Children’s Repetitive Ear Infections Due to Antibiotic Resistant

Children’s Repetitive Ear Infections Due to Antibiotic Resistant

Acute middle ear infection is common in children. Its incidence rises during the winter, when respiratory tract infections are common. With prompt treatment, the prognosis is excellent; however, prolonged fluid buildup in the middle ear causes chronic middle ear infection, with possible puncturing of the eardrum, which transmits sound vibrations to the inner ear.


Ear infections most often occur in children under the age of 2, but the problem can also be common between the ages of 5 and 6 — triggered by the respiratory illnesses picked up in kindergarten or first grade. Colds or allergies cause congestion, which may squeeze shut your child's eustachian tube, the tiny drainage pipe for the middle ear. Fluid trapped in the middle ear can become a breeding ground for viruses or bacteria.

Some people think that children with colds need antibiotics to prevent ear or sinus infections. Following a cold, about 10% of children will develop an ear infection and 1% will develop a sinus infection. Giving antibiotics to the other 89% who don't need them can cause the bacteria to become more resistant and your child to have unnecessary side effects. It is better to wait and give antibiotics to children who really have a bacterial infection. Widespread use will result in an increased incidence of resistance in the population and subsequent transmission of resistant strains.

Otitis media refers to inflammation in the middle ear area. There are different forms of otitis media. Typically, when the doctor refers to an ear infection, he or she is most likely talking about "acute otitis media" (although there's also the common ear infection called swimmer's ear, or otitis externa).

General practitioners are still prescribing antibiotics for up to 80% of cases of sore throat, otitis media, upper respiratory tract infections, and sinusitis, despite the fact that official guidance warns against this practice, according to an analysis of the world's largest primary care database of consultations and prescriptions, published in a supplement to the Journal of Antimicrobial Chemotherapy.

The intense and widespread use of antibiotics is leading to a serious global problem of bacterial resistance to common antibiotics. In the U.S., nearly a quarter of S. pneumoniae are currently resistant to at least three antibiotics. High rates of resistance strains are even being observed in infants. In general, regions and institutions with the highest rate of resistance are those in which antibiotics are the most heavily prescribed.

Why children often repetitively affected by ear infection or otitis media:

Weak immune systems: Children have more trouble fighting infections because of their immune systems are still developing. The clinical impact of antibiotic resistance varies with the site of infection, the ability of antibiotics to penetrate to that site, and the ability of the immune response to clear the infection. An eardrum that's red, bulging, and possibly draining is likely infected.

Eustachian tube: The lack of ventilation of eustachian tube may allow fluid from the tissue that lines the middle ear to accumulate. If the eustachian tube remains plugged, the fluid cannot drain and begins to collect in the normally air-filled middle ear.

Adenoids: Adenoids are composed largely of cells (lymphocytes) that help fight infections. They are positioned in the back of the upper part of the throat near the eustachian tubes. Enlarged adenoids can, because of their size, interfere with the eustachian tube opening. In addition, adenoids may themselves become infected, and the infection may spread into the eustachian tubes.

Bacteria: For children with symptoms related to the ear, tender swelling behind the pinna is classified as mastoiditis; visible pus discharge from the ear canal for less than 14 days is classified as an acute ear infection; similar symptoms for more than 14 days are classified as a chronic ear infection. Resistant of pneumococci can vary greatly in their degree of resistance to a particular drug. Both viral agents (e.g. respiratory syncitial virus and parainfluenza virus), and bacterial agents (primarily S. pneumoniae, H. influenzae), can cause pneumonia, meningitis and otitis media.

Traditionally, doctors have prescribed oral antibiotics for the treatment of ear infection, one of the most common disorders in children. In 1998, however, eardrops containing a very broad-spectrum antibiotic, fluoroquinolone, were introduced and billed as the treatment of choice. Recently, experts have raised concerns about overuse of the ear drops and the development of resistant bacteria.

But the latest study looked at children ages 6 months to 12 years who had ear tubes, middle ear infections, and visible drainage in the ear. Both the oral and topical antibiotics cure the infections in more than 70 percent of cases. But the topical drops resolved the ear drainage three to five days faster and resulted in more clinical cures overall — 85 percent for those taking drops, compared to 59 percent for oral administration of medication — according to the study of a UT Southwestern Medical Center researcher reports.

The diagnosis of acute otitis media, though sometimes difficult to reach, can be established from the presence of local signs (eg, otorrhea from the middle ear, cloudy or purulent fluid behind a bulging tympanic membrane accompanied by erythema). Although ear pain is a useful diagnostic clue in older children and adults, ear-pulling in infants should not be automatically attributed to acute otitis media.

Some researchers told that biofilms are antibiotic resistant colonizations of bacteria that attach to surfaces and form a slime-like barrier that acts as a formidable defense mechanism, protecting the bacteria from eradication. Recently, resistance to and clinical failure of the extended-spectrum cephalosporins, ceftriaxone and cefotaxime in the treatment of pneumococcal meningitis have been noted in Spain and the USA.

Though recent research shows that many ear infections eventually clear up on their own without any treatment; when it comes to babies, doctors will almost always reach for an antibiotic. "With young infants it's usually better to err on the side of caution and prescribe something," says Robert Ruben, an otolaryngologist.

Serious complications from childhood ear infections are on the rise, primarily because the bacterium most often responsible for the infection is growing increasingly resistant to antibiotics, University of Florida researchers report. Researchers tested the bacterium responsible for a majority of childhood ear infections and the rising rate of mastoiditis, streptococcus pneumoniae, for its susceptibility to antibiotics and found it was penicillin-resistant in all but one of eight tested samples.

An emerging "super bug" that causes ear infections in children and is resistant to multiple antibiotics can only be treated with an adult medication, researchers report. Two Rochester, N.Y., pediatricians report finds a multiple antibiotic resistant strain of Streptococcus pneumoniae that caused ear infections in nine children in their practice over three years. The only antibiotic that was effective in treating these infections was levofloxacin, which isn't approved by the U.S. Food and Drug Administration for use in children.

"We found a super bug causing ear infections in Rochester -- the Legacy strain -- that's resistant to all antibiotics approved by the FDA for use in children," said the study's lead author, Dr. Michael Pichichero, a professor of microbiology, immunology and pediatrics at the University of Rochester Medical Center, and a private practice pediatrician with the Legacy Pediatric Group.

The resistant infections accounted for only 1.5 percent of the ear infections in their practice, Pichichero noted. The findings are published in the issue of the Journal of the American Medical Association. While a vaccine (brand name Prevnar) is available that covers seven strains of pneumococcal disease, a strain dubbed serotype 19A isn't currently one of them. However, the vaccine's manufacturer, Wyeth Pharmaceuticals, reports that it's currently in phase III trials of the next generation vaccine, which does include serotype 19A.

"Prevnar is a fantastic vaccine that is taking care of the top seven strains of pneumococcal disease, but after you've knocked down the other strains, of course others will become more prominent," Pichichero explained.

Dr. Peter Paradiso is vice president of scientific affairs for Wyeth Pharmaceuticals. He said, "When we developed Prevnar, we had hoped that the response to serotype 19F would provide some cross-protection against 19A." When it became clear that there was no cross-protection, and other strains needed to be addressed, Wyeth added six more strains to the next generation vaccine. The company plans to begin the regulatory filings needed for FDA approval sometime in 2009, after the phase III trials are completed, he said.

In the meantime, Pichichero said physicians need to do more ear tap procedures to identify which bacteria are causing antibiotic-resistant ear infections. Doing so, he said, would help avoid the unnecessary use of antibiotics and allow for a more targeted approach to treating ear infections.

From 2003 until 2006, Pichichero and his colleagues saw just over 1,800 youngsters with ear infections, according to the study. Of those children, 212 had ear taps, known as tympanocentesis, a procedure that draws fluid out from behind the ear drum. Much like when a tooth cavity is filled, children are given local anesthetic to make the procedure pain-free.

Using this procedure, the doctors found that 59 of the ear infections were caused by S. pneumoniae. One particular strain of the bacterium -- serotype 19A -- had developed a new genotype that was resistant to all of the antibiotics approved for use in children. Pichichero and his colleague, Dr. Janet Casey, dubbed this the Legacy strain. Nine children were found to be infected with this strain.

The only antibiotic effective against this super bug is levofloxacin (brand name, Levaquin). But, levofloxacin has never been approved for use in children. Pichichero said that because previous studies on young animals have suggested that the drug might cause irreversible damage to growing cartilage, the "FDA has put significant barriers for the use of the antibiotics in children." No such effects have been found in adults, and it's a commonly used antibiotic in adults.

However, in these nine pediatric cases, no other treatments were effective, and the children were at risk of losing their hearing. Since Pichichero had been involved in previous research on levofloxacin's use in children, he knew the correct dose to administer, and it was effective.

But, he cautioned, because the drug hasn't been well studied in children, "I would not allow a child to receive levofloxacin unless I knew for sure [that it was the Legacy strain]."

Dr. Katherine Poehling, a pediatrician at Brenner Children's Hospital at Wake Forest University Baptist Medical Center, said the new findings are worrisome, but "nine cases out of 1,800 doesn't make me panic. We've always had some ear infections that are very hard to treat, but they usually aren't serotypes to figure out what they are."

Poehling, who's been involved in research on the current pneumococcal vaccine, added that the "pneumococcal conjugate vaccine has been extraordinarily successful, and children continue to benefit from this vaccine."

Paradiso agreed, adding that the current vaccine has caused a dramatic -- 99 percent -- reduction in infections in the serotypes that are covered by the vaccine. The CDC recommends that the current vaccine be given to all infants younger than 24 months of age at 2, 4, and 6 months of age, followed by a booster dose at 12-15 months of age.

So many cases happening:

Streptococcus pneumoniae, bacteria that can cause life-threatening infections in adults and especially children, are rapidly becoming resistant to penicillin and cephalosporins such as ceftriaxone, the most widely used antibiotics currently available to treat bacterial infections, according to Moshe Arditi, M.D., author of an article in the issue of Pediatrics and director of Cedars-Sinai Medical Center's Division of Pediatric Infectious Diseases.

S. pneumonia is not new in Canada. It causes hundreds of chest and throat infections and ear infections each year. A child had been treated in the intensive care unit but is now in a ward room, continuing to battle the infection, hospital officials say. The child is being treated with antibiotics normally reserved for adults, after a litany of antibiotics for children proved ineffective.

A new strain of bacteria is emerging as a major cause of childhood infections but even drug-resistant versions of the bug can be killed off with the right antibiotics.” I think clinicians should be aware that the vaccine, as effective as it is, still leaves children at risk for invasive pneumococcal disease," Dr. Stephen Pelton, chief of pediatric infectious disease at Boston University, told.

Warning:

Pneumococcal infections are caused by S. pneumoniae, and can include ear infections, sinus infections, pneumonia, meningitis and bloodstream infections. Some of these infections can be life-threatening. Young children are most susceptible to pneumococcal infections, according to the U.S. Centers for Disease Control and Prevention. Fortunately, the serious forms of the disease are rare, causing about 4,500 illnesses each year. However, pneumococcal infections cause more than 3 million ear infections each year, according to the CDC.

CDC also warned to all that many antibiotics have serious side effects in children, and using antibiotics when they are not needed can lead to the development of drug-resistant forms of bacteria in your children. If this happens, the antibiotics will not be able to kill the resistant bacteria the next time your child needs the same antibiotic to treat ear, sinus, or other infections that children frequently develop.

Viral infections like colds and flu are not treated with antibiotics. New strains of bacteria have become resistant to some antibiotics because the antibiotics have been overused. When your child is sick, antibiotics are not always the answer. Your pediatrician will let you know if an antibiotic would help your child; according to American academy of pediatrics.

Antibiotic use propagates the problem," Charles Ballow, Pharm.D., reported at the Inter Science Conference on Anti-Microbial Agents and Chemotherapy.” We’re a society that thinks that for every ailment, there's a pill. You have a sick child, you expect to be able to go to the doctor and get medicine. We grew up in the antibiotic era and we have come to expect it. But very often, the cause of the ear infection is viral, not bacterial, and in that case, you don't need an antibiotic."

Researcher’s continually searching new option to solve this bacterial resistance problem. Parents might one day give their children a weekly treatment with a nasal spray of virus enzymes to prevent them from getting a severe middle ear infection, based on results of a study done in mice by investigators from St. Jude Children's Research Hospital and The Rockefeller University in New York. Such a treatment would kill the disease-causing bacteria without the use of antibiotics, thereby avoiding the problem of antibiotic resistance.

A successful vaccine decreases infection rates, decreases antibiotic use, and prolongs the effectiveness of active drugs. If the pneumococcal vaccine were as effective as the vaccine against H. influenzae, the resistance of pneumococci would not pose such a threat. Currently, routine vaccination of all children with the pneumococcal–CRM197 conjugate vaccine is our best strategy for reducing the burden of early-childhood pneumococcal diseases, including otitis media. Continued surveillance of the distribution of pneumococcal serotypes and patterns of drug resistance is necessary and will dictate the development of future vaccine approaches; experts advised.

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