February 1996
GAINESVILLE, Fla.—Emergence of Streptococcus pneumoniae that are resistant to penicillin and other drugs places an onus on pediatricians to rethink how they care for children with otitis media.
Although treatment failures due to highly penicillin-resistant S pneumoniae are uncommon, pediatricians can no longer trust that standard empiric therapy with a 10-day course of amoxicillin will work. They also must prescribe antibiotics with an eye toward preventing development of drug-resistant pathogens, according to researchers.
Michael D. Poole, MD, PhD, Associate Professor of Otolaryngology and Pediatrics at the University of Florida, Gainesville, believes pediatricians can stem the unnecessary flow of antibiotics into the community by being more accurate in their diagnosis of otitis media. Accurately diagnosing otitis media requires a "fair amount" of clinical expertise, Poole said, and those providers who only occasionally care for children may misdiagnose otitis media. "We commonly see patients treated for red ear drum [with] no evidence of middle ear fluid or infection," he said.
He pointed to a series of 18 patients referred to his institution for tympanocentesis because they purportedly had persistent otitis media (OM). On examination, only five had received an accurate diagnosis, Poole said.
"We see particular problems in the indigent and Medicaid population," Poole said, "where providers may not have the clinical expertise of the more typical private practice pediatrician."
Even experienced pediatricians may have difficulty examining young children. Children younger than 2 years, who are at particularly high risk for drug-resistant bacterial ear infections, frequently have narrow ear canals that obstruct a view of the ear drum. "One little speck of wax keeps you from seeing very well," Poole said. In addition, young children may move about, making it difficult to inspect the ear drum carefully, "So the population that is getting to be the biggest therapeutic dilemma is the hardest to examine," Poole said.
Uncertain of their diagnosis, health care providers in emergency departments and clinics may be more apt to prescribe antibiotics, Poole said.
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Besides making an accurate diagnosis, another way to prevent drug-resistant organisms from emerging is to restrict the duration of antibiotic therapy. Pediatricians may be able to select patients for whom shorter courses of antibiotic therapy would be appropriate. Jack L. Paradise, MD, Professor of Pediatrics at the University of Pittsburgh, believes that pediatricians would be prudent if they limited duration of AOM therapy to 5 days in patients likely to have a favorable near-term outcome.
Writing in Pediatrics, Paradise stated that it "now seems reasonable" to individualize duration of therapy based on such factors as the child's age (generally, the older the child, the more favorable the outcome), severity of the AOM episode, season of the year, frequency of prior OM episodes, and the child's response to current treatment.
Embracing a 5-day regimen is "a leap of faith," though, because study data supporting its efficacy are limited and inconclusive, Paradise told Infectious Diseases in Children. His advocacy of a 5-day course of amoxicillin for treating AOM is based on clinical experience that the regimen works fine for some patients, whereas treatment for longer than 10 days often will be required for patients with stubborn infections. The crucial question for pediatricians is which patients will have good outcomes.
He noted that duration of treatment does not have to be decided at the first visit. Pediatricians can evaluate the patient on the fifth day of therapy and decide whether to continue therapy or stop it.
The threat posed by penicillin-resistant S pneumoniae has prompted Paradise and other OM authorities to call for greater restraint in the use of antibiotic prophylaxis to prevent recurrent AOM. Paradise believes that antibiotic prophylaxis for AOM should be avoided whenever possible, he said.
"If somebody had asked me 2 years ago what do you do with a kid with recurrent acute otitis media," he said, "I would have said, 'Put him on prophylaxis.' With more and more drug-resistant S pneumoniae emerging, however, "we have to back away from practices that we think encourage that to happen."
"It's a matter of going for restraint, not abolition," Paradise added.
In his Pediatrics commentary, he argued that "because of the probable contribution of antibiotic usage generally and of antibiotic prophylaxis specifically to pneumococcal resistance, subjecting children routinely to sustained antimicrobial prophylaxis seems dubious, its risks potentially outweighing its likely benefits. This seems particularly so for children in day care, who in any case are at increased risk of colonization with multiply resistant S pneumoniae."
Colin D. Marchant, MD, Associate Professor of Pediatrics at Tufts University, Boston, said he agrees with Paradise that pediatricians should use antibiotics more judiciously so as to prevent the spread of drug-resistant organisms. Toward that end, Marchant tries to limit antibiotic prophylaxis to 3 months instead of the 6- to 8-month courses he used to favor. Marchant said he supports antibiotic prophylaxis as first-line treatment for children at high risk for recurrent AOM. In these children, "we actually get more bang for our buck" preventing illness than treating it, he said. He also observed, "I would give prophylaxis at least a 3-month try before I'd put tubes in just about anybody."
Pediatricians should try antibiotic prophylaxis before ordering insertion of tympanostomy tubes, Marchant said. Amoxicillin, sulfisoxazole, and trimethoprim-sulfamethoxazole (TMP-SMX) are among the appropriate prophylactic drugs. At the last annual meeting of the American Academy of Pediatrics, G. Scott Giebink, MD, Professor of Pediatrics and Otolaryngology, at the University of Minnesota, Minneapolis, noted that amoxicillin prophylaxis is associated with a 44% to 60% decrease in the frequency of AOM. Sulfisoxazole is associated with a 43% to 86% decrease, and TMP-SMX, a 56% to 86% decrease, he said. When deciding whether to prescribe AOM prophylaxis, pediatricians should consider whether children are at increased risk for recurrent AOM. Children have this increased risk if they attend group day care, are exposed to tobacco smoke, have not been breast fed, have a cleft palate, or have siblings with a history of recurrent AOM, Giebink said. In addition to the risk factors that Giebink mentioned, pacifier use also may be associated with increased incidence of AOM, according to a recent study.
Pediatricians also may be able to reduce their use of antibiotics by preventing OM in the first place. They can try to address factors that put children at risk for OM, such as attendance at large day care centers, exposure to tobacco smoke, and not being breast fed.
To decrease an infant's risk for AOM and chronic OME, pediatricians might advise parents to avoid putting children into day care during the first 6 months of life, particularly babies who have not been breast fed, Giebink said. In addition, parents should opt for small day care facilities such as family day care. "Day care size, not the time spent in day care...is a very strong determinant of recurrent AOM and chronic OME," Giebink said. Parents also should choose day care centers where a separate staff takes care of infants exclusively, rather than day care centers where staff move between infants and older children. Such a system reduces the likelihood of transmission of pathogens to infants. If children live in households where they are exposed to tobacco smoke, pediatricians should tell parents that the smoke increases a child's risk for AOM.
Because penicillin-resistant and multidrug-resistant S pneumoniae may lead to AOM treatment failure, pediatricians must be sure to follow patients closely, Poole said. "Clinicians have to go back to fairly compulsive clinical follow-up of patients with AOM and other respiratory tract infections to make sure patients are responding to empiric therapy," Poole said.
In some places, failure of empiric AOM treatment frequently is related to infection with highly penicillin-resistant S pneumoniae (HPRSP). For example, a study of children from rural Kentucky showed that HPRSP caused 19 of 63 cases (30%) of AOM that did not respond to recent antibiotic treatment, defined as treatment within 3 days of when investigators obtained a culture sample of middle ear fluid.
Pediatricians may be tipped off to possible infection with drug-resistant S pneumoniae if AOM persists despite treatment with agents that provide good coverage for S pneumoniae and for gram-negative bacteria, Poole noted. Pediatricians also should heed clinical signs of S pneumoniae infection, such as rapid onset of febrile illness or spontaneous perforation of the tympanic membrane, Poole said. S pneumoniae is more likely to cause a serious illness than M catarrhalis and H influenzae. "The more fulminant the course of OM, the more likely it is to be streptococcal," Poole said.
For more information, see:
Paradise JL. Managing otitis media: A time for change. Pediatrics. 1995;96(4pt1):712-15.
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