Acute-Phase Reactants and Acute Bacterial Otitis Media Mark A. Del Beccaro, MD; Paul M. Mendelman, MD; Andrew F. Inglis, MD; Mark A. Richardson, MD; Newton O. Duncan, MD; Richard P. Shugerman, MD \s=b\ Objective.\p=m-\Todetermine if the erythrocyte sedimentation rate and C-reactive protein level are elevated in uncomplicated acute bacterial otitis media. Design.\p=m-\Investigator-blinded,antibiotic efficacy trial. Setting.\p=m-\Theemergency department of an urban regional children's hospital with 24 000 annual visits. Participants.\p=m-\Thirty-onechildren with symptoms of acute bacterial otitis media of 7 days' duration or less. Selection Procedure.\p=m-\Volunteersample. Interventions.\p=m-\Tympanocentesis,oral antibiotics for 10 days, and three follow-up visits in the next 30 days. Measurements/Results.\p=m-\Theerythrocyte sedimentation rate and C-reactive protein level were obtained at time of entry into the antibiotic study. Seventeen patients (55%; 95% confidence interval, 37% to 72%) had either an erythrocyte sedimentation rate above 20 mm/h or a C-reactive protein level above 8 mg/L. Eleven patients (35%) had a re-
current episode of acute bacterial otitis media during the follow-up period. The relative risk of recurrence of otitis media given an elevated erythrocyte sedimentation rate or C-reactive protein level was 8.24 (95% confidence interval,
sedimentation rate (ESR), C-reactive blood cell (WBC) count and and investigators to help are frequently by distinguish or follow the course of patients with invasive bacterial infections, such as meningitis,1 epiglottitis,2 bac¬ teremia,2-3 pneumonia,3 and bone or joint infections,4-5 from those with viral or noninfectious illnesses. Although an elevation of the CRP level has been reported in culture-proven acute otitis media (AOM),6-7 the response of the ESR in these patients is less well docu¬ mented. A search of otolaryngology textbooks and Index Medicus as well as a computerized search of the National Library of Medicine revealed three relevant articles. McCarthy et al3 studied children younger than age 2 years who had a temperature of 40.0°C or higher and found a mean ESR of 22.5 mm/h in the 126 children with uncom¬ plicated AOM. Principi et al8 studied children between the ages of 6 months and 12 years, more than 80% of whom
had both bilateral AOM and a temperature above 38.0°C, and found a mean ESR of 38.6 mm/h (range, 7 to 111 mm/h). Neither of the above studies used tympanocentesis to bacteriologically confirm the clinical diagnosis of AOM. The single study that measured ESR in culture-proven AOM was performed in 1953 by Lahikainen.9 One hundred fifty-eight (47%) of the 337 culture-proven cases had an ESR above 30 mm / h. Thirty-seven (11%) had an ESR above 60 mm/h. Unfortunately, many of these patients were hospitalized with other diseases, and an unknown number were hospitalized for treatment of complications of AOM or were adults with AOM. In the present study we measured the ESR, CRP level, and WBC count in children with culture-proven uncom¬ plicated AOM.
erythrocyte Theprotein white (CRP) level, used clinicians
Accepted for publication May 11, 1992. From the Children's Hospital and Medical Center, Seattle, Wash (Drs Del Beccaro, Mendelman, Inglis, Richardson, Duncan, and Shugerman)
and the Departments of Pediatrics (Drs Del Beccaro, Mendelman, and Shugerman) and Otolaryngology (Drs Inglis, Richardson, and Duncan), University of Washington, Seattle. Dr Mendelman is currently at Merck Research Laboratories, West Point, Pa. Dr Duncan is currently at Baylor University School of Medicine, Houston, Tex. Reprint requests to Emergency Services, Children's Hospital and Medical Center, PO Box C5371 MS CH-04, Seattle, WA 98105 (Dr Del Beccaro).
56.74; Fisher's Exact Test; P=.007). Conclusions.\p=m-\Clinicians who use elevated acute-phase reactants as possible indicators of invasive bacterial infections should be aware that an elevated erythrocyte sedimentation rate or C-reactive protein level is also consistent with acute bacterial otitis media. An elevated erythrocyte sedimentation rate or C-reactive protein level also appears to be associated with an increased risk of recurrence of acute bacterial otitis media. If these findings can be confirmed in a larger study, the erythrocyte sedimentation rate or C-reactive protein level could be used to assess the risk of recurrent otitis media. 1.20 to
(AJDC. 1992;146:1037-1039)
PATIENTS AND METHODS Patients between the ages of 2 months and 18 years with AOM
(defined as fever, irritability, or ear pain and a red or bulging tympanic membrane [TM]) with a duration of symptoms of 7 days
fewer were enrolled in our study as part of a multicenter single-blind study comparing the efficacy and safety of a new extended-spectrum oral cephalosporin, cefpodoxime proxetil (Vantin), vs cefixime (Suprax) in a 2:1 ratio. or
Patients were recruited between October 1990 and October 1991 Hospital and Medical Center, Seattle, Wash. Chil¬ dren were recruited from the emergency department (n=5) or acute care clinic (n=29) exclusively during regular otolaryngology clinic hours. The acute care clinic is staffed by pediatrie nurse at Children's
Downloaded From: http://archpedi.jamanetwork.com/ by a University of Iowa User on 06/19/2015
Table 1.—Acute-Phase Reactants in Children With Culture-Proven AOM*
ESR, mm/h
Variable
(n
=
CRP, mg/L
26)
(n
=
WBC
31)
Count, (n
=
x
10VL
Cells, X10VL
Band
29)
(n
=
29)
Median
20
0
11.7
335
Mean (SD)
26(19)
...t
12.7(4.3)
396(561)
4-78
current episode of acute bacterial otitis media during the follow-up period. The relative risk of recurrence of otitis media given an elevated erythrocyte sedimentation rate or C-reactive protein level was 8.24 (95% confidence interval,
sedimentation rate (ESR), C-reactive blood cell (WBC) count and and investigators to help are frequently by distinguish or follow the course of patients with invasive bacterial infections, such as meningitis,1 epiglottitis,2 bac¬ teremia,2-3 pneumonia,3 and bone or joint infections,4-5 from those with viral or noninfectious illnesses. Although an elevation of the CRP level has been reported in culture-proven acute otitis media (AOM),6-7 the response of the ESR in these patients is less well docu¬ mented. A search of otolaryngology textbooks and Index Medicus as well as a computerized search of the National Library of Medicine revealed three relevant articles. McCarthy et al3 studied children younger than age 2 years who had a temperature of 40.0°C or higher and found a mean ESR of 22.5 mm/h in the 126 children with uncom¬ plicated AOM. Principi et al8 studied children between the ages of 6 months and 12 years, more than 80% of whom
had both bilateral AOM and a temperature above 38.0°C, and found a mean ESR of 38.6 mm/h (range, 7 to 111 mm/h). Neither of the above studies used tympanocentesis to bacteriologically confirm the clinical diagnosis of AOM. The single study that measured ESR in culture-proven AOM was performed in 1953 by Lahikainen.9 One hundred fifty-eight (47%) of the 337 culture-proven cases had an ESR above 30 mm / h. Thirty-seven (11%) had an ESR above 60 mm/h. Unfortunately, many of these patients were hospitalized with other diseases, and an unknown number were hospitalized for treatment of complications of AOM or were adults with AOM. In the present study we measured the ESR, CRP level, and WBC count in children with culture-proven uncom¬ plicated AOM.
erythrocyte Theprotein white (CRP) level, used clinicians
Accepted for publication May 11, 1992. From the Children's Hospital and Medical Center, Seattle, Wash (Drs Del Beccaro, Mendelman, Inglis, Richardson, Duncan, and Shugerman)
and the Departments of Pediatrics (Drs Del Beccaro, Mendelman, and Shugerman) and Otolaryngology (Drs Inglis, Richardson, and Duncan), University of Washington, Seattle. Dr Mendelman is currently at Merck Research Laboratories, West Point, Pa. Dr Duncan is currently at Baylor University School of Medicine, Houston, Tex. Reprint requests to Emergency Services, Children's Hospital and Medical Center, PO Box C5371 MS CH-04, Seattle, WA 98105 (Dr Del Beccaro).
56.74; Fisher's Exact Test; P=.007). Conclusions.\p=m-\Clinicians who use elevated acute-phase reactants as possible indicators of invasive bacterial infections should be aware that an elevated erythrocyte sedimentation rate or C-reactive protein level is also consistent with acute bacterial otitis media. An elevated erythrocyte sedimentation rate or C-reactive protein level also appears to be associated with an increased risk of recurrence of acute bacterial otitis media. If these findings can be confirmed in a larger study, the erythrocyte sedimentation rate or C-reactive protein level could be used to assess the risk of recurrent otitis media. 1.20 to
(AJDC. 1992;146:1037-1039)
PATIENTS AND METHODS Patients between the ages of 2 months and 18 years with AOM
(defined as fever, irritability, or ear pain and a red or bulging tympanic membrane [TM]) with a duration of symptoms of 7 days
fewer were enrolled in our study as part of a multicenter single-blind study comparing the efficacy and safety of a new extended-spectrum oral cephalosporin, cefpodoxime proxetil (Vantin), vs cefixime (Suprax) in a 2:1 ratio. or
Patients were recruited between October 1990 and October 1991 Hospital and Medical Center, Seattle, Wash. Chil¬ dren were recruited from the emergency department (n=5) or acute care clinic (n=29) exclusively during regular otolaryngology clinic hours. The acute care clinic is staffed by pediatrie nurse at Children's
Downloaded From: http://archpedi.jamanetwork.com/ by a University of Iowa User on 06/19/2015
Table 1.—Acute-Phase Reactants in Children With Culture-Proven AOM*
ESR, mm/h
Variable
(n
=
CRP, mg/L
26)
(n
=
WBC
31)
Count, (n
=
x
10VL
Cells, X10VL
Band
29)
(n
=
29)
Median
20
0
11.7
335
Mean (SD)
26(19)
...t
12.7(4.3)
396(561)
4-78
