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Persistent acute otitis media: II. Antimicrobial treatment
M E Pichichero1, C L Pichichero
1Department of Pediatrics, University of Rochester Medical Center, NY 14642, USA.
Abstract:
In this three-year prospective study, 137 children with acute otitis media (AOM) that had not responded after one or two empiric antimicrobial treatment courses (termed persistent AOM) underwent tympanocentesis to determine additional antimicrobial therapy based on in vitro susceptibility testing of the bacterial isolate(s). One hundred eleven children with AOM not previously treated are described for comparison. In the persistent AOM group middle ear aspirates grew Streptococcus pneumoniae (24%), Haemophilus influenzae (7%), Brahamella catarrhalis (7%), Streptococcus pyogenes (6%), Staphylococcus aureus (5%), two pathogens (3%) or no bacterial growth (49%); pathogens in previously untreated AOM were similar but fewer patients (30%) had no bacterial growth. After tympanocentesis additional antimicrobial therapy for persistent AOM patients utilizing drugs shown to be effective in vitro against the isolated pathogen failed to produce clinical resolution of infection in 27 (28%) of ears. Differing clinical efficacy was observed with various antimicrobials: amoxicillin (57% failure); trimethoprim/sulfamethoxazole (75% failure); cefaclor (37% failure); cefixime (23% failure); amoxicillin/clavulanate (12% failure); and cefuroxime axetil (13% failure). Presumptive clinical cure for previously untreated AOM patients was similar to that for untreated AOM except for fewer amoxicillin failures (30%). We conclude that clinical failure in persistent AOM occurs (1) even when no pathogen is isolated from tympanocentesis (50% of patients) and (2) despite demonstrated in vitro activity against culture-proved pathogens.
Insights
Persistent acute otitis media (AOM) treatment often fails, even with targeted antibiotics. This study found clinical failure in AOM patients occurred despite in vitro susceptibility testing and even when no bacteria were identified.
Area of Science:
- Pediatrics
- Infectious Diseases
- Microbiology
Background:
- Acute otitis media (AOM) is common in children.
- Persistent AOM, unresponsive to initial antibiotic courses, presents a clinical challenge.
- Understanding pathogen prevalence and antimicrobial resistance is crucial for effective AOM management.
Purpose of the Study:
- To investigate the efficacy of additional antimicrobial therapy guided by tympanocentesis and in vitro susceptibility testing in children with persistent AOM.
- To compare treatment outcomes between persistent AOM and previously untreated AOM cases.
- To identify factors contributing to clinical failure in persistent AOM.
Main Methods:
- Prospective study of 137 children with persistent AOM undergoing tympanocentesis.
- Bacterial culture and in vitro susceptibility testing of middle ear aspirates.
- Comparison with 111 children with previously untreated AOM.
- Administration of additional antimicrobial therapy based on susceptibility results.
Main Results:
- In persistent AOM, middle ear aspirates revealed pathogens in 51% of cases, with Streptococcus pneumoniae being most common (24%).
- Despite in vitro susceptibility, 28% of persistent AOM cases failed to achieve clinical resolution with additional antimicrobial therapy.
- Amoxicillin showed the highest failure rate (57%), while amoxicillin/clavulanate (12%) and cefuroxime axetil (13%) demonstrated better efficacy.
Conclusions:
- Clinical failure in persistent AOM is frequent, occurring in 50% of cases even without identifiable pathogens.
- Treatment failure can occur despite demonstrated in vitro activity of prescribed antimicrobials against isolated pathogens.
- Current antimicrobial strategies may be insufficient for managing persistent AOM, necessitating further research into alternative treatments and resistance mechanisms.