kakakeiopri
TRANSCRIPT
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The changing guidelines for AOM treatment along with the
growing antibiotic resistance globally may lead to a rise in the number of AOM
complications [23]. The incidence of AM in our
hospital district has increased relative to earlier data. ifferent
pathogens cause different clinical findings of AM.
!t is important to ta"e bacterial cultures of the middle ear effusion and to treat the patients according to these results. !n our
sub#ect pool$ older children had more previous antibiotic
treatment %p & '.'(). This partially e*plains the tendency towards
more culture+negative findings.
,e compared our data with the data published by -es"inen
et al. [] The patients in their study comprised children %'/0(
years) treated for AOM complications at 1elsin"i niversity
entral 1ospital$ epartment of Otorhinolaryngology$ between
0' and 2'''. The incidence of complications was higher in our
material %0.44 vs. 0.050'' '''5year). 6. pneumoniae %347 vs. 2(7)
and 6. pyogenes %007 vs. 87) were more common$ but 9. aeruginosaless common %007 vs. 227) in our material. Mastoidectomy was
more common in the earlier material %((7 vs. 3:7). The sub#ect
pools were otherwise similar$ but differed in the number of 08+
year+olds %2 in our study) and in complications other than AM %37
in their study).
6. pneumoniae is "nown to be the predominant pathogen in
children with AM [08$2:]. Our results support this finding. 6.
pneumoniae wasmore common in younger than in older children. Of
the typical AOMpathogens$ 6. pneumoniae has been associated with
the greatest virulence [02$0:]. Otalgia and retroauricular symptoms
were common in patients with 6. pneumoniae. Otorrhoea was less
common %p & '.'3) in patients with 6. pneumoniae than in patients of
other pathogen groups. 9atients with 6. pneumoniae had more
destruction of the mastoid septa %p & '.'() relative to all other
pathogen groups.Mastoidectomy was performed in 3:7 of all cases$
most commonly in patients with 6. pneumoniae !5;.
;esistance problems of 6. pneumoniae to penicillin and
cefalosporines have been reported in several countries including
the nited 6tates [0($08] and
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burden caused by AOM and its complications. This may also
influence the resistance situation [2(]. 9> is "nown to decrease
the incidence of invasive 6. pneumoniae infections [28]. 9> is also
"nown to decrease the incidence of recurrent acute otitis media
[2?] and the need for tympanostomy tube insertions [2?$24].1owever$
no decrease has been reported in the incidence of AM after the introduction of 9> [08$2:]. Moreover$ a decrease in the
incidence after introduction of the vaccination followed by a rapid
return to pre+vaccination levels has been described [2]. Thismay
be due to pneumococcal serotype replacement [2$3']. A pneumococcal
con#ugate vaccination$ 9>0'$ was introduced to the
=innish national immuni@ation protocol in 6eptember 2'0'. The
effect of these vaccinations on the incidence of AM has not yet
been estimated in =inland [30]. espite vaccinations$ 6. pneumoniae
must remain our main target when treating AOM and AM.
;esistance problems must be considered and antibiotics chosen
accordingly. nnecessary prescription of antibiotics must beavoided but complicated cases of OM need prompt treatment.
6. pyogenes was the most common isolated pathogen in AOM
in the first half of the 2'th century [32]. AOM caused by
6. pyogenes has been associated with older age in children$ higher
local aggressiveness and higher rates of tympanic perforations
and mastoiditis [33]. Our findings were similar$ although
periosteal symptoms and protrusion of the pinna were less
common in the 6. pyogenes group than in other pathogen groups.
9atients with 6. pyogenes had less otalgia and less retroauricular
symptoms than the other groups. Otorrhoea was found in (?7 of
patients with 6. pyogenes. ,e hypothesi@e that otorrhoea may
lead to less otalgia by releasing the tension of the tympanic
membrane. AM caused by 6. pyogenes was more common in older
children.
9. aeruginosa is an opportunistic ram+negative bacterium
that causes infections when host defences are compromised$ [3:]
for e*ample$ after tympanostomy tube insertion [23]. Ongoing
pneumococcal infection may protect from and prior pneumococcal
infection predispose to pseudomonas infection [23].
9. aeruginosa has often been associated with mastoiditis caused
by chronic otitis media$ but has in previous studies been found to be a common pathogen in AM$ especially in children aged older
than : years [3(]. !n our study$ 9. aeruginosa was found in 007 of
patients$ all of whom were older than 2 years. The patients with
AM caused by 9. aeruginosa had mild signs and symptoms of
infection$ but all had otorrhoea. A clear correlation was found
between previous tympanostomy tubes and AM caused by
9. aeruginosa %p B '.''0).
Mastoidectomies were significantly more common in patients
who had received a@ithromycin prior to hospitali@ation %p & '.'2).
Co significant differences emerged in the number of mastoidectomies
performed between the groups receiving amo*icillin/ clavulanate$ amo*icillin or cephalosporines or in the group of
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patients receiving no previous antibiotic treatment. A@ithromycin
should not be used to treat AOM without results from bacterial
culture indicating its use. !n =inland$ the current recommended
dose of amo*icillin in the treatment of AOM is :' mg5"g5day [(]. !n
other countries$ a higher initial dose %4'/' mg5"g5day) is
recommended [2(]. linically$ amo*icillin/clavulanate is a goodchoice in treating AOM. !t has more adverse effects than
amo*icillin$ but has the best antibiotic coverage for all the usual
pathogens of AOM [2(]. The local antibiotic resistance pattern and
the bacteriology of AOM must be followed also after the launch of
9> vaccinations$ and future recommendations should be based on
these.
AM is a rare complication of AOM that must be treated
promptly to avoid potential further complications. Dacterial
cultures must be ta"en and the treatment chosen according to
the causative pathogen. 6. pneumoniae is the most common
pathogen in AM$ and initial treatment must cover it. 9neumococcalantibiotic resistance should be ta"en into account when treating
AOM and its complications.
(. onclusion
The clinical findings of AM differ according to the causative
pathogen.
6. pneumoniae$ especially strains with reduced susceptibility for
common antimicrobials$ causes severe symptoms and leads to
mastoidectomy more often than the other pathogens. 6. pneumoniae
with reduced susceptibility %!5;) was clearly overrepresented
in our mastoiditis children relative to the bac"ground population
%p B '.''0). 6. pyogenes causes less otalgia than the other
pathogens.
9. aeruginosa seems to especially affect children with tympanostomy
tubes$ but causes a less aggressive form of disease. =unding
This pro#ect was financially supported by the research funds of
1elsin"i niversity entral 1ospital and the =innish ;esearch
=oundation for Otology.
onflict of interest
,e have no conflicts of interest to declare.
Ac"nowledgements
The authors