Acute Otitis Media: Influence of the PCV-7 vaccine on changes in the disease and its management

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Acute Otitis Media: Influence of the PCV-7 vaccine on changes in the disease and its management

J Fam Pract. 2005 November;54(11):961-968

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References

1. Fireman B, Black SB, Shinefield HR, et al. Impact of the pneumococcal conjugate vaccine on otitis media. Pediatr Infect Dis J. 2003;22:10-16.

2. Eskola J, Kilpi T, Palmu A, et al. Efficacy of a pneumococcal conjugate vaccine against acute otitis media. N Engl J Med. 2001;344:403-409.

3. Block SL, Harrison CH, Hedrick J, et al. Restricted use of antibiotic prophylaxis for recurrent acute otitis media in the era of penicillin non-susceptible Streptococcus pneumoniae. Int J Pediatr Otorhinolaryngol. 2001;61:47-60.

4. Advisory Committee on Immunization Practices. Preventing pneumococcal disease among infants and young children: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2000;49(RR-9):1-35.

5. American Academy of Family Physicians Subcommittee on Management of Acute Otitis Media. Diagnosis and management of acute otitis media. Pediatrics. 2004;113:1451-1465.

6. Dowell SF, Butler JC, Giebink GS, et al. Acute otitis media: management and surveillance in an era of pneumococcal resistance—a report from the Drug-resistant Streptococcus pneumoniae Therapeutic Working Group. Pediatr Infect Dis J. 1999;18:1-9.

7. Block SL. Causative pathogens, antibiotic resistance and therapeutic considerations in acute otitis media. Pediatr Infect Dis J. 1997;16:449-456.

8. Bluestone CD, Stephenson JS, Martin LM. Ten-year review of otitis media pathogens. Pediatr Infect Dis J. 1992;11(suppl 8):S7-S11.

9. Block SL, Hedrick J, Harrison CJ, et al. Community-wide vaccination with the heptavalent pneumococcal conjugate significantly alters the microbiology of acute otitis media. Pediatr Infect Dis J. 2004;23:829-833.

10. Casey JR, Pichichero ME. Changes in frequency and pathogens causing acute otitis media in 1995-2003. Pediatr Infect Dis J. 2004;23:824-828.

11. Centers for Disease Control and Prevention. Updated recommendations on the use of pneumococcal conjugate vaccine: suspension of recommendation for third and fourth dose. MMWR Morb Mortal Wkly Rep. 2004;53:177-178.

12. Centers for Disease Control and Prevention. Pneumococcal conjugate vaccine shortage resolved. MMWR Morb Mortal Wkly Rep. 2004;53:851-852.

13. Prevnar® (pneumococcal 7-valent vaccine) [prescribing information]. Philadelphia, Pa: Wyeth Pharmaceuticals. Rev. 01/04.

14. Watson W. Pneumococcal conjugate vaccines. Pediatr Infect Dis J. 2000;19:331-332.

15. Giebink GS. The prevention of pneumococcal disease in children. N Engl J Med. 2001;345:1177-1183.

16. Pelton SI, Loughlin AM, Marchand CD. Seven valent pneumococcal conjugate vaccine immunization in two Boston communities: changes in serotypes and antimicrobial susceptibility among Streptococcus pneumoniae isolates. Pediatr Infect Dis J. 2003;23:1015-1022.

17. Freed GL, Davis MM, Clark SJ. Variation in public and private supply of pneumococcal conjugate vaccine during a shortage. JAMA. 2003;289:575-578.

18. Centers for Disease Control and Prevention. Decreased availability of pneumococcal conjugate vaccine. MMWR Morb Mortal Wkly Rep. 2001;50:783-784.

19. Centers for Disease Control and Prevention. Limited supply of pneumococcal conjugate vaccine: suspension of recommendation for fourth dose. MMWR Morb Mortal Wkly Rep. 2004;53:108-109.

20. CDC National Immunization Survey. Estimated vaccination coverage with individual vaccines and selected vaccination series by 24 months of age by state and immunization action plan area US, Q3/2003-Q4/2004. Available at: http://www2a.cdc.gov/nip/coverage/nis/nis_iap.asp?fmt=v&rpt=tab09_24mo_iap_0304&qtr=Q3/2003-Q2/2004. Accessed September 20, 2005.

21. Whitney CG, Farley MM, Hadler J, et al. Decline in invasive pneumococcal disease after the introduction of protein-polysaccharide conjugate vaccine. N Engl J Med. 2003;348:1737-1746.

22. Black S, Shinefield H, Baxter R, et al. Postlicensure surveillance for pneumococcal invasive disease after use of heptavalent pneumococcal vaccine in Northern California Kaiser Permanente. Pediatr Infect Dis J. 2004;23:485-489.

23. Pichichero ME, Casey JR. Acute otitis media: Making sense of recent guidelines on antimicrobial treatment. J Fam Pract. 2005;54:313-332.

24. Block SL, Harrison CJ. Diagnosis and Management of Acute Otitis Media, 3rd ed. In press.

Selecting Among Recommended Antibiotic Choices

As antibiotic preparations for treating bacterial AOM are oral suspensions, taste is a major factor for pediatric patients. TABLE 4 summarizes comparative taste ratings for antibiotic suspensions based on several studies and shows the range, from those that can enhance compliance to those that discourage compliance.²³

Adverse events, especially diarrhea, nausea/vomiting, and gastritis, are also of concern. These are shortcomings of amoxicillin/clavulanate, which has a higher incidence of diarrhea and nausea than cephalosporins.²⁴

Dosing frequency is also a factor among recommended agents. Amoxicillin, amoxicillin/clavulanate, cefprozil, and cefpodoxime require twice-daily dosing. Cefdinir can be effective at once-daily dosing.²⁴

Duration of approved therapy is perhaps the most critical selection factor given the reality of patient behaviors. Cefpodoxime and cefdinir are the only 2 FDA-approved agents for 5-day treatment of bacterial AOM that are also guideline-recommended.

TABLE 4

Compliance-Enhancing Ranking of Antibiotic Suspensions

STRONGLY COMPLIANCE-ENHANCING
Amoxicillin Cefdinir (Omnicef) Loracarbef (Lorabid)	Cefaclor (Ceclor) Cefixime (Suprax)
MODERATELY COMPLIANCE-ENHANCING
Cefprozil (Cefzil)	Ceftibuten (Cedax)
EQUIVOCAL COMPLIANCE-ENHANCING
Azithromycin (Zithromax)
NOT COMPLIANCE-ENHANCING
Amoxicillin-clavulanate (Augmentin) Erythromycin-sulfasoxazole (Pediazole) TMP-SMX (Bactrim or Septra)
DISCOURAGES COMPLIANCE
Cefpodoxime (Vantin) Clarithromycin (Biaxin)	Cefuroxime (Ceftin)
TMP-SMX, trimethoprim sulfamethoxazole
Sources: Adapted from Steele RW, et al. Pediatr Infect Dis J. 2001;20:1-5.
Demers DM, et al. Pediatr Infect Dis J. 1994;13:87-89.
Ruff ME, et al. Pediatr Infect Dis J. 1991;10:30-33.

Choices for Effective Initial Therapy

Considering the changing microbial population in bacterial AOM and the increasing concern of effectiveness of amoxicillin and other antibiotics against β-lactamase–producing H influenzae, the choice of therapy may need modification. Specifically, that may mean changing the choice of effective antibiotic, taking into consideration the compliance-enhancing advantages of available options.

FAST TRACK

Amoxicillin may no longer be the best first choice for AOM if there is an increase in β-lactamase-producing pathogens

Based on efficacy, the overall prevalence of antibiotic-resistant AOM pathogens for PCV-7-vaccinated children, the potential for adverse effects, and patient compliance issues, Block and Harrison developed an algorithm (FIGURE) for the management of AOM diagnosed by strict criteria in an otherwise healthy child between 4 months and 36 months old.²⁴ As the environment of AOM evolves, the choices for treatment must be not only effective but also the best and most appropriate.

FIGURE Antibiotic Choices for Acute Otitis Media in the 2000s