IMMUNOLOGY/INFECTIOUS DISEASES: New perspectives on common infections

Acute otitis media (AOM) and acute bacterial sinusitis (ABM) are 2 of the most common infections affecting young children. They are also 2 of the most frequent indications for antibiotic therapy in a pediatric practice, and, as such, have been the focus of scrutiny as a source of antibiotic overuse.

Ellen R. Wald, MD, reviewed proper diagnosis of AOM and ABM as a foundation for appropriate antibiotic prescribing and discussed the changing microbiology of these infections as a guide to effective antibiotic selection in her presentation titled “Otitis Media and Sinusitis: An Update.”

According to updated AOM guidelines, which were released by the AAP in 2013, the diagnosis of AOM hinges on careful otoscopy to identify a bulging tympanic membrane. The diagnosis of ABS is made based on application of stringent historic criteria. It requires onset with persistent symptoms (>10 days); onset with severe symptoms; or onset with worsening symptoms, which represents a third scenario for diagnosis added in the 2013 AAP ABS guidelines.

Antibiotic treatment of AOM and ABS is based on understanding of the most common pathogens for these infections, Wald said. While microbiological data are limited, it appears there has been a shift in their bacterial etiology that is likely attributable to the now near universal use of the pneumococcal conjugate vaccine. Available information from evaluation of tympanocentesis samples shows a decrease in AOM cases caused by Streptococcus pneumoniae and an increase in the prominence of Haemophilius influenzae infections, including a rise in the proportion of cases with beta-lactamase-positive strains.

These findings support choosing amoxicillin-clavulanate over amoxicillin as the preferred first-line treatment for AOM and using a “regular dose” versus a “high dose” regimen (45 mg/kg rather than 90 mg/kg of amoxicillin), according to Wald, noting this recommendation varies slightly from that in the AOM guideline.

She made the same recommendation for antibiotic treatment of ABS while observing that lack of current microbiological data is an even bigger issue with ABS than for AOM. However, Wald explained that it is reasonable to expect that bacterial causes are similar for the 2 infections because the pathogenesis of both involves secondary bacterial infection by common normal nasopharyngeal flora.

Ellen R. Wald, MD, FAAP, is professor and chair, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison.

Acute otitis media (AOM) and acute bacterial sinusitis (ABS) are 2 very common considerations in any busy pediatrician's office. In order to treat only those children who will truly benefit from antibiotic therapy, AOM and ABS should be diagnosed according to strict guidelines that have been developed by the AAP. Wald is a leading expert on the diagnosis and management of these conditions, and offers important advice for practitioners. She emphasizes the changing bacterial causes of AOM, especially the decrease in cases attributed to Streptococcus pneumoniae because of the widespread use of pneumococcal conjugate vaccine. With the decline of S pneumoniae and a rising number of Haemophilus influenzae infections in the upper respiratory tract, it is reasonable now to return to using antibiotics such as amoxicillin-clavulanate as first-line therapy instead of high-dose amoxicillin, which had been preferred for S pneumoniae. I think this advice will be especially important for community-based pediatricians who are on the front line of care for these common conditions. 

Paul Spearman, MD, is Nahmias-Schinazi Research Professor and Vice Chair for Research, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, and chief research officer, Children’s Healthcare of Atlanta.