among S. pneumoniae is not only found among a high proportion of all pneumococci isolated 21,22 , but isolates possess levels of resistance to penicillin of 1 to 4 mg L and occasionally up to 8 to 16 mg L 23 . Recent clinical studies have shown that P-lactams are generally still useful for the treatment of pneumococcal infections that do not involve cerebrospinal fluid 24,25 as pneumococcal bacteremia caused by PNSP is not associated with increased morbidity or mortality 26 and there is no poorer outcome for pneumo-coccal pneumonia caused by intermediately resistant strains, when patients were treated with amoxicillin 27 . It is less clear whether this is also the case for otitis media 28...

BL in Clinical Infections

BL activity was detected in 46 of 88 (55 ) ear aspirates that contained BLPB (184). Brook et al. found BL activity in ear aspirates of 30 of 38 (79 ) children with chronic otitis media (209), in 17 of 19 (89 ) ear aspirates of children with acute otitis media who failed amoxicillin (AMX) therapy (210), and in 12 sinus aspirates (three acute and nine chronic infection) of the 14 aspirates that contained BLPB. The predominant BLPBs in acute sinusitis were H. influenzae, and Moraxella catarrhalis those in chronic sinusitis were S. aureus, Prevotella spp., Fusobacterium spp., and B. fragilis (see Table 5, chapter 14) (211).

Specimen Collection and Transport

For the laboratory diagnosis of external otitis, the external ear should be cleansed with a mild germicide such as 1 1000 aqueous solution of benzalkonium chloride to reduce the contaminating skin flora before obtaining the culture. Material from the ear, especially that obtained after spontaneous perforation of the eardrum or by needle aspiration of middle ear fluid (tympanocentesis), should be collected by an otolaryngologist, using sterile equipment. Cultures from the mastoid are generally taken on swabs during surgery, although actual bone is preferred. Specimens should be transported anaerobically.

Temporomandibular Disorder

TMD can produce a range of symptoms, most commonly pain in or around the jaw joint. Other symptoms include limited movement or locking of the jaw pain that radiates to the face, neck, or shoulders a painful clicking, popping, or grating sound in the jaw joint when the mouth is opened and a sudden change in the way the upper and lower teeth fit together. Headaches, earaches, hearing problems, and dizziness also may sometimes be linked to TMD.

Reduction of Unnecessary Antimicrobials

Correct diagnosis to differentiate viral from bacterial infection is a key to limiting unnecessary antimicrobials. Unfortunately, there is a lack of rapidly available, cost-effective diagnostic tests, which reliably differentiate self-limiting, viral from bacterial infection. However, practice guidelines can offer pragmatic criteria for better antimicrobial usage. For example, restriction of antibiotic therapy in otitis media to those children with acute bacterial disease and avoidance in otitis media with effusion could reduce unnecessary use by two-thirds (35). The Consensus Group concluded that antibiotics that maximize bacterial eradication improve both short- and long-term clinical outcomes, reduce overall costs particularly those relating to treatment failure and consequent hospital admis-sion and assist in the minimization of resistance emergence and dissemination. They believe that a radical re-evaluation of RTI therapy, incorporating these principles, is long overdue, to...

Effect Of Interventions On Patient Outcomes

Two studies examining the effect of patient-based interventions on antibiotic use also examined the effect of withholding antibiotics on the clinical outcomes of enrolled patients. Both of these studies examined the effect of delaying antibiotic prescriptions, one for acute otitis media in children and one for the common cold in adults. Both studies documented reduced antibiotic use by those patients randomized to the delayed antibiotics groups of the respective studies. In the otitis media study (Little et al., 2001), parents were requested to complete a daily diary regarding presence of symptoms (earache, unwellness, sleep disturbance), perceived severity of pain, number of episodes of distress, use of paracetamol, and temperature measurements. Overall, parents of patients in the immediate antibiotic group reported fewer days of crying and sleep disturbance as well as less paracetamol use however, there was no difference in mean pain scores, episodes of distress or absence from...

Emergence of MDR Pathogens

Group A streptococcus (GAS) is the most common cause of tonsillopharyngitis requiring antibiotic therapy (25). GAS is associated with both suppurative and nonsuppurative complications (26). Suppurative complications include local cellu-litis, abscess formation, myositis, fasciitis, otitis media, and sinusitis. Nonsuppura-tive complications include rheumatic fever, streptococcal toxic shock syndrome, and glomerulonephritis. Prevention of acute rheumatic fever is the principle goal of treatment, but antibiotic therapy also reduces severity and duration of symptoms, shortens the infective period, and reduces suppurative complications.

Interventions to Improve Antibiotic Prescribing in the Community

Streptococcus pneumoniae is the most common community-acquired pathogen causing meningitis, bacteremia, pneumonia, and otitis media in young children. Population-based surveillance for invasive pneumococcal disease by the US Centers for Disease Control in selected regions has revealed an overall incidence of 21-24 cases per 100,000 population (Centers for Disease Control and Prevention, 2001). Antimicrobial resistance, especially penicillin resistance, among isolates of S. pneumoniae has increased throughout the world (where the incidence is substantially greater) since the late 1980s and early 1990s and threatens the ability to treat pneumococcal infections. Over the course of 8 years, the prevalence of invasive penicillin-resistant (intermediate

Measles Edmonston virus MeV

Prodromal stage 4-5 days, followed by mounting fever, the appearance of Koplik's spots on the buccal mucosa and rash on head and neck spreading to the trunk and limbs. Recovery usually rapid but the disease can be fatal, especially in poorly nourished children. The rash is dependent on the presence of a specific immune response and is absent from certain immunodeficient patients. The patient is most infectious in the prodromal period and transmission is by airborne droplets. Respiratory complications and otitis media due to secondary bacterial infection are common. Encephalitis occurs rarely but is a serious complication with high mortality and incidence of sequelae. Subacute sclerosing panencephalitis, a rare progressive degenerative disease of the CNS, is associated with chronic infection. Virion ether-sensitive, roughly spherical, 150 nm in diameter, buoyant density in CsCl about 1.27g ml, and contains a helical nucleocapsid of about 17 x 1100nm. The...

Peter W M Hermans Marcel Sluijter and Alex van Belkum 1 Introduction

Streptococcus pneumoniae (pneumococcus) is one of the leading bacterial pathogens causing illness and death among young children, the elderly, and persons with certain underlying medical conditions (1). Pneumococci are often part of the normal nasopharyngeal flora, especially in young children. Pneu-mococcal colonization is an important risk factor children colonized with S. pneumoniae more often develop acute otitis media than children who are not colonized (2-5).

The Clinical Consequences of Penicillin Resistance in Patients with Pneumonia

In recent years, there has been a greater concern to know the extent to which antimicrobial resistance may come to influence the morbidity and mortality of pneu-mococcal infections, specifically pneumonia. Treatment failures due to drug resistance have been reported with meningitis (Catalan et al., 1994 Sloas et al., 1992) and otitis media (Jacobs, 1996 Poole, 1995), but the relationship between drug resistance and treatment failures among patients with pneumococcal pneumonia is less clear (Buckingham et al., 1998 Choi and Lee, 1998 Deeks et al., 1999 Dowell et al., 1999 Feikin et al., 2000b Turett et al., 1999). Several studies of patients with CAP failed to find an independent association between pneumococcal resistance and outcome when strains with penicillin MICs < 1 mg l were considered (Feikin et al., 2000a Friedland, 1995 Pallares et al., 1995). For strains with penicillin MICs of 2-4 mg l some data suggest that there is no increase in therapeutic failure rates (Choi and Lee,...

Epidemiology And Risk Factors

Heparin- or heparinoid-induced thrombocytopenia Disseminated intravascular coagulation Cryofibrinogenemia Elevated coagulation factors VII, VIII Protein C and protein S deficiency Infections Otitis, mastoiditis, sinusitis Meningitis Infections were the leading cause of CVT until the development of antibiotics. Otitis and mastoiditis can cause thrombosis via direct seeding to the adjacent sigmoid and transverse sinuses (Table 1 ).

Historical Perspective

In the first three decades of the 20 th century there were numerous reports of PTS occurring in conjunction with chronic suppurative otitis media and mastoiditis to the extent that Symonds 170 in 1931 felt able to define a condition of otitic hydrocephalus in which CSF excess due to over-production or impaired absorption followed cranial venous sinus, particularly but not exclusively transverse sinus obstruction, occurring secondary to chronic middle ear or other infection. In addition, Liedler in 1928 102 was probably the first to describe PTS after ligation of one or both internal jugular veins in the treatment of chronic ear disease. Symonds' concept did not, however, survive the neuroradiological developments of the 1930s when the newly introduced techniques of encephalography and ventriculography showed that there was no demonstrable increase in the volume of fluid in the intracranial CSF-containing spaces in these cases. This has, of course, been an enduring difficulty in...

Streptococcus pneumoniae

Streptococcus pneumoniae is the most frequently isolated respiratory pathogen in community-acquired pneumonia and also a major cause of meningitis, otitis media and sinusitis, resulting in high rates of morbidity and mortality in Different from pneumonia, treatment failures due to pneumococcal resistance have been documented for meningitis and otitis media (Dowell et al. 1999). As far as pneumococcal meningitis is concerned, the level of penicillin attained in the cerebral spinal fluid (CSF), around 1 mg ml, does not sufficiently exceed the MIC of the penicillin nonsusceptible strain (Fernandez Viladrich

Resistance and Empiric Substitution

We calculated that the average spending per prescription for antibiotics to treat new cases of otitis media during 1997 and 1998 was 18.41. Our predicted per-prescription cost is 19.20 (95 confidence interval 17.08, 21.39). We estimated by restricting the coefficients on the year-attribute interactions to be zero that in the absence of resistance, the per-prescription cost would be only 15.05 (95 confidence interval 13.66, 17.03). Multiplying the difference between the actual per prescription cost and the simulated per-prescription cost by the total number of prescriptions for otitis media per year about 12 million yields an estimate of the impact of resistance on antibiotic costs ( 18.01 - 15.09) x 12,000,000 40,000,000. Thus we concluded that resistance increases total spending on antibiotics to treat new episodes of ear infection (about 216 million) by about 20 .

David H Howard and Kimberly J Rask

The data used to estimate the relationship come from a physician office visit-level survey spanning the period 1980 to 1998. They consist of 6,928 observations on patients younger than 18 years of age with a diagnosis of otitis media who received a prescription for 1 of 18 antibiotics. We use a conditional logit model to estimate market shares for each drug as a function of drug attributes such as price. We combine these attributes with a time trend variable and interpret these time-attribute interactions as measuring the impact of resistance levels (which are not observed) on physicians' drug choice. Using these results, we simulate what market shares would have been in 1997 and 1998 had resistance levels remained at 1990 levels by restricting the time-attribute coefficients to zero. By multiplying the market share for each drug by its price and then summing over drugs, we estimate what total spending would have been. Comparing this figure with actual spending, we conclude that...

Therapy And Prophylaxis

Supportive therapy only is indicated for most well nourished children. Antibiotic treatment is indicated for bacterial otitis media and pneumonia. Vitamin A (100,000 units for less than 12 months of age, 200,000 units for over 12 months of age) has resulted in 50 reduction of mortality in developing countries. In severe cases (including immunocompromised children), ribavirin has been administered systemically based on in vitro susceptibility testing, and some children have shown evidence of clinical response. Human immunoglobulin administered after exposure in a dose of 0.25 ml kg modifies the disease in most children if given within 3-5 days after exposure. A dose of 0.5 ml kg is recommended for immunocompromised children. An attenuated measles vaccine is available either as a single formulation or combined with attenuated mumps and rubella viruses (MMR). About 98 of children immunized at the age of 12-15 months develop an antibody response and vaccine efficacy is 90 following a...

Clinical Decision Support to Improve Antimicrobial Prescribing

A point-of-care decision support tool was used to improve antimicrobial selection and duration of therapy for acute otitis media 50 . This was a RCT involving 38 resident and attending physicians at a university-affiliated primary care pediatrics clinic in Seattle (Wash., USA) In this setting computerized prescriptions were used, and providers in the intervention arm received pop-up windows with evidence-based recommendations related to their antimicrobial selection, indication and duration of treatment. Providers had the option to view more detailed information or an abstract of the publication that was the source of the recommendation. The primary outcome was a reduction in duration of therapy below 10 days a secondary outcome was a reduction in use of any antimicrobial for otitis media. The proportion of episodes treated with less than 10 days of antimicrobials increased by 44 in the intervention group and 10 in the control group (p < 0.01). The proportion receiving any...

Biofilms and Persisters

According to the CDC, 65 of all infections in developed countries are caused by biofilms, bacterial communities that settle on a surface and are covered by an exopolymer matrix (Hall-Stoodley et al. 2004). These include common diseases such as childhood middle ear infection and gingivitis infections of all known indwelling devices such as catheters, orthopedic prostheses, and heart valves and the incurable disease of cystic fibrosis. Biofilms are produced by most if not all pathogens. Pseudomonas aeruginosa, causing an incurable infection in cystic fibrosis patients (Singh et al. 2000), and Staphylococcus aureus and Staphylococcus epider-midis, infecting indwelling devices (Mack et al. 2004), are probably the best-known biofilm-producing organisms. Biofilm infections are highly recalcitrant to antibiotic treatment. However, planktonic cells derived from these biofilms are in most cases fully susceptible to antibiotics. Importantly, biofilms do not actually grow in the presence of...

Clinical Presentation

Children with AOM typically complain of acute unilateral ear pain that occurs several days after a viral upper respiratory infection. The symptoms frequently start early in the morning and are associated with irritability and fever, although nausea, vomiting, and diarrhea are not uncommon. Otoscopy usually reveals a red, thickened, and bulging tympanic membrane. Insufflation (pneumatic otoscopy) generally demonstrates poor mobility of the drum. Importantly, the drum may also appear red in a crying child (because of increased vascularity of the tympanic membrane) and may lead to an incorrect diagnosis of AOM (see Table 7). Erythema of the tympanic membrane, AND OR Ear pain clearly relatable to the ears

Definitions and Epidemiology

Acute otitis media (AOM) refers to an acute suppurative infection of the middle ear space that usually lasts for 3 wk or less. Otitis media with effusion (OME previously referred to as secretory or serous otitis media) represents persistent middle ear fluid that most often follows an episode of AOM and may last for many months. Recurrent AOM is defined as three or more episodes of AOM during the preceding 6 mo. AOM is the most frequently diagnosed disease of children and is unusual in adult patients. It occurs in roughly 60 of children by the age of 1 yr and in 80 by age 3. Half of all children have had three or more episodes of AOM by age 3. Otitis media with effusion is similarly common, noted in approx 50 of patients during the first year of life.

Risk Factors For Resistance

Previous antibiotic use is the major risk factor for macrolide resistance (42). As a result, the prevalence of resistance is higher in children (particularly those with recurrent otitis media or in day care), recently hospitalized patients, and patients with penicillin-resistant isolates (14). In a study of adults with bacteremic pneumococcal pneumonia, prior exposure to a macrolide antimicrobial agent, failure to complete the course of prescribed drugs, prior flu vaccination, and Hispanic ethnicity were associated with an increased probability of macrolide resistance (43). However, in the same study, 55 of patients with macrolide-resistant infections reported no antimicrobial drug exposure in the preceding 6 months. Increasing use of new longer-acting macrolides has been strongly correlated with increasing resistance rates (16,44,45). It has been suggested that long-acting macrolides are more likely to lead to resistance due to lower peak serum concentrations and longer periods with...

Streptococcus Pneumoniae Resistance to Penicillin Mechanism and Clinical Significance

Streptococcus pneumoniae (S. pneumoniae) is the most commonly identified bacterial cause of meningitis (Schuchat et al., 1997), otitis media and acute sinusitis in adults (Barnett and Klein, 1995 Jacobs, 1996), and community-acquired pneumonia (CAP) at all ages throughout the world (Marston et al., 1997). It is also a frequent cause of bacteremia and one of the most frequent pathogens involved in Chronic Obstructive Pulmonary Disease (COPD) exacerbations.

Miscellaneous Other Grampositive Cocci

Th other genera listed in Table 17-2 are of low virulence and are almost exclusively associated with in-iections involving compromised hosts.19 A possible exception is the association of Alloiococcus otitidis with chronic otitis media in children.4 Certain intrinsic features, such as resistance to vancomycin among Leucono-slot p. and pediococd, may contribute to the ability of these organisms to survive in the hospital environment. However, whenever they are encountered, strong consideration must be given to then clinical relevance and potential as contaminants. These organisms can also challenge many identification schemes used for grampositive cocci, and they may be readily misidentified as viridans streptococci.

Streptococcus Pneumoniae And Viridans Streptococci

S. pneumoniae is a primary cause of bacterial pneumonia, meningitis, and otitis media, and the antiphagocytic properties of the polysaccharide capsule is the key to the organism's virulence. The organism may harmlessly inhabit the upper respiratory tract but may also gain access to the lungs by aspiration, where it may establish an acute suppurative pneumonia. In addition, this organism also accesses the bloodstream and the meninges to cause acute, purulent, and often life-threatening infections.

Box 14 Vaccine Resistant Pathogens

Vaccines for Streptococcus pneumoniae (also known as pneumococ-cus) illustrate the principle of replacement.29 This organism, which causes pneumonia, otitis media (middle ear infection), sinusitis, and meningitis, colonizes the nasopharynx of 50 of children and about 2.5 of adults. Two types of vaccine are available, one prepared against polysaccharides of 23 pneumococcal strains and the other against a nontoxic diphtheria protein conjugated to polysaccharide from 7 strains of S. pneumoniae. The former reduces the impact of disease, whereas the latter also eliminates colonization by the pathogen. Because more than 90 strains (serotypes) of S. pneumoniae have been identified, neither vaccine was expected to provide full coverage. Nevertheless, the 7-strain vaccine reduced invasive pneumococcal disease by more than 70 . The fraction of antibiotic-resistant pneumococci also dropped. However, elimination of vaccine strains as colonizers created an ecological niche for nonvaccine strains....

Evaluaton of Patients With Recurrent or Persistent Sinusitis

Fifty percent of children and 30-40 of adults with recurrent or chronic sinusitis are sensitized to common aeroallergens such as plant pollens, house dust mite, and animal danders. Assessment of IgE-mediated hypersensitivities by allergy skin testing or in vitro blood assays should therefore be performed in all patients because they may benefit from a comprehensive program of allergen avoidance, anti-allergic drug therapy, and, in selected cases, immunotherapy. Patients with severe, recurrent episodes of sinusitis associated with other infections (e.g., otitis, bronchitis, and pneumonia) may suffer from one of the antibody deficiency syndromes and should undergo a screening assessment of their immunoglobulin levels. If a deficiency is noted or still suspected after the initial testing, these patients should be referred to an allergist immunologist for further evaluation. Factors Associated With Otitis Media

Suggested Reading Sinusitis

Otitis Media Bluestone CD, Hebda PA, Alper CM, et al. Recent advances in otitis media. 2. Eustachian tube, middle ear, and mastoid anatomy physiology, pathophysiology, and pathogenesis. Ann Otol Rhinol Laryngol Suppl 2005 194 16-30. Daly KA, Rovers MM, Hoffman HJ, et al. Recent advances in otitis media. 1. Epidemiology, natural history, and risk factors. Ann Otol Rhinol Laryngol Suppl 2005 194 8-15. Hendley JO. Clinical practice. Otitis media. N Engl J Med 2002 347(15) 1169-1174. Rosenfeld RM, Culpepper L, Doyle KJ, et al. American Academy of Pediatrics Subcommittee on Otitis Media with Effusion American Academy of Family Physicians American Academy of Otolaryngol-ogy-Head and Neck Surgery. Clinical practice guideline otitis media with effusion. Otolaryngol Head Neck Surg 2004 130(5 suppl) S95-118.

Mild Infections Require Placebo Controlled Trials Industry Balks

Otitis media or middle ear infection might be the clearest example. These are the typical ear infections occurring mainly in childhood starting at around 6 months of age. Otitis media is painful and for many years clinical practice in the US was to treat them with antibiotics in the belief that killing the bacteria that cause the infection would result in more rapid relief of pain and would prevent potentially serious complications. Many parents in the US have had the experience of taking their sick child to their physician or to an emergency room for these infections. Some children who had repeated episodes were even given antibiotic prescriptions in a just in case sort of arrangement. If they had typical symptoms, they would call their doctor and start antibiotics until they could get into the office. It goes without saying that many antibiotics have FDA approval for their use in otitis media -all based on trials comparing one antibiotic with another and none with a placebo control....

Pkpd Characteristicsmagnitude Of Measure Predictive Of Activity

A variety of experiments have also demonstrated that the pharmacodynamic target is similar in treatment of infections at different sites of infection and for different infecting microbial species (1,4,6,24,25,38). For example, Leggett et al. (25) demonstrated that the 24 h AUC MIC of the fluoroquinolone ciprofloxacin necessary for efficacy (1 to 2 log reduction in bacterial numbers) against a species of Klebsiella pneumoniae and Pseudomonas aeruginosa, in both a thigh sepsis and pneumonia models was similar (approximately 24 h AUC MIC 100). Most importantly, the pharmacodynamic target associated with outcome has been shown to be similar among different animal species, including humans. For example, study T> MIC needed for efficacy with amoxicillin against pneumococci has been shown to be 40 to 50 in mice, rats, children with otitis media, and adults with sinusitis (4,6,12,36-38). The concordance of this pharmacodynamic target among animal species is not surprising, as the receptor...

Pneumonia The New Frontier New Trial Requirements for Pneumonia Will Make Approval Much More Difficult and Costly and

Along the same lines as their inquiry on otitis, sinusitis and bronchitis, the FDA recently examined the role of antibiotics in pneumonia. Those of us in the infectious diseases community held our collective breath waiting to see if the FDA would decide that they did not understand whether antibiotics had an effect on bacterial pneumonia. To us clinicians, that antibiotics have a dramatic beneficial effect in the treatment of pneumonia was obvious and well proven by our own personal experiences as physicians and by clear historical precedent. Many of us could not understand what the FDA was thinking.

Clinical Use Of Pharmacokinetics And Pharmacodynamics

Pneumococci, pharmacodynamic analysis would predict treatment failure for many of the antibiotics included in this group. The elevation in MIC reduces the T> MIC for all available oral cephalosporins well below the 40 target, and treatment failure would be anticipated (13,16,51). These predictions have been confirmed in studies of patients with both community-acquired pneumonia and upper respiratory tract infection (12,35-37,41). This type of pharmacodynamic knowledge has been used to develop treatment guidelines for otitis media, sinusitis, and community-acquired pneumonia, and these differences in pharmacodynamic potency are reflected in recent recommendations (13,14,16). In addition, these approaches to understanding antimicrobial efficacy have been used to determine the MIC levels for which organisms should be labeled susceptible or resistant, termed susceptibility breakpoints (10,52).

Pkpd And Hospital Treatment Guidelinesalgorithms

Similar to the modeling process described above, first the PK-PD measure that best predicts antimicrobial activity in vivo for the drug classes under consideration is identified. Next, the magnitude of the PK-PD parameter required for efficacy is determined (i.e., PK-PD target) for each drug-organism combination, and resistance may be defined for situations in which the PK-PD goal cannot be achieved. Subsequently, data from population pharmacokinetics and large in vitro susceptibility surveillance projects may be considered in the context of the PK-PD target. Finally, the likelihood of treatment success in the empiric therapy of the infection for each of the drugs can be determined. The most detailed prediction analysis has been undertaken by the Sinus and Allergy Health Partnership (16) for the development of appropriate antibacterial therapies for bacterial sinusitis and otitis media.

Abscesses Of The Head And Neck General Considerations

Staphylococcus aureus and Group A beta-hemolytic streptococci (GABHS) were established as the predominant pathogens in abscesses of the head and neck in most studies done until 1970 (1). However, when methodologies suitable for recovery of anaerobic bacteria were used, these organisms were found to predominate especially in infections that originated from sites where these organisms are the predominant flora (i.e., dental, sinus, and tonsillar infections) (2,3). The recovery of anaerobes from abscesses and other infections of the head and neck is not surprising because anaerobic bacteria outnumber aerobic bacteria in the oral cavity by a ratio of 10 1 (4). Furthermore, these organisms were recovered from chronic upper respiratory infections such as otitis and sinusitis, and from periodontal infections (1).

Pathogenesis and Microbiology

The adenoids are believed to play a role in several infectious and noninfectious upper airway illnesses. They may be implicated in the etiology of otitis media (87-91), rhinosinusitis (92,93), adenotonsillitis (94), and chronic nasal obstruction due their hypertrophy (95,96). Brook et al. (98) determined the qualitative and quantitative microbiology of core adenoid tissue obtained from four groups of 15 children each with recurrent otitis media (ROM), RAT, obstructive adenoid hypertrophy (OAH), and occlusion or speech abnormalities (controls).

Complications

These include acute otitis media (that is related to eustachian tube dysfunction or due to the presence of nasogastric tube), aspiration pneumonia, hypoxic encephalopathy, hyponatremia due to excretion of antidiuretic hormone in response to decreased atrial filling because of venous pooling in the paralyzed infant, urinary tract infection due to indwelling bladder catheter, Clostridium difficile collitis due to colonic stasis with manifestations of toxic megacolon and necrotizing enterocolitis (47), and septicemia associated with intravascular catheters.

Macrolides

Macrolides and azalides (e.g., azithromycin) exhibit time-dependent killing however, they produce prolonged postantibiotic effects (1,20,43). The pharmacodynamic parameter for these agents that correlates with efficacy is the AUC MIC ratio, rather than T> MIC. The AUC MIC ratio of free drug that predicts efficacy with drugs from the macrolide and azalide class in animal infection models is approximately 25 (20). Because the AUC is the integral of concentration over time, this value of 25 is essentially like averaging a drug concentration at one times the MIC over a 24-hour period, or 1 X 24. Studies in otitis media examining bacteriologic outcomes of azithromycin against pneumococci with varying in vitro susceptibility observed treatment success against organisms with lower MIC when the AUC MIC ratio would exceed a value of 25 (35). However, in treatment of infection due to less susceptible strains, the AUC MIC value was far below this target value and frequent bacteriologic...

Incidence

The incidence of M parallels that of AOM, peaking in those aged 6 to 13 months. The incidence of M has decreased since the advent of antimicrobial agents and has become quite rare. The incidence of M from AOM in the U.S.A., and other developed countries is currently 0.004 (1-3). However, developing countries have a higher incidence of M, mostly as a consequence of untreated otitis media. Although the incidence of the disease has significantly declined in the U.S.A., it is still a significant infection with the potential of life-threatening complications. Of great concern is the sharp increase noted in the last decade in the incidence of acute M in several locations (2). This increase may be due to the greater recovery rate of resistant organisms, increased virulence of the pathogens and a lower use of antibiotics for the therapy of AOM (3).

Diagnosis

Most of the literature has focused on overuse of antibacterial agents in situations where antibacterial treatment may not provide benefit. Examples of these situations include upper respiratory infection syndromes, acute non-P-hemolytic streptococcal pharyngitis, and acute bronchitis. Data from the 1996 National Ambulatory Medical Care Survey revealed that 61 to 72 of patients diagnosed with a cold, upper respiratory infection, or acute bronchitis were prescribed an antibacterial drug. Such prescriptions accounted for 15 of the total prescriptions for antibacterial drugs (9). Colds, upper respiratory infection syndromes, and acute bronchitis (in adults) are almost always caused by viral infection, and antibacterial therapy does not improve the outcome (10). Although acute sinusitis is frequently managed with antibacterial drugs, most patients have spontaneous resolution of symptoms. A recent placebo-controlled trial of amoxicillin treatment of acute sinusitis did not show a...

Etiology

After the diagnosis is made and the clinician determines that antibacterial treatment is warranted, the infectious etiology needs further consideration. The etiology for some infections may be established on the basis of clinical presentation, whereas further diagnostic testing is needed in other cases. In considering the need for etiologic diagnosis, clinicians must consider the difficulty of obtaining an appropriate specimen, laboratory costs, the likelihood of finding the etiology, the likelihood of serious outcome or complication with inappropriate therapy, and often, knowing how the etiology will alter treatment. For example, culture and pathogen identification is generally not needed for acute otitis media, acute rhinosinusitis, or uncomplicated urinary tract infections. In cases of simple cellulitis, the difficulty of obtaining uncontaminated specimens and low yield precludes routine culturing. The role of sputum cultures with community-acquired pneumonia is controversial for...

Reminders

Physician reminders, at the point of care, have been assessed by three physician randomized RCTs attempting to reduce antibiotic prescribing for two clinical syndromes, acute otitis media (Christakis et al., 2001) and sore throat (two studies of a similar intervention) (McIsaac and Goel, 1998 McIsaac et al., 2002) (Table 6). The principle behind this type of intervention is that if physicians are provided with information about specific treatments, at the time they are making prescribing decisions, inappropriate antibiotic use may be reduced. In one study, an online prescription writer was used to present computer-based point-of-care evidence on the optimal duration of antibiotics for acute otitis media in children in an effort to reduce the duration of prescribing for this condition (Christakis et al., 2001). The results indicated a significant increase in the proportion of prescriptions for otitis media that were of less than 10 days duration for intervention physicians compared...

Europe

In Norway, the most commonly recorded diagnosis was urinary tract infections, followed by acute bronchitis, ear infections, and non-specific upper respiratory tract infections in 1989 (Straand, 1998). The most prescribed antibiotics were narrow-spectrum penicillins (29 ), followed by tetracyclines (24 ), trimethoprim-sulfamethoxazole (17 ), and erythromycin (12 ). Narrowspectrum penicillin was used in a majority of ear infections, tonsillitis, nonspecific upper respiratory tract infections and sinusitis. Tetracyclines were most often prescribed for acute bronchitis and pneumonia and trimethoprim-sulfamethoxazole for urinary tract infections. In Sweden, a 1-week survey on 7,700 visits for infectious diseases in five counties was conducted in the year 2000 (Stalsby et al., 2002). Respiratory tract infections accounted for 70 of the diagnoses, of which 54 were prescribed an antibiotic, of which narrow-spectrum penicillin accounted for 62 of prescriptions, followed by tetracycline (14 )....

United States

In a sample survey 2,500-5,000 office-based physicians reported data on office visits, including information on antimicrobial drug prescribing between 1980 and 1992 (McCaig and Hughes, 1995). During the years, an increasing trend in the visit rate to office-based physicians for otitis media was observed, while the visit rate for sinusitis among adults was found to be higher in 1992 than in each of the other study years. The five leading diagnoses for which oral antibiotics were prescribed were otitis media, upper respiratory tract infection, bronchitis, pharyngitis, and sinusitis. A sample of community-based physicians in the National Ambulatory Medical Care Survey was used to collect data on 60,252 visits in 1991-2, 62,169 visits in 1994-5, and 37,467 visits in 1998-9 (Steinman et al., 2003). The estimated annual national number of prescriptions decreased from 230 million prescriptions in 1991-2 to 190 million prescriptions in 1998-9. Antibiotics were less frequently used in 1998-9...

Australia

Diagnoses for which patients were prescribed antibiotics were obtained from a survey, based on a sample of 420 general practitioners, stratified in line with the total population by age, location, and practice size (McManus et al., 1997). In 1995, for sinusitis, the most prescribed antibiotics were tetracycline (21 ), amoxicillin-clavulanate (18 ), and cefaclor (15 ). For otitis media, the most prescribed antibiotics were cefaclor (36 ), amoxicillin (21 ), and amoxicillin-clavulanate (21 ) and for bronchitis, amoxicillin (18 ) was followed by roxithromycin (17 ) and cefaclor (15 ). In urinary tract infections, trimethoprim-sulfamethoxazole (29 ) was most commonly prescribed followed by cephalexin (19 ), and amoxicillin-clavulanate (17 ).

Intervention Studies

In 1995, the CDC launched the Campaign for Appropriate Antibiotic Use in the Community (Emmer and Besser 2002). This campaign targeted the five respiratory conditions that account for more than 75 of all office-based prescriptions for all ages combined otitis media, sinusitis, pharyngitis, bronchitis, and the common cold. In collaboration with the American Academy of Pediatrics (AAP) and the American Academy of Family Physicians, the CDC developed six principles for appropriate use of antibiotics for pediatric upper respiratory tract infections (Dowell et al. 1998). They also produced health education materials for both parents and providers to promote appropriate use of antibiotics use. The objective of these materials was to stimulate discussion between patients and providers and change the current social perspective toward antibiotic drugs (Table 28.1). Acute otitis media (AOM) is one of the most common infections for which antibiotics are prescribed in the pediatric population,...

Alglucosidase Alfa

And launched as the ERT for Pompe disease. As a recombinant human enzyme, it is produced by transfected CHO cells as a 110-kDa precursor that targets lysosomes via the mannose-6-phosphate (M6P) receptor. Following endocytosis, the enzyme is transformed to its mature 76-kDa form that restores glycogen processing and reverses accumulation. The dosing regimen of alglucosidase alfa is 20mg kg infused over a period of 4h every two weeks. The pharmaco-kinetic properties are dose-proportional between 20 and 40 mg kg. Following a single infusion of 20mg kg, a Cmax of 162 + 31 mg mL, a clearance of 25 + 4mL h kg, a volume of distribution of 96 + 16L, and a half-life of 2.3 +0.4 h are observed. Two separate clinical trials evaluated the safety and efficacy of alglucosidase alfa. The first study restricted inclusion to patients less than seven months of age with demonstrated cardiac hypertrophy but no ventilatory support at first infusion. Efficacy was determined by decreased mortality and...

The Ketek Scandal

As I noted earlier, there are lots of antibiotics, including penicillin, approved for otitis, sinusitis and bronchitis based on the old approach (comparative rather than placebo-controlled trials). Some of these older antibiotics even have some level of toxicity. According to the FDA's own calculus, these products have a risk benefit ratio of zero since their benefit has never been shown using superiority or placebo-controlled trials. Has the FDA moved to remove marketing approval for these indications from these older antibiotics No. This point was driven home recently by the scandal over the FDA handling of a new antibiotic, Ketek (telithromycin). Even Congress got involved. This is a story I have followed closely and I was present at the final FDA meeting dealing with this new antibiotic. The Ketek story illustrates the effect of political pressure on the FDA process, FDA's inconsistent treatment of branded compared to generic antibiotics, and, in my view, their lack of leadership...

Antibody Disorders

Immunodeficiencies primarily affecting IgG antibody production usually do not result in recurrent infection until after maternal antibody wanes at 6-12 mo of age. Bruton's disease or X-linked agammaglobulinemia (XLA) is a primary immunodeficiency that is characterized by an inability to produce antibody because of the absence of mature B-cells. The defect resides in a gene, labeled the btk gene for Bruton tyrosine kinase, which is located on the X chromosome. Bruton tyrosine kinase is necessary for signal transduction in B-cell differentiation. Mutations in p heavy-chain and components of the surrogate light chain of B-cells results in defective B-cell maturation. Autosomal recessive agammaglobulinemia (ARA) is a phenotypically similar primary immunodeficiency. Defects in the B-cell linker protein (BLNK) and the transmembrane signal transducer Ig-a (CD79a) prevent B-cell development and cause ARA. The functional loss of these receptor proteins in ARA and btk in XLA blocks B-cell...

Newer Vaccines

Approximately 2.0 of the 10.6 million deaths that occur in young children each year are due to pneumonia (Wardlaw et al. 2006). About half of these deaths occur among children in sub-Saharan Africa and another 30 occur in the countries of south Asia (Bryce et al. 2005). In developing countries 11-20 million children with severe pneumonia are known to require hospital admission (Rudan et al. 2004). Streptococcus pneumoniae has been identified as a main bacterial cause of pneumonia (Shann 1986) and other pneumococcal diseases particularly in very young children where a polysaccharide vaccine is not very effective. Recent estimates from WHO indicate that pneumococcal infections are responsible for 1.6 million deaths each year, half of them in the age group under 5 and the highest risk is among the children less than 2 years old and in elderly person (WHO, 2007). Emergence of penicillin- and multiple drug-resistant pneumococci has compounded the problems of managing children with...

The Data

From the NAMCS for 1980, 1981, 1985, and 1989 to 1998, we selected as our initial sample all patients younger than 18 years of age with a diagnosis of otitis media, as long as that diagnosis was listed before any mention of a diagnosis for a respiratory problem (NAMCS allows physicians to record up to three diagnoses). This last step was taken so we could be reasonably certain that any antibiotic received was for otitis media rather than another problem. From the medical literature, we compiled a list of medications commonly prescribed for otitis media. We then narrowed the sample by selecting only patients who received one of the 18 drugs from this list for which at least 25 patients in the sample had received prescriptions. The 18 drugs account for more than 99 of all antibiotic prescriptions in the sample. Approximately 30 of otitis media patients do not receive an antibiotic. This percentage has remained constant over time, and we omitted these individuals from our analysis. The...

Studies in Children

Brook et al. (31) correlated the microbiology of concurrent chronic otitis media with effusion and chronic maxillary sinusitis in 32 children. Two-third of the patients had a bacterial etiology. The most common isolates were H. influenzae (9 isolates), S. pneumoniae (7), Prevotella spp. (8), and Peptostreptococcus spp. (6). Microbiological concordance between the ear and sinus was found in 22 (69 ) of culture-positive patients.