A systematic review and meta-analysis of antimicrobial resistance in paediatric acute otitis media
Introduction
Acute otitis media (AOM) is defined as the presence of inflammation in the middle ear associated with an effusion, and accompanied by the rapid onset of signs and symptoms of an ear infection [1]. It is the single largest cause of infections amongst children [2] and is the most common cause for antimicrobial prescriptions for children in economically developed countries [1].
Many national guidelines for AOM recommend either immediate or delayed antimicrobial prescribing (amoxicillin in most circumstances), or observation with close follow-up [[3], [4], [5], [6]]. These guidelines are, in part, based on work which has shown that after two to three days of watchful waiting approximately 80% of children will spontaneously recover [7]. Important exceptions to this include; children younger than 2 years, those with bilateral AOM, and those with AOM and otorrhoea, where antibiotics may be more beneficial [8]. Despite these evidence-based guidelines, large scale studies from North America [[9], [10]], Europe [11], and the UK [12] have demonstrated excessive and inconsistent antimicrobial prescribing in paediatric AOM in general practice and secondary care.
There is a clear association between antimicrobial prescribing and the development of antimicrobial resistance [13], and the World Health Organisation (WHO) calculated that in Europe alone infections due to drug-resistant bacteria cause in excess of 25,000 deaths and cost at least 1.5 billion euros each year in direct healthcare costs and lost productivity [14]. Furthermore, there is also evidence that specifically associates antimicrobial use to the development of antimicrobial resistance in AOM, and demonstrates that this increases the likelihood of treatment failure [15].
Recent studies have sought to identify the pathogens responsible for paediatric acute otitis media [16], and older studies have also investigated the overall effectiveness of antibiotics in children with acute otitis media [8]. We present a comprehensive review and meta-analysis, of both the microbiology and antimicrobial resistance of AOM organisms to commonly used antimicrobial agents, with the aim of informing responsible antimicrobial stewardship.
Section snippets
Systematic review
A comprehensive literature search was performed using Medline, Embase and the Cochrane library up to and including January 2017. A keyword search was undertaken using the search terms ‘otitis media’ AND each of the following search terms: ‘aetiology’, ‘otopathogens’, ‘pathogens’, ‘microbiology’, ‘bacteria’, ‘anti-bacterial agents’, and ‘antibiotic resistance’. Search results were limited to those that were in the English language, human-only studies, and published from 1980 onwards. Duplicated
Results
The literature search yielded 7598 articles following the key-word search. Studies were limited to English language, human only studies, and studies from 1980-present day. Following deduplication this provided 4249 unique articles. Abstracts were screened for relevance to bacteriology or antimicrobial resistance in acute otitis media in children, which identified 204 articles. The full texts and bibliographies were read, and 48 articles [[17], [18], [19], [20], [21], [22], [23], [24], [25], [26]
Discussion
Even when a bacteriological cause for AOM is confirmed, many first-line antimicrobial treatments for AOM demonstrate drug-resistance. Whilst the analysed data indicates a pathogenic bacterial species was isolated in two out of every three cases of AOM, it is possible that the children in the studies analysed are at the more severe end of the AOM spectrum as they have engaged with medical services and had an intervention, such as tympanocentesis.
Of the positive cultures the bacteriology of AOM
Conclusions
Commonly used first-line antimicrobial agents are unlikely to confer any positive effect in many cases of paediatric AOM. Firstly, due to the frequently non-bacterial nature of the condition; and secondly, the evidence of bacterial resistance to commonly used first-line antimicrobial agents.
Author contributions
MM was responsible for the conception and content of the article, the database searches, data interpretation, and preparation of the manuscript. MD performed the statistical analysis, data interpretation, and assisted in manuscript preparation. JDP assisted with microbiological data interpretation and manuscript preparation. SP contributed clinical interpretation of data and manuscript preparation. JW contributed clinical interpretation of data and manuscript preparation. JP was responsible for
Data availability
The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.
Funding source
This work received no specific funding.
Competing financial interests disclosure
The authors have no financial relationships relevant to this article to disclose.
Conflicts of interest
The authors have no conflicts of interest relevant to this article to disclose.
Acknowledgements
Not applicable.
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