Bacterial pathogens and antimicrobial resistance in acute otitis media

Anales
de
Pedia ía
100
(2024)
173---179
www.analesdepedia ia.o g
ORIGINAL
ARTICLE
Bac e ial
pa hogens
and
an imic obial
esis ance
in
acu e
o i is
media夽
Amaia
Sánchez
A leguia,
Jo ge
del
A co
Rod ígueza,
Xabie
De
Velasco
Vázqueza,
Mikel
Gallego
Rod igob,
Ike
Gangoi ia,
San iago
Min egia,∗
aSe icio
de
U gencias
de
Pedia ía,
Hospi al
Uni e si a io
C uces,
Ins i u o
de
In es igación
Sani a ia
Bioc uces
Bizkaia,
Uni e sidad
del
País
Vasco,
UPV/EHU,
Ba akaldo,
País
Vasco,
Spain
bSe icio
de
Mic obiología,
Hospi al
Uni e si a io
C uces,
Ins i u o
de
In es igación
Sani a ia
Bioc uces
Bizkaia,
Ba akaldo,
País
Vasco,
Spain
Recei ed
13
Sep embe
2023;
accep ed
20
Decembe
2023
A ailable
online
12
Feb ua y
2024
KEYWORDS
Acu e
o i is
media;
An ibio ic;
Haemophilus
influenzae
Abs ac
In oduc ion:
Recen
s udies
show
an
inc ease
in
he
p e alence
o
Haemophilus
influenzae
and
a
dec ease
in
S ep ococcus
pneumoniae
among
he
bac e ia
ha
cause
acu e
o i is
media
(AOM).
The
objec i e
o
ou
s udy
was
o
analyse
he
dis ibu ion
o
pa hogens
iden ified
in
child en
aged
less
han
14
yea s
p esen ing
o
he
eme gency
depa men
wi h
AOM
and
hei
pa e ns
o
an imic obial
esis ance.
Pa ien s
and
me hods:
Single
cen e
e ospec i e,
analy ical
s udy
in
pa ien s
aged
less
han
14
yea s
wi h
a
diagnosis
o
AOM
in
whom
an
ea
d ainage
sample
was
collec ed
o
cul u e
in
he
paedia ic
eme gency
depa men
o
a
e ia y
ca e
hospi al
be ween
2013
and
2021.
Resul s:
Du ing
he
s udy
pe iod,
he e
we e
14
684
documen ed
ca e
episodes
co esponding
o
child en
wi h
a
diagnosis
o
AOM.
An
ea
d ainage
cul u e
was
pe o med
in
768
o
hose
episodes.
The
median
age
o
he
pa ien s
was
2
yea s,
57%
we e
male
and
70%
had
a
p e-
ious
his o y
o
AOM.
The
mos
equen ly
isola ed
pa hogens
we e:
Haemophilus
influenzae
(n
=
188
[24.5%];
15.5%
o
hem
esis an
o
ampicillin),
S ep ococcus
pyogenes
(n
=
86
[11.2%]),
S aphylococcus
au eus
(n
=
82
[10.7%]),
S ep ococcus
pneumoniae
(n
=
54
[6.9%];
9.4%
wi h
in e media e
esis ance
o
penicillin),
Pseudomonas
ae uginosa
(n
=
42
[5.5%])
and
Mo axella
ca a halis
(n
=
11
[1.4%]).
No
pa hogen
was
isola ed
in
34.9%
o
cases.
DOI
o
o iginal
a icle:
h ps://doi.o g/10.1016/j.anpedi.2023.12.008
夽P e ious
mee ings:
This
s udy
was
p esen ed
a
he
69
Cong ess
o
he
AEP,
June
1---3,
2023,
and
a
he
XXVI
Annual
o
he
Sociedad
Espa˜
nola
de
U gencias
de
Pedia ía,
May
16---18,
2022.
∗Co esponding
au ho .
E-mail
add ess:
[email p o ec ed]
(S.
Min egi).
2341-2879/©
2023
Asociaci´
on
Espa˜
nola
de
Pedia ´
ıa.
Published
by
Else ie
Espa˜
na,
S.L.U.
This
is
an
open
access
a icle
unde
he
CC
BY-NC-ND
license
(h p://c ea i ecommons.o g/licenses/by-nc-nd/4.0/).
A.
Sánchez
A legui,
J.
del
A co
Rod íguez,
X.
De
Velasco
Vázquez
e
al.
Conclusions:
Haemophilus
influenzae
is
he
leading
cause
o
AOM
in
child en
aged
less
han
14
yea s.
This,
combined
wi h
he
low
equency
o
isola ion
and
penicillin
esis ance
o
S ep o-
coccus
pneumoniae,
calls
in o
ques ion
he
app op ia eness
o
high-dose
amoxicillin
o
empi ic
ea men
o
AOM.
©
2023
Asociaci´
on
Espa˜
nola
de
Pedia ´
ıa.
Published
by
Else ie
Espa˜
na,
S.L.U.
This
is
an
open
access
a icle
unde
he
CC
BY-NC-ND
license
(h p://c ea i ecommons.o g/licenses/by-nc-nd/
4.0/).
PALABRAS
CLAVE
O i is
media
aguda;
An ibió ico;
Haemophilus
influenzae
Pa ógenos
bac e ianos
y
esis encia
a
los
an ibió icos
en
o i is
media
aguda
Resumen
In oducción:
Es udios
ecien es
se˜
nalan
un
aumen o
de
la
p e alencia
de
Haemophilus
influen-
zae
y
una
disminución
de
S ep ococcus
pneumoniae
en e
las
bac e ias
causan es
de
o i is
media
aguda
(OMA).
El
obje i o
del
es udio
es
conoce
la
dis ibución
de
mic oo ganismos
pa ógenos
iden ificados
en
U gencias
en
los
meno es
de
14
a˜
nos
con
OMA
y
su
pa ón
de
esis encias.
Pacien es
y
mé odos:
Es udio
e ospec i o,
analí ico
y
unicén ico
incluyendo
pacien es
meno es
de
14
a˜
nos
diagnos icados
de
OMA
en
los
que
se
ecogió
un
cul i o
de
sec eción
ó ica
en
el
se icio
de
u gencias
pediá icas
de
un
hospi al
e cia io
en e
2013
y
2021.
Resul ados:
Du an e
el
pe iodo
de
es udio,
se
egis a on
14684
episodios
con
diagnós ico
de
OMA,
ecogiéndose
en
768
cul i o
de
sec eción
ó ica.
La
mediana
de
edad
ue
de
2
a˜
nos,
el
57%
a ones
y
el
70%
habían
p esen ado
al
menos
una
OMA
p e ia.
Los
pa ógenos
más
e-
cuen emen e
aislados
ue on:
Haemophilus
influenzae
188
(24,5%;
de
ellos
15,5%
esis en es
a
ampicilina),
S ep ococcus
pyogenes
86
(11,2%),
S aphylococcus
au eus
82
(10,7%),
S ep ococ-
cus
pneumoniae
54
(6,9%,
de
ellos
9,4%
con
esis encia
in e media
a
penicilina),
Pseudomonas
ae uginosa
42
(5,5%)
y
Mo axella
ca a halis
11
(1,4%).
En
el
34.9%
no
se
aisla on
pa ógenos.
Conclusiones:
Haemophilus
influenzae
es
la
p ime a
causa
de
OMA
en
meno es
de
14
a˜
nos.
Es e
hecho,
jun o
a
la
baja
asa
de
aislamien os
y
esis encia
a
penicilina
de
S ep ococcus
pneumo-
niae,
cues iona
la
idoneidad
de
la
amoxicilina
a
dosis
ele adas
como
a amien o
an ibió ico
empí ico
de
la
OMA.
©
2023
Asociaci´
on
Espa˜
nola
de
Pedia ´
ıa.
Publicado
po
Else ie
Espa˜
na,
S.L.U.
Es e
es
un
a ´
ıculo
Open
Access
bajo
la
licencia
CC
BY-NC-ND
(h p://c ea i ecommons.o g/licenses/by-
nc-nd/4.0/).
In oduc ion
Acu e
o i is
media
(AOM)
is
one
o
he
mos
equen
ea-
sons
o
seeking
medical
ca e
and
ecei ing
an ibio he apy
in
child en,1,2 and
is
mo e
equen
be ween
ages
6
and
24
mon hs.3A
p esen ,
we
know
ha
app oxima ely
70%---92%
o
AOM
episodes
esol e
spon aneously
wi hou
need
o
an ibio he apy,
so
ini ia ion
o
empi ic
an ibio he apy
is
ec-
ommended
only
in
selec
pa ien s
based
on
age,
whe he
AOM
is
unila e al
o
bila e al,
he
in ensi y
o
pain,
he
se e i y
o
e e ,
he
p esence
o
isk
ac o s
o
he
impos-
sibili y
o
adequa e
ollow-up.4
The
mos
equen
causa i e
agen s
o
AOM
a e
S ep o-
coccus
pneumoniae,
Haemophilus
influenzae
and
Mo axella
ca a halis.1,5,6 The
p edominan
pa hogen
is
usually
S
pneu-
moniae,
and
he
ecommended
empi ic
he apy
is
high-dose
amoxicillin
due
o
he
high
p opo ion
o
s ains
wi h
in e -
media e
penicillin
esis ance.
In
ecen
yea s,
he e
ha e
been
a
numbe
o
ele an
changes.
On
one
hand,
he
es ic ion
o
he
indica ion
o
ea men
o
selec
pa ien s
has
been
associa ed
wi h
a
educ ion
in
he
equency
o
amoxicillin
esis ance
in
S
pneumoniae.7On
he
o he
hand,
ollowing
he
in oduc-
ion
o
he
7- alen
and
13- alen
pneumococcal
conjuga e
accines
(PCV7
and
PCV13),
he
dis ibu ion
o
pa hogens
has
been
changing.
Be o e
he
in oduc ion
o
hese
ac-
cines,
he
S
pneumoniae
se o ypes
co e ed
by
he
PCV7
accoun ed
o
60%---70%
o
cases.8,9 A e
he
in oduc ion
o
he
PCV13,
app oxima ely
15%---25%
o
cases
a e
caused
by
S
pneumoniae,6,10,11 while
he
p opo ion
o
AOM
cases
caused
by
M
ca a halis
and
H
influenzae
has
been
inc eas-
ing,
wi h
he
la e
bac e ium
accoun ing
o
50%---60%
o
cases.6Di e en
s udies
conduc ed
ou side
o
Spain
ha e
iden ified
H
influenzae
as
he
mos
equen
ae iological
agen
in
child en.12 Howe e ,
he
mos
ecen
guidelines
do
no
con empla e
changing
he
ecommended
empi ical
he -
apy
o
child en
wi h
AOM.11 Empi ic
he apy
mus
a ge
he
mos
equen
pa hogens.
I
he
change
in
he
ae iologi-
cal
agen
dis ibu ion
and
he
p edominance
o
H
influenzae
we e
co obo a ed
in
ou
s udy,
we
conside ed
ha
i
would
be
necessa y
o
adap
he
ecommenda ion
o
he
ini ial
empi ic
an ibio he apy.
Ou
wo king
hypo hesis
was
ha
H
influenzae
is
he
lead-
ing
pa hogen
causing
AOM
in
ou
a ea
and
ha
he
equency
o
in e media e-le el
penicillin
esis an
S
pneumoniae
is
low.
174
Anales
de
Pedia ía
100
(2024)
173---179
The
main
objec i e
o
he
s udy
was
o
de e mine
he
p e alence
o
di e en
bac e ial
pa hogens
and
hei
d ug
esis ance
p ofile
in
child en
aged
less
han
14
yea s
wi h
a
diagnosis
o
AOM
in
ou
au onomous
communi y.
The
sec-
onda y
objec i e
was
o
assess
he
app op ia eness
o
he
empi ic
an ibio he apy
cu en ly
ecommended
o
child en
wi h
AOM.
Me hods
We
conduc ed
a
single-cen e
e ospec i e
and
desc ip i e
s udy
in
pa ien s
wi h
AOM
in
whom
ea
d ainage
cul u e
was
pe o med
o
diagnosis
a
he
paedia ic
eme gency
depa -
men
(PED)
o
a
e ia y
ca e
hospi al
in
he
2013---2021
pe iod.
This
depa men
manages
app oxima ely
55
000
episodes
a
yea
in
child en
aged
0---14
yea s.
In
he
PED,
he
diagnosis
o
AOM,
o o hoea
and
mas-
oidi is
is
based
on
he
diagnos ic
c i e ia
es ablished
by
he
Sociedad
Espa˜
nola
de
U gencias
de
Pedia ía
(Spanish
Socie y
o
Paedia ic
Eme gency
Medicine)
and
he
In e -
na ional
Classifica ion
o
Diseases,
10 h
e ision
(ICD-10)
coding
sys em.13
We
conside ed
he
ollowing
a
ele an
pe sonal
his o y:
•
Follow-up
in
he
Depa men
o
O o hinola yngology
due
o
one
o
he
ollowing:
ecu en
AOM,
se ous
o i is
media,
adenoid
o
onsil
enla gemen ,
pa ien s
wi h
ea
ubes,
hea ing
loss,
choles ea oma
o
any
o he
disease
in ol ing
he
middle
o
inne
ea .
•
Cu en
ea men
ha
could
acili a e
he
de elopmen
o
bac e ial
in ec ions,
such
as
s e oids
o
immunosup-
p essan
d ugs.
The
s udy
included
e e y
pa ien
aged
less
han
14
yea s
gi en
a
diagnosis
o
AOM
in
whom
an
ea
d ainage
sample
was
collec ed
o
cul u e
(index
case).
In
ou
PED,
he
decision
o
pe o m
an
ea
d ainage
cul u e
es s
wi h
he
physicians
in
cha ge
o
he
pa ien ,
in
mos
cases
medical
esiden s
in
he
speciali y
o
paedia ics
unde
he
supe ision
o
an
eme -
gency
medicine
paedia ician
on
si e.
We
defined
e u n
isi
as
any
ca e
episode
o
which
he
same
pa ien
isi ed
he
PED
again
wi hin
72
h
o
he
ini ial
isi .
We
excluded
pa ien s
wi h
a
diagnosis
o
AOM
in
whom
an
ea
discha ge
cul u e
was
no
pe o med
and
hose
wi h
incomple e
da a
(missing
da a
on
isola ed
pa hogens,
d ug
esis ance
p ofile).
The
ea
discha ge
cul u e
was
ca ied
ou
by
seeding
he
discha ge
on
blood
aga ,
MacConkey
aga
and
en iched
chocola e
aga
pla es,
incuba ed
o
48
h
in
an
ae obic
a mo-
sphe e
o
he
MacConkey
aga ,
in
anae obic
condi ions
o
he
chocola e
aga
and
in
a
CO2-en iched
a mosphe e
o
he
blood
aga .
An ibio ic
suscep ibili y
es s
we e
conduc ed
an
in e -
p e ed
acco ding
o
he
cu en
s anda ds
o
he
Clinical
&
Labo a o y
S anda ds
Ins i u e
(CLSI)
o
each
pa hogen
and
each
yea .
The
p ima y
a iable
in
he
s udy
was
he
ea
discha ge
cul u e,
while
he
seconda y
a iables
we e
he
ele an
elemen s
o
he
pe sonal
his o y,
demog aphic
cha ac e -
is ics,
clinical
mani es a ions
and
findings
o
he
physical
Table
1
Cha ac e is ics
o
he
768
pa ien s
wi h
a
diagnosis
o
suppu a i e
acu e
o i is
media
in
whom
an
ea
discha ge
cul u e
was
pe o med.
Age
in
yea s
2
(1−4)
Male
sex
438
(57%)
Rele an
pe sonal
his o y
335
(43.6%)
P e ious
episode
o
acu e
o i is
media
538
(70.1%)
Fe e
241
(31.4%)
Ea ache
462
(60.2%)
Cold
symp oms 441
(57.4%)
Ea
displaced
away
om
head
15
(1.9%)
Bila e al
o i is
95
(12.4%)
Vomi ing
24
(3.1%)
Dia hoea
17
(2.2%)
Du a ion
in
hou s
24
(8−48)
Da a
exp essed
as
absolu e
equency
and
pe cen age
sa e
o
age
and
he
du a ion
in
hou s
o
he
o i is,
which
a e
exp essed
as
median
and
in e qua ile
ange.
examina ion,
he
ea men
ecei ed
in
he
PED
and
pa ien
ou comes.
S a is ical
analysis
We
ha e
exp essed
quali a i e
a iables
as
absolu e
and
ela i e
equencies
and
95%
confidence
in e als.
We
summa ised
con inuous
a iables
as
mean
and
s anda d
de i-
a ion
o
median
and
in e qua ile
ange
depending
on
hei
dis ibu ion.
We
compa ed
quan i a i e
a iables
wi h
he
S uden
es
and
ca ego ical
a iables
wi h
he
␹2 es
o
he
Fishe
exac
es .
We
conside ed
P
alues
o
less
han
.05
s a is ically
significan .
The
s udy
was
app o ed
by
he
Clinical
Resea ch
E hics
Commi ee
wi h
code
E22/35.
Resul s
In
he
pe iod
unde
s udy,
he e
we e
441
728
documen ed
ca e
episodes
in
child en
aged
less
han
14
yea s,
o
who
14
684
ecei ed
a
diagnosis
o
AOM
(3.3%).
In
his
subse ,
an
ea
discha ge
sample
was
collec ed
om
768
pa ien s
(5.2%).
Cul u es
we e
pe o med
mo e
equen ly
in
he
win-
e
mon hs,
wi hou
changes
du ing
he
s udy
pe iod
excep
o
a
dec ease
in
yea s
2020
and
2021.
Cha ac e is ics
o
he
pa ien s
The
median
age
was
2
yea s,
438
pa ien s
(57%)
we e
male,
335
(43.6%)
had
a
ele an
pe sonal
his o y
and
538
(70.1%)
had
had
a
leas
one
p e ious
episode
o
AOM.
Table
1
p esen s
he
cha ac e is ics
o
he
768
pa ien s
included
in
he
s udy.
O e all,
H
influenzae
was
he
mos
equen ly
iden ified
bac e ium,
p esen
in
188
pa ien s
(24.5%)
and
S
pneumoniae
was
isola ed
in
53
pa ien s
(6.9%),
wi h
he
pa hogen
dis ibu ion
changing
significan ly
based
on
he
age
o
he
pa ien s
(Table
2).
In
child en
aged
less
han
5
yea s,
H
influenzae
and
S
pyogenes
we e
he
mos
equen ly
iden ified
bac e ia.
In
olde
child en,
he
mos
equen
pa hogens
we e
S aphylo-
175
A.
Sánchez
A legui,
J.
del
A co
Rod íguez,
X.
De
Velasco
Vázquez
e
al.
Table
2
P e alence
o
mic oo ganisms
in
ea
discha ge
cul u es
om
pa ien s
wi h
a
diagnosis
o
suppu a i e
AOM
by
pa ien
age.
<2
yea s
2−5
yea s
6−13
yea s
To al
Haemophilus
influenzae
123
(34.6%)
58
(20.8%)
7
(5.3%)
188
(24.5%)
[21.6%---27.6%]
S ep ococcus
pyogenes
34
(9.6%)
46
(16.5%)
6
(4.5%)
86
(11.2%)
[9.2%---13.6%]
S aphylococcus
au eus
29
(8.1%)
22
(7.9%)
31
(23.3%)
82
(10.7%)
[8.7%---13.1%]
S ep ococcus
pneumoniae
31
(8.7%)
19
(6.8%)
3
(2.3%)
53
(6.9%)
[5.3%---8.9%]
Pseudomonas
ae uginosa
8
(2.2%)
17
(6.1%)
18
(13.5%)
43
(5.6%)
[4.2%---7.5%]
Mo axella
ca a halis
4
(1.1%)
7
(2.5%)
0
11
(1.4%)
[0.8%---2.5%]
Supe ficial
sap ophy ic
g ow h
51
(14.3%)
48
(17.2%)
32
(24.1%)
131
(17.1%)
[14.6%---19.9%]
O he
14
(3.9%) 11
(3.9%) 12
(9.0%)
37
(4.8%)
[3.5%---6.6%]
Nega i e
cul u e 62
(17.4%) 51
(18.3%) 24
(18.0%) 137
(17.8%)
[15.3%---20.7%]
Da a
exp essed
as
absolu e
equency
and
pe cen age
wi h
he
addi ion
o
he
95%
confidence
in e al
in
he
o al
column.
P
<
.01.
coccus
au eus
and
Pseudomonas
ae uginosa,
usually
ound
in
child en
wi h
o i is
ex e na.
The
median
age
o
he
pa ien s
wi h
isola ion
o
S
au eus
(3.5
yea s)
o
P
ae ugi-
nosa
(4
yea s)
was
significan ly
highe
compa ed
o
all
o he
pa hogens
( 1 --- 2
yea s;
P
<
.01)
and
hese
pa hogens
we e
iso-
la ed
mo e
equen ly
in
he
wa m
mon hs
(34.1%
S
au eus
and
50%
P
ae uginosa,
s
7.4%
o
he
es
o
pa hogens,
P
<
.01).
Table
3
summa ises
he
clinical
cha ac e is ics
o
he
pa ien s
in
ela ion
o
he
causa i e
agen
o
AOM.
The
dis ibu ion
o
bac e ia
did
no
change
significan ly
based
on
he
p esence
o
a
ele an
his o y
o
he
yea
unde
s udy,
excep
o
a
dec ease
in
he
isola ion
o
S
pyogenes
in
2020
and
2021.
Table
4
p esen s
he
d ug
esis ance
pa e ns
in
H
influen-
zae
and
S
pneumoniae.
In
all
153
pa ien s
wi h
a
diagnosis
o
AOM
and
an
ea
dis-
cha ge
cul u e,
a
s ain
o
S
pneumoniae
wi h
in e media e
esis ance
o
amoxicillin
was
isola ed
om
he
cul u e.
Discussion
The
bac e ium
isola ed
mos
equen ly
om
he
cul u es
o
ea
discha ge
samples
collec ed
om
child en
aged
less
han
14
yea s
wi h
a
diagnosis
o
AOM
in
ou
PED
was
H
influenzae.
To
ou
knowledge,
his
is
he
only
s udy
ca ied
ou
ecen ly
in
ou
a ea
in
a
la ge
sample
o
paedia ic
pa ien s,
and
i
co obo a es
he
findings
epo ed
elsewhe e.5,14 A
sys ema ic
e iew
ha
included
s udies
conduc ed
be ween
1993
and
201715 ound
ha
he
bac e ia
isola ed
mos
e-
quen ly
in
child en
wi h
AOM
we e
S
pneumoniae
(26.1%),
H
influenzae
(18.8%),
S
au eus
(12.3%)
and
S
pyogenes
(11.8%),
wi hou
clea
changes
du ing
hose
yea s,
p oba-
bly
on
accoun
o
he
limi ed
in o ma ion
a ailable
ega ding
he
pneumococcal
accina ion
s a us
o
he
child en
and
he
limi ed
da a
om
ecen
yea s.15 In
any
case,
mos
s udies
highligh ed
he
impac
o
he
pneumococcal
conjuga e
ac-
cine
and
he
shi
in
he
pa hogens
iden ified
in
child en
wi h
AOM,5,11,16 including
hose
wi h
se e e
disease.12 In
ou
se ies,
independen ly
o
whe he
he
pa ien s
had
no
did
no
ha e
a
ele an
his o y,
he
mos
equen ly
iden ified
bac e ium
was
H
influenzae,
ollowed
by
S
pyogenes,
while
S
pneumoniae
was
isola ed
in
sligh ly
less
han
7%
o
cases
and
isola ion
o
M
ca a halis
was
a e.
The
only
ele an
change
du ing
he
s udy
pe iod
was
he
dec ease
in
he
equency
o
isola ion
o
S
pyogenes
in
2020
and
2021,
a
finding
ha
mus
be
in e p e ed
wi h
cau ion
due
o
he
impac
o
he
p o ec i e
measu es
es ablished
on
accoun
o
he
COVID-
19
pandemic
on
espi a o y
diseases.
These
measu es
would
also
explain
he
dec ease
in
he
pe o mance
o
cul u es,
gi en
he
educ ion
in
he
diagnosis
o
espi a o y
in ec ions
ha
occu ed
in
hose
yea s.
An ibio ic
esis ance
pa e ns
mus
also
be
aken
in o
accoun
in
he
selec ion
o
empi ic
an ibio he apy.
App ox-
ima ely
15%
o
he
H
influenzae
isola es
we e
esis an
o
amoxicillin,
which
was
consis en
wi h
he
findings
o
se e al
p e ious
s udies12 and
lowe
compa ed
o
he
50%
epo ed
in
o he s.17 On
he
o he
hand,
none
o
he
S
pneumoniae
isola es
in
his
case
se ies
was
ully
esis an
o
penicillin
(minimum
inhibi o y
concen a ion
[MIC]
>
2),
while
9.3%
exhibi ed
in e media e
suscep ibili y.
This
a e
o
esis-
ance
is
lowe
compa ed
o
he
p e ious
li e a u e,
in
which
a es
o
15%---30%
ha e
been
epo ed,
due
o
he
eme -
gence
o
non accine
se o ypes.11 Today,
due
o
he
inc ease
in
he
equency
o
isola es
o
non accine
se o ypes15,18,19
wi h
educed
suscep ibili y
o
amoxicillin,
p esc ip ion
o
he
s anda d
dose
is
no
cu en ly
ecommended.11 The
p edominance
o
H
influenzae
in
ou
s udy
and
he
ac
ha
S
pneumoniae
s ains
wi h
in e media e
suscep ibil-
i y
o
amoxicillin
caused
app oxima ely
1
in
150
cases
o
AOM
b ings
in o
ques ion
he
app op ia eness
o
high-dose
amoxicillin
o
empi ic
ea men
o
child en
wi h
AOM.
Ou
findings
suppo
he
p esc ip ion
o
he
s anda d
dose
o
amoxicillin-cla ulanic
acid
o
ini ial
ea men .11,16,17,20
Howe e ,
he
modifica ion
o
he
an ibio ic
mus
be
con em-
pla ed
wi h
cau ion
gi en
ha
in
cu en
clinical
p ac ice,
he
eal-wo ld
equency
o
esolu ion
o
AOM
ea ed
wi h
na ow
spec um
e sus
b oad-spec um
an ibio ics
is
96.9%
e sus
96.6%.21 This
is
p obably
due
o
he
inc eased
p e a-
lence
o
o ganisms
ha
a e
mo e
likely
o
ha e
a
benign
cou se
and
cause
sel -limi ed
illness
in
addi ion
o
o e -
diagnosis
in
hese
pa ien s.17 Fu he mo e,
a
shi
om
he
p esc ibing
o
na ow-spec um
an ibio ics
o
b oad-
spec um
an ibio ics
could
significan ly
inc ease
mo bidi y
on
accoun
o
he
ad e se
e ec s
o
he
la e ,
o
ins-
ance,
h ough
inc easing
in
he
p e alence
o
in ec ion
by
Clos idium
di ficile
and
he
de elopmen
o
an imic obial
176
Anales
de
Pedia ía
100
(2024)
173---179
Table
3
Cha ac e is ics
o
he
pa ien s
in
ela ion
o
he
causa i e
agen
o
acu e
o i is
media.
H
influenzae
n
=
188
S
pyogenes
n
=
86
S
pneumoniae
n
=
53
M
ca a halis
n
=
11
S
au eus
n
=
82
P
ae uginosa
n
=
42
Age
in
yea s
1
(0.25−2)
[1.5−1.9]
2
(1−4)
[2.2−3.2]
1
(0−2.5)
[1.4−2.4]
2
(0−4)
[1.2−3.4]
3.5
(1−7)
[3.6−5.2]
4
(2−7)
[3.8−5.8]
Male
sex
113
(60.1%)
[53%---66.8%]
49
(57%)
[46.4%---66.9%]
24
(45.3%)
[32.6%---58.5%]
9
(81.8%)
[52.3%---94.9%]
50
(61%)
[50.2%---70.8%]
18
(42.9%)
[29.1%---57.8%]
Rele an
pe sonal
his o y
79
(42%)
[35.2%---49.2%]
27
(31.4%)
[0.11%---9.19%]
17
(32.1%)
[21.1%---45.5%]
3
(27.3%)
[9.7%---56.6%]
45
(54.9%)
[44.1%---65.2%]
22
(52.4%)
[37.7%---66.6%]
P e ious
acu e
o i is
media
151
(80.3%)
[74.1%---85.3%]
40
(46.5%)
[36.3%---57%]
34
(64.1%)
[50.7%---75.7%]
8
(72.7%)
[43.4%---90.3%]
57
(69.5%)
[58.9%---78.4%]
28
(66.7%)
[51.6%---79%]
Fe e
48
(25.5%)
[19.8%---32.2%]
39
(45.3%)
[35.2%---55.8%]
21
(39.6%)
[27.6%---53.1%]
2
(18.2%)
[5.14%---47.7%]
18
(22%)
[14.3%---32%]
8
(19%)
[10%---33.3%]
Cold
symp oms
115
(61.2%)
[54.1%---67.8%]
59
(68.6%)
[58.2%---77.4%]
34
(64.1%)
[50.7%---75.7%]
6
(54.5%)
[28%---78.7%]
36
(43.9%)
[33.7%---54.7%]
17
(40.5%)
[27%---55.5%]
Ea ache
99
(52.7%)
[46%---59.7%]
57
(66.3%)
[55.8%---75.4%]
33
(62.3%)
[48.8%---74.1%]
6
(54.5%)
[28%---78.7%]
38
(46.3%)
[35.9%---57%]
30
(71.4%)
[56.4%---82.8%]
Bila e al
o i is
17
(9%)
[5.7%---14%]
5
(5.8%)
[2.5%---12.3%]
0
(0%)
[0%---6.8%]
0
(0%)
[0%---25.9%]
4
(4.9%)
[1.9%---11.9%]
1
(2.4%)
[0.4%---12.3%]
Ea
displaced
away
om
head
au icula
0
(0%)
[0%---0.02%]
4
(4.6%)
[1.8%---11.4%]
1
(1.9%)
[0.3%---10%]
0
(0%)
[0%---25.9%]
0
(0%)
[0%---4.5%]
4
(9.5%)
[3.8%---22.1%]
Vomi ing
5
(2.7%)
[1.1%---6.1%]
2
(2.3%)
[0.6%---8.1%]
1
(1.9%)
[0.3%---10%]
0
(0%)
[0%---25.9%]
2
(2.4%)
[0.7%---8.5%]
1
(2.9%)
[0.4%---12.3%]
Dia hoea
3
(1.6%)
[0.5%---4.6%]
3
(3.5%)
[1.1%---9.8%]
4
(7.6%)
[3%---17.9%]
0
(0%)
[0%---25.9%]
2
(2.4%)
[0.7%---8.5%]
0
(0%)
[0%---8.4%]
Du a ion
in
hou s
15
(8−48)
24
(8−72)
22
(8−48)
10
(7.5−30)
24
(8−48)
24
(12−108)
July-Augus -
Sep embe
13
(6.9%)
[4.1−11.5]
8
(9.3%)
[4.8−17.3]
3
(5.7%)
[1.9−15.4]
1
(9.1%)
[1.6−37.7]
28
(34.1)
[24.8−45.5]
21
(50%)
[35.5−65.6]
Da a
exp essed
as
absolu e
equency
and
pe cen age
sa e
o
age
and
he
du a ion
in
hou s
o
he
o i is,
which
a e
exp essed
as
median
and
in e qua ile
ange,
in
addi ion
o
he
95%
confidence
in e al.
177

A.
Sánchez
A legui,
J.
del
A co
Rod íguez,
X.
De
Velasco
Vázquez
e
al.
Table
4
An imic obial
d ug
esis ance
p ofile
o
H
influenzae
and
S
pneumoniae.
H
influenzae
S
pneumoniae
[2.0]
Low-dose
ampi-
cillin/amoxicillin
Suscep ible
153
(81.4%)
[75.2%---86.3%]
48
(90.6%)
[79.7%---95.9%]
In e media e
0
(0%)
[0%---2%]
5
(9.4%)
[4.1%---20.2%]
Resis an
(MIC
≥
2
␮g/mL)
28
(14.5%)
[10.5%---20.7%]
0
(0%)
[0%---6.8%]
[2.0]
Amoxi-
cillin
+
cla ulanic
acid
Suscep ible
181
(96.3%)
[92.5%---98.2%]
In e media e
6
(3.2%)
[1.5%---6.8%]
Resis an
(MIC
≥
2
␮g/mL) 1
(0.5%)
[0.1%---2.3%]
Da a
exp essed
as
absolu e
equency
(pe cen age)
[95%
confidence
in e al].
MIC,
minimum
inhibi o y
concen a ion.
esis ance.17 The
modifica ion
o
empi ic
an ibio he apy
o
AOM
in
child en
should
be
accompanied
by
he
de elopmen
o
a
obus
mul icen e
su eillance
sys em,
clinical
as
well
as
mic obiological,
o
moni o
he
impac
o
he
change.
One
possibili y
would
be
o
indi idualise
an ibio he apy,
as
he e
a e
ce ain
di e ences
in
he
clinical
p esen a ion
o
AOM
based
on
he
causa i e
bac e ia.
Fo
ins ance,
i
is
known
ha
child en
wi h
a
p e ious
his o y
o
AOM
a e
mo e
likely
o
be
in ec ed
by
H
influenzae.1In
ou
s udy,
pa ien s
wi h
AOM
caused
by
H
influenzae
and
S
pneumoniae
we e
younge
compa ed
o
pa ien s
wi h
AOM
o
all
o he
ae iologies,
while
pa ien s
wi h
AOM
caused
by
H
influenzae
we e
mo e
likely
o
ha e
had
p e ious
episodes
o
AOM
o
ha e
a
ele an
pe sonal
his o y,
bu
hese
di e ences
we e
no
su ficien ly
la ge
o
es ablish
a
use ul
pa e n
o
suspec
he
ae iology
o
AOM.
Las
o
all,
app oxima ely
15%
o
cul u es
led
o
isola ion
o
S
au eus
o
P
ae uginosa,
bac e ia
usually
associa ed
wi h
o i is
ex e na,
in
ag eemen
wi h
p e ious
s udies.12 Based
on
ou
findings,
he
diagnosis
o
AOM
in
a
child
aged
mo e
han
6
yea s
wi h
ea ache
and
suppu a ion
should
be
made
wi h
cau ion,
especially
in
he
wa m
mon hs,
as
many
o
hese
cases
could
ac ually
be
o
o i is
ex e na.
The e
a e
limi a ions
o
ou
s udy.
On
one
hand,
a
cul u e
was
no
pe o med
in
e e y
child
wi h
a
diagnosis
o
AOM
who
had
ea
discha ge.
Whe he
o
no
o
o de
a
cul u e
was
le
o
he
judgmen
o
he
paedia ician
in
cha ge
o
he
pa ien .
I
is
possible
ha
cul u es
we e
o de ed
mo e
equen ly
in
pa ien s
wi h
mo e
se e e
AOM,
who
we e
no
heal hy
p io
o
he
episode
o
wi h
ea men
ailu e.
On
he
o he
hand,
bac e ia
we e
iden ified
by
means
o
con en ional
cul u e.
This
may
ha e
esul ed
in
he
unde es ima ion
o
he
p e alence
o
hese
pa hogens,
as
me hods
based
on
polyme ase
chain
eac ion
a e
mo e
accu a e
han
cul u e
o
middle
ea
fluid,22 especially
in
he
case
o
Mo axella
ca a halis.
The
s udy
was
conduc ed
in
a
single
cen e,
so
i s
findings
mus
be
ex apola ed
o
o he
se ings
wi h
cau ion,
al hough
we
belie e
ha
he
esul s
would
be
simila
in
o he
a eas
o
se ings
wi h
sim-
ila
social
and
heal h
ca e
condi ions,
chiefly
uni e sal
and
ee
accina ion
agains
pneumococcal
disease.
Las ly,
we
did
no
ha e
in o ma ion
on
he
se o ypes
o
he
isola ed
S
pneumoniae
s ains.
Al hough
his
was
no
an
objec i e
o
he
s udy,
i
would
ha e
allowed
us
o
de e mine
whe he
he
isola es
in
ou
hospi al
co esponded
o
he
g oup
o
cu en ly
eme ging
se o ypes
(23B,
24F,
14
and
11A).11
Las ly,
his
s udy
unde sco es
he
impo ance
o
es ab-
lishing
pe manen
su eillance
sys ems
o
moni o
he
mic obiological
p ofiles
o
di e en
in ec ious
diseases,
including
an imic obial
esis ance
pa e ns.18
I
is
easonable
o
conclude
ha
H
influenzae
is
now
he
leading
cause
o
AOM.
This
ac ,
combined
wi h
he
low
equency
o
isola ion
and
penicillin
esis ance
in
S
pneu-
moniae,
challenges
he
app op ia eness
o
using
high-dose
amoxicillin
o
empi ic
ea men
o
AOM.
P ospec i e
mul-
icen e
s udies
a e
equi ed
o
confi m
hese
findings.
Conflic s
o
in e es
The
au ho s
ha e
no
conflic s
o
in e es
o
decla e.
Re e ences
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