Letters to the Editor
P
Antibiotic
Recommendations for
Acute Otitis Media and
Acute Bacterial Sinusitis
To The Editors:
D
rs Wald and DeMuri provide an excel-
lent summary of the evolution of acute
otitis media (AOM) pathogens since the intro-
Downloaded from https://journals.lww.com/pidj by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3c9CHBlrWfCpzQmEuCIZKS2wG/j/yMsLSe8nW3n5cxnpGSBgnM8zWPw== on 03/18/2019
duction of the pneumococcal conjugate vac-
cine.1 However, predicting clinical treatment
failure rates by in vitro susceptibilities alone
has significant shortcomings, and we do not
agree that these epidemiologic changes alone
are sufficient to justify the recommendation
to use amoxicillin-clavulanate as a first-line
therapy for all patients.
First, despite the changes in micro-
bial epidemiology, the percentage of patients
potentially benefitting from broad-spectrum
antibiotic therapy is relatively small. For
example, clinical outcomes vary substan-
tially across pathogens; while only 19% of
AOM cases caused by Streptococcus pneu-
moniae self-resolve, 48% of Haemophilus
influenzae and 75% of Moraxella catarrha-
lis cases self-resolve.2,3 Thus, it is likely that
fewer patients benefit from treatment as the
proportion of patients with H. influenzae or
M. catarrhalis increases.
Based on the AOM pathogen distri-
bution provided by Drs Wald and DeMuri,
the spontaneous resolution rates previ-
ously mentioned and an assumption that
35% of H. influenzae produce β-lactamase,
we estimate that at least 58% of patients
will require no antibiotics, 29% will ben-
efit from amoxicillin and only 13% will
benefit from amoxicillin-clavulanate.
Furthermore, serious complications from
AOM are exceedingly rare and do not dif-
fer between patients who receive placebo
versus antibiotics.4 A marginal benefit in
symptom reduction is achieved with anti-
biotics; however, the number needed to
treat for symptomatic benefit at days 2–3
is 20 patients.4
Second, recent data show that the
clinical treatment failure for acute respiratory
infections in children is low and does not dif-
fer between patients who receive narrow- and
broad-spectrum antibiotics (3.1% narrow
The authors have no funding or conflicts of interest
to disclose.
Address for correspondence: Holly M. Frost, MD;
E-mail: holly.frost2@dhha.org.
Copyright © 2019 Wolters Kluwer Health, Inc. All
rights reserved.
ISSN: 0891-3668/19/3802-0215
DOI: 10.1097/INF.0000000000002085
The Pediatric Infectious Disease Journal  •  Volume 38, Number 2, February 2019 www.pidj.com | 217
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
spectrum vs. 3.4% broad spectrum).5 Unfor-
tunately, post–pneumococcal conjugate
vaccine clinical trials evaluating treatment
failure rates for AOM specifically, including
those by Hoberman, Cohen, Tähtinen, and
Pichichero, have exclusively used broad-
spectrum antibiotics (amoxicillin-clavulanate
or cefpodoxime proxetil) leaving the clinical
failure rate of amoxicillin for treatment of
AOM in the post–pneumococcal conjugate
vaccine era unknown.5
Third, because AOM is, by far, the
most common indication for antibiotic use
in children, the potential downsides of this
recommendation are profound. Broad-spec-
trum antibiotic use places children at greater
risk for adverse drug events,5 selection for
antimicrobial resistant organisms and dys-
biosis of the microbiome. Additionally, a
recent cost-utility analysis by Shaikh et al6
found that the incremental cost-utility ratio
for treatment of AOM with amoxicillin-
clavulanate compared with amoxicillin was
high at $2331.18 per quality-adjusted life-
day gained.
While we acknowledge that changes
in the microbiology of AOM are important,
we would caution the use of in vitro data
alone to change treatment recommenda-
tions. Further studies evaluating the clini-
cal failure rate of amoxicillin compared
with broader-spectrum antibiotics, such
as amoxicillin-clavulanate, are needed to
inform recommendations. Given the lack of
certainty of the benefit of broader-spectrum
antibiotic use and the known harms, we are
not convinced that the use of amoxicillin-
clavulanate as a first-line therapy is justified
without additional data.
Holly M. Frost, MD
Department of Pediatrics
University of Colorado, Denver, CO
Department of Pediatrics
Denver Health and Hospital Authority,
Denver, CO
Jeffrey S. Gerber, MD, PhD
Division of Pediatric Infectious Diseases
Department of Pediatrics
University of Pennsylvania School of
Medicine, Philadelphia, PA
Adam L. Hersh, MD, PhD
Division of Pediatric Infectious Diseases
Department of Pediatrics
University of Utah, Salt Lake City, UT
REFERENCES
1. Wald ER, DeMuri GP. Antibiotic recommenda-
tions for acute otitis media and acute bacterial
sinusitis: conundrum no more. Pediatr Infect
Dis J. 2018;37:1255–1257.
2. Howie VM, Ploussard JH. Efficacy of fixed com-
bination antibiotics versus separate components
in otitis media. Effectiveness of erythromycin
estrolate, triple sulfonamide, ampicillin, erythro-
mycin estolate- triple sulfonamide, and placebo
in 280 patients with acute otitis media under two
and one-half years of age. Clin Pediatr (Phila).
1972;11:205–214.
3. Klein JO. Microbiologic efficacy of antibacterial
drugs for acute otitis media. Pediatr Infect Dis J.
1993;12:973–975.
4. Venekamp RP, Sanders SL, Glasziou PP, Del
Mar CB, Rovers MM. Antibiotics for acute otitis
media in children. Cochrane Database Syst Rev.
2015;(6):CD000219.
5. Gerber JS, Ross RK, Bryan M, et al. Association
of broad- vs narrow-spectrum antibiotics with
treatment failure, adverse events, and quality of
life in children with acute respiratory tract infec-
P
tions. JAMA. 2017;318:2325–2336.
6. Shaikh N, Dando EE, Dunleavy ML, et al. L
A cost-utility analysis of 5 strategies for the
management of acute otitis media in children.
J Pediatr. 2017;189:54–60.e3. H
2
Bacteremia by
Chryseobacterium
oranimense,
A Colistin-Resistant
Gram-Negative Bacilli, in
an Immunocompetent
Pediatric Patient 0
To the Editors:
W
e report the case of a 6-year-old
girl, with autism spectrum disorder,
who attended the emergency department T
because of an episode of decreased level of
consciousness without paroxysmal move-
ments, lasting 3 minutes, with fever the last
few hours. She showed somnolence, leth-
argy and incomprehensible sounds, without
neck stiffness, meningeal or focal signs. A
blood sample was taken with normal results F
except C-reactive protein 74 mg/L, and lum-
bar puncture was performed (cerebrospinal
fluid : glucose 53 mg/dL; proteins 25,5 mg/ 2
dL, 1 leucocyte/mm3). The patient was
admitted and treated with intravenous acy-
clovir and cefotaxime. On the third day, the
blood culture showed the isolation of Chry-
seobacterium oranimense. No other samples
were taken for further cultures. Polymerase
The authors have no funding or conflicts of interest
to disclose.
Address for correspondence: M. José Cilleruelo
Ortega, MD, PhD, Pediatric Infectious Diseases
Unit, Hospital Universitario Puerta de Hierro
Majadahonda, Calle Manuel de Falla, 1, 28222
Majadahonda, Madrid, Spain. E-mail: mjose.cil-
leruelo@gmail.com.
Copyright © 2019 Wolters Kluwer Health, Inc. All
rights reserved.
ISSN: 0891-3668/19/3802-0215
DOI: 10.1097/INF.0000000000002236