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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. Different
pathogens cause different clinical findings of AM.
It is important to take bacterial cultures of the middle ear
effusion and to treat the patients according to these results. In our
subject pool, older children had more previous antibiotic
treatment (p = 0.05). This partially explains the tendency towards
more culture-negative findings.
We compared our data with the data published by Leskinen
et al. [9] The patients in their study comprised children (015
years) treated for AOM complications at Helsinki University
Central Hospital, Department of Otorhinolaryngology, between
1990 and 2000. The incidence of complications was higher in our
material (1.88 vs. 1.1/100 000/year). S. pneumoniae (38% vs. 25%)
and S. pyogenes (11% vs. 6%) were more common, but P. aeruginosa
less common (11% vs. 22%) in our material. Mastoidectomy was
more common in the earlier material (55% vs. 34%). The subject
pools were otherwise similar, but differed in the number of 16year-olds (2 in our study) and in complications other than AM (3%
in their study).
S. pneumoniae is known to be the predominant pathogen in
children with AM [16,24]. Our results support this finding. S.
pneumoniae wasmore common in younger than in older children. Of
the typical AOMpathogens, S. pneumoniae has been associated with
the greatest virulence [12,14]. Otalgia and retroauricular symptoms
were common in patients with S. pneumoniae. Otorrhoea was less
common (p = 0.03) in patients with S. pneumoniae than in patients of
other pathogen groups. Patients with S. pneumoniae had more
destruction of the mastoid septa (p = 0.05) relative to all other
pathogen groups.Mastoidectomy was performed in 34% of all cases,
most commonly in patients with S. pneumoniae I/R.
Resistance problems of S. pneumoniae to penicillin and
cefalosporines have been reported in several countries including
the United States [15,16] and European countries [4]. However, in
a recent Swedish study of AM patients, S. pneumoniae with
reduced sensitivity to beta-lactam antibiotics was found in less
than 1% of the patients [8]. In our patients, 48% of the S.
pneumoniae had reduced susceptibility to penicillin or cefalosporines
(I or R). These bacteria were even more common in
younger children. Only 30% of them were totally resistant to
penicillin but 50% to 1st and 2nd generation cefalosporins.
(Table 4) The Swedish guidelines for diagnosis and treatment of
AOM introduced in 2000 propose watchful waiting as a treatment
option in healthy 216 year-old children with uncomplicated
AOM [3]. The Finnish guidelines mention this option but do not
suggest it as strongly. (Table 1) It is possible that this influences
the resistance situation in Finland. The prevention of otitis media
with vaccines is a promising approach to diminish the disease

burden caused by AOM and its complications. This may also


influence the resistance situation [25]. PCV is known to decrease
the incidence of invasive S. pneumoniae infections [26]. PCV is also
known to decrease the incidence of recurrent acute otitis media
[27] and the need for tympanostomy tube insertions [27,28].However,
no decrease has been reported in the incidence of AM after
the introduction of PCV [16,24]. Moreover, a decrease in the
incidence after introduction of the vaccination followed by a rapid
return to pre-vaccination levels has been described [29]. Thismay
be due to pneumococcal serotype replacement [29,30]. A pneumococcal
conjugate vaccination, PCV10, was introduced to the
Finnish national immunization protocol in September 2010. The
effect of these vaccinations on the incidence of AM has not yet
been estimated in Finland [31]. Despite vaccinations, S. pneumoniae
must remain our main target when treating AOM and AM.
Resistance problems must be considered and antibiotics chosen
accordingly. Unnecessary prescription of antibiotics must be
avoided but complicated cases of OM need prompt treatment.
S. pyogenes was the most common isolated pathogen in AOM
in the first half of the 20th century [32]. AOM caused by
S. 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 S. pyogenes group than in other pathogen groups.
Patients with S. pyogenes had less otalgia and less retroauricular
symptoms than the other groups. Otorrhoea was found in 57% of
patients with S. pyogenes. We hypothesize that otorrhoea may
lead to less otalgia by releasing the tension of the tympanic
membrane. AM caused by S. pyogenes was more common in older
children.
P. aeruginosa is an opportunistic Gram-negative bacterium
that causes infections when host defences are compromised, [34]
for example, after tympanostomy tube insertion [23]. Ongoing
pneumococcal infection may protect from and prior pneumococcal
infection predispose to pseudomonas infection [23].
P. 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 4 years [35]. In our study, P. aeruginosa was found in 11% of
patients, all of whom were older than 2 years. The patients with
AM caused by P. 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
P. aeruginosa (p < 0.001).
Mastoidectomies were significantly more common in patients
who had received azithromycin prior to hospitalization (p = 0.02).
No significant differences emerged in the number of mastoidectomies
performed between the groups receiving amoxicillin
clavulanate, amoxicillin or cephalosporines or in the group of

patients receiving no previous antibiotic treatment. Azithromycin


should not be used to treat AOM without results from bacterial
culture indicating its use. In Finland, the current recommended
dose of amoxicillin in the treatment of AOM is 40 mg/kg/day [5]. In
other countries, a higher initial dose (8090 mg/kg/day) is
recommended [25]. Clinically, amoxicillinclavulanate is a good
choice in treating AOM. It has more adverse effects than
amoxicillin, but has the best antibiotic coverage for all the usual
pathogens of AOM [25]. The local antibiotic resistance pattern and
the bacteriology of AOM must be followed also after the launch of
PCV 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. Bacterial
cultures must be taken and the treatment chosen according to
the causative pathogen. S. pneumoniae is the most common
pathogen in AM, and initial treatment must cover it. Pneumococcal
antibiotic resistance should be taken into account when treating
AOM and its complications.
5. Conclusion
The clinical findings of AM differ according to the causative
pathogen.
S. pneumoniae, especially strains with reduced susceptibility for
common antimicrobials, causes severe symptoms and leads to
mastoidectomy more often than the other pathogens. S. pneumoniae
with reduced susceptibility (I/R) was clearly overrepresented
in our mastoiditis children relative to the background population
(p < 0.001). S. pyogenes causes less otalgia than the other
pathogens.
P. aeruginosa seems to especially affect children with tympanostomy
tubes, but causes a less aggressive form of disease. Funding
This project was financially supported by the research funds of
Helsinki University Central Hospital and the Finnish Research
Foundation for Otology.
Conflict of interest
We have no conflicts of interest to declare.
Acknowledgements
The authors