Prof.Dr.Gazmend Bojaj Ph.D, Dr.med.

Gylxhan Hasani MD

Abstract
Acute otitis media and acute bacterial sinusitis are 2 of the most common indications for
antimicrobial agents in Children and Adults. Together, they are responsible for billions of dollars
of health care expenditures. The pathogenesis of the 2 conditions is identical. In the majority of
children with each condition, a preceding viral upper respiratory tract infection predisposes to
the development of the acute bacterial complication. It has been shown that viral upper
respiratory tract infection predisposes to the development of acute otitis media in 37% of
cases.
Currently, precise microbiologic diagnosis of acute otitis media and acute bacterial sinusitis
requires performance of tympanocentesis in the former and sinus aspiration in the latter. The
identification of a virus from the nasopharynx in either case does not obviate the need for
antimicrobial therapy. Furthermore, nasal and nasopharyngeal swabs are not useful in
predicting the results of culture of the middle ear or paranasal sinus. However, it is possible
that a combination of information regarding nasopharyngeal colonization with bacteria and
infection with specific viruses may inform treatment decisions in the future.

Background. A national 5-year follow-up study of infection-specific antibiotic use in primary

care was conducted to see if prescribing practices change after implementing new treatment
guidelines.

Methods. The data were collected during 1 week of November each year from 2012 to 2015
from 26 health care centers that covered a total population of 919,555 persons and in 2012 from
20 control health care centers that covered a population of 445,098 persons. National guidelines
for 6 major infections (otitis media, sinusitis, throat infection, acute bronchitis, urinary tract
infection, and bacterial skin infection) were published in 2010–2012. Multifaceted interventions
were performed by local trainers teaching his or her coworkers, supported by feedback and
patient and public information.

Results. The 6 infections targeted for intervention, together with unspecified upper respiratory
tract infection constituted 80%–85% of all infections. The proportion of patients who received
prescriptions for antibiotics did not change significantly. However, use of first-line antibiotics
increased for all infections, and the change was significant for sinusitis (P < .001), acute
bronchitis (P = .015), and urinary tract infections (P = .009). Also, the percentage of antibiotic
treatments prescribed for the recommended duration increased significantly. Correct prescribing
for respiratory tract infections improved by 6.4 percentage units (P < .001). However, there was
no statistically significant difference in performance between study and control health care
centers at follow-up.

Conclusions. Moderate qualitative improvements in antibiotic use were observed after

multifaceted intervention, but prescribing for unjustified indications, mainly acute bronchitis, did
not decrease. Obtained infection-specific information on management of patients with infections
in primary health care is an important basis for planning targeted interventions in the future.

Topic:
otitis media, acute child ear, middle health expenditures paranasal sinuses infection bacteria
diagnosis nasopharynx nose viruses upper respiratory infections antimicrobials
tympanostomy
microbial colonization
aspiration of nasal sinus
acute bacterial sinusitis
Issue Section:
supplement articles

Table 1.
Respiratory Viruses Detected During 864 Episodes of Upper Respiratory Tract Infection (URI)

Virus  Percentage of episodes 

Adenovirus  29 

Rhinovirus  25 

Enterovirus  18 

Coronavirus  9 
 Virus  Percentage of episodes 

Parainfluenza  8 

RSV  6 

Influenza A and
5 
B 

Virus  Percentage of episodes 

Adenovirus  29 

Rhinovirus  25 

Enterovirus  18 

Coronavirus  9 

Parainfluenza  8 

RSV  6 

Influenza A and
5 
B 

Overall, 37% of the episodes of URI were complicated by the development of AOM. Figure 1
depicts the rate of AOM and otitis media with effusion (OME), by virus, for all virus detection
methods combined. For example, for adenovirus, 70% of cases were associated with the
development of fluid in the middle ear; 45% were AOM and 25% were OME. Coronaviruses and
respiratory syncytial virus (RSV) were most likely to be associated with the development of
AOM. Of particular interest, AOM was more likely to develop when the virus was isolated by
culture rather than by polymerase chain reaction (PCR), reflecting the higher inoculum of virus
required for positive growth.

1 .Chonmaitree T,  Revai K,  Grady JJ, et al.

Viral upper respiratory tract infection and otitis media complication in young children, ClinInfect
Dis , 2008, vol. 46(pg. 815-23)

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2. Vesa S ,KleemolaM , Blomqvist S ,Takala A , Kilpi T , Hovi T.

Epidemiology of documented viral respiratory infections and acute otitis media in a cohort of
children followed from two to twenty-four months of age ,

Pediatr Infect Dis J, 2001, vol.20(pg.574-81)

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3. Alper CM , Winter B ,Mandel EM , Hendley JO ,Doyle WJ .

Rate of concurrent otitis media in upper respiratory tract infections with specific viruses,

Arch Otolaryngol Head Neck Surg,200, vol. 135(pg.17-21)

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4.Revai K,Mamidi D ,Chonmaitree T.

Association of nasopharyngeal bacterial colonization during upper respiratory tract infection
and the development of acute otitis media, Clin Infect Dis,2008, vol.46(pg.e34-7)

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