Pediatric Infection: Otitis Media Therapy and Drug Resistance Part 2: Current Concepts and New Directions

Eugene Leibovitz, MD, Ron Dagan, MD, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel

Infect Med. 2001;18(5) 

In This Article

Prevention

The efficacy of different antibiotic regimens for the prevention of AOM -- such as amoxicillin or sulfisoxazole at half the therapeutic daily doses -- has been evaluated in many previous controlled clinical trials. A meta-analysis study found a significant reduction of new and symptomatic episodes of AOM in the treated groups.[54,55,56,57,58,59] The major concern related to the extensive use of chemoprophylaxis for AOM is the risk of emergence of resistant organisms.

At present, we must consider the tremendous increase in the resistance to antibiotics of the main pathogens that cause AOM ( particularly S pneumoniae) and the high rate of nasopharyngeal colonization with these pathogens in infants and toddlers, as well as the potential of prolonged antibiotic administration to considerably increase the resistance of these organisms. As a result, the decision to start antibiotic prophylaxis in a patient who has AOM must be made on an extremely selective basis.

This prophylactic approach should be limited to only those few patients who have entered the vicious circle in which they spend weeks and months almost continuously taking antibiotic treatment for recurrent AOM. The present recommendations reserve antimicrobial prophylaxis for children with recurrent AOM defined by having 3 or more documented episodes in 6 months or 4 or more episodes in 12 months.[59]

The concern for increased antibiotic resistance has led various investigators to examine the role of oligosaccharides and xylitol in the prevention of AOM episodes.[60,61,62,63] Children who used daily xylitol chewing gum or suspension were found to have significantly fewer AOM episodes than children who used sucrose chewing gum or suspension.[63,64]

Prevention of pneumococcal invasive diseases and also of AOM caused by pneumococci represents a tremendous challenge, especially in this era of antibiotic-resistant organisms. The excellent results obtained with the large-scale use of H influenzae type b conjugate vaccine have paved the way for the development of multivalent pneumococcal conjugate vaccines to be used for the prevention of pneumococcal invasive diseases and AOM.

Immunogenicity studies have indicated that infants respond to each conjugate polysaccharide type with concentrations of antibodies believed to be protective.[64] In addition, the use of conjugate vaccines in infants and toddlers has been shown to decrease the nasopharyngeal carriage of many pneumococcal serotypes, especially the resistant strains included in the vaccine.[65,66,67,68]

Three recent studies have demonstrated the clinical benefit of the conjugated vaccines in the prevention of AOM caused by S pneumoniae. Two of them, performed in California[69] and Finland,[70,71] showed a reduction in pneumococcal AOM after the administration of a 7-valent pneumococcal conjugate vaccine in infants. The third study, from Israel,[72] showed a reduction in respiratory infections, including AOM, and a reduction in antibiotic use in toddlers attending day-care centers following the administration of a 9-valent pneumococcal CRM197 vaccine.

Future studies require more complete answers to additional questions related to the reduction in the carriage of resistant strains, the possible replacement of vaccine strains by nonvaccine strains, the overall impact on the prevalence of multidrug-resistant strains, and the serum and local antibody levels required to confer protection against AOM.

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