American Journal of Therapeutics 0, 000–000 (2014)

Acute Mastoiditis Before Pneumococcal Vaccination: The Experience of a Large Tertiary Care Pediatric Hospital Miguel Glatstein, MD,1* Sharon Morag, MD,2 Dennis Scolnik, MBChB,3 Arik Alper, MD,2 Shimon Reif, MD,2 and Galia Grisaru-Soen, MD4

To report the experience of a large tertiary care pediatric center during a period of increasing Streptococcus pneumoniae antimicrobial resistance before the introduction of pneumococcal vaccine in Israel. Retrospective chart review of children diagnosed acute mastoiditis (AM) between January 1997 and December 2007. The children were divided into 4 age groups (6–11, 12–23, 24–35, and 36–40 months), and each group was compared with the others. A total of 198 AM episodes were recorded during the 10-year study period. The most prevalent pathogen was S. pneumonia, with a very low (15%) penicillin resistance rate (minimal inhibitory concentration $ 2). Complications were more prevalent in the 12- to 23-month age group. The number of AM cases increased during the study period. Penicillin resistance did not play an important role in determining the morbidity before the introduction of pneumococcal conjugate vaccine. Keywords: acute mastoiditis, pediatric, Streptococcus pneumonia, otitis media, penicillin resistance

BACKGROUND Acute mastoiditis (AM), an infectious process of the pneumatic spaces of the temporal bone, is the most common intratemporal complication of acute otitis media (AOM).1,2 AM was the most common complication of AOM in the preantibiotic era, often resulting

1

Division of Pediatric Emergency Medicine, Department of Pediatrics, Dana-Dwek Children Hospital, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv, Israel; 2 Divisions of Pediatric Department, Dana-Dwek Children Hospital, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv, Israel; 3Divisions of Pediatric Emergency Medicine and Clinical Pharmacology and Toxicology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada; and 4Division of Infectious Disease, Department of Pediatrics, Dana-Dwek Children’s Hospital Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv, Israel. The authors have no conflicts of interest to declare. *Address for correspondence: Division of Pediatric Emergency Medicine, Dana-Dwek Children’s Hospital, 6 Weizman St, Tel-Aviv 6423906, Israel. E-mail: [email protected] 1075–2765  2014 Lippincott Williams & Wilkins

in substantial morbidity and mortality,3 but the frequency of AM decreased sharply with the widespread availability of antibiotics.4 Since the 1950s, and before the introduction of pneumococcal conjugate vaccines, the incidence and complication rate of AM remained relatively unchanged despite increasing antibiotic effectiveness.1 Incidences of 1.2–3.8 cases per 100,000 population-years were reported in the western world until 1990–2000,2 when a significantly increased incidence was reported by several centers in the United States and Europe.5,6 Incidence and morbidity differ markedly between countries.5,7 The commonest bacterial pathogens are Streptococcus pneumoniae, nontypable Haemophilus influenza and Moraxella catarrhalis, although Streptococcus pyogenes, Staphylococcus aureus, and Pseudomonas aeruginosa can also be implicated.8 Treatment of AM has shifted from surgical curettage of the mastoid cavity to intravenous antibiotics with simple drainage by means of a wide-field myringotomy or insertion of a tympanostomy tube.9 Surgical intervention is now reserved for patients in whom intravenous antibiotics are not curative. Although AM is a serious disease, most children make an uncomplicated recovery. Attempts to prevent AM through early initiation of antibiotic therapy for www.americantherapeutics.com

Copyright ª Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

2

AOM need to balance against public health risks associated with antibiotic resistance.5,10 Pneumococcal vaccination has been shown to be one of the factors influencing the incidence of AOM and AM.11 Prevnar was introduced to the vaccination program in Israel in July 2009. We undertook this study to help establish the incidence of AM in an era before the use of pneumococcal vaccination, in which other variables, such as the availability of antibiotics and access to medical care, remained relatively stable. It is our hope that this information will help inform public health policy in jurisdictions still considering the introduction of this vaccination.

METHODS After obtaining institutional medical records research committee approval, we reviewed the medical records of all children with a discharge diagnosis of AM from January 1997 through December 2007 at the DanaDwek Children’s Hospital, Tel Aviv, Israel. This is a tertiary care pediatric hospital serving a relatively stable population. AM was confirmed when current or recent (,4 weeks) AOM was accompanied by at least one of the following physical signs of AM: retroauricular redness, protrusion of the ear, edema or swelling of the mastoid, pain or tenderness to palpation over the mastoid, and/or “sagging” of the ear canal. Patients with immune deficiencies, comorbidities, or prematurity were excluded. Data regarding demographics, presentation, clinical course, laboratory tests, medical and surgical interventions, and outcomes were extracted and analyzed in 4 age groups (,6, 6–11, 12–23, 24–35, and 36+ months). Identity and antimicrobial susceptibility profiles were collected for pathogens. The complication dichotomous outcome was compared using Fisher exact test. Since the result of the overall test was significant; pairwise comparisons were performed. The false discovery rate method for adjustment of significance level was used. Data were analyzed using Microsoft Excel.

Glatstein et al

6.01 6 3.33 days. Ninety-two children (47%) were treated with an antibiotic before admission: amoxicillin (21%), amoxicillin/clavulanate (10%), oral cephalosporin (7%), macrolides (5%), intravenous cephalosporin (1.5%), and others (5%). Complications were encountered in 24 patients (12%), and included subperiosteal abscess in 19, epidural abscess in 4, and meningitis in 1 patient. Both rate of antibiotic pretreatment and complication rates were greatest in 12- to 23-month-old children (Table 1). Surgery was necessitated in 88 children (45.1%) and included simple mastoidectomy (15 patients), mastoidectomy with drainage of an abscess (9 patients), and tympanostomy tube insertion (64 patients). Fifty-one children (25.8%) have had episodes of AOM in the past, 27 (14%) had recurrent or chronic otitis media, and 13 (6%) had a history of AM. Cultures of middle ear fluid were obtained on admission from 131 patients (66%) (59 from ear discharge and 72 from tympanocentesis). Positive cultures were reported in 62 cases (Table 3). The most prevalent pathogen was S. pneumonia (51%), which exhibited a very low penicillin minimal inhibitory concentration of $ 2. Five of the S. pneumonia isolates (15%) were not susceptible to penicillin, but all were susceptible to ceftriaxone. Antibiotic use during admission was recorded for 98% of patients. All received intravenous antibiotics: cefuroxime (39%), amoxicillin/clavulanate (34%), and ceftriaxone (6%).

DISCUSSION Between 1990 and 2000, an increased incidence of AM was reported by several centers in the United States and Europe.5,6 The authors of these reports suggested that policies aimed at restricting the use of antibiotics for AOM were associated with this increase. Other authors attributed the rise to antibiotic resistance or

RESULTS A total of 198 AM episodes were recorded during the 10-year study period. The average number of cases per year increased until 2000, after which the numbers remained stable at approximately 24 cases per year (Figure 1). Patients’ demographic details and clinical presentations are shown in Tables 1 and 2. Ages ranged from 1 to 183 months (mean 28 6 28 months), 79 (40%) were in their second year of life and 119 (60%) were males. The mean duration of hospitalization was American Journal of Therapeutics (2014) 0(0)

FIGURE 1. Yearly distribution of the 198 episodes of AM during the study period. www.americantherapeutics.com

Copyright ª Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

Acute Mastoiditis Before Pneumococcal Vaccination

3

Table 1. Demographic and clinical details of the 198 episodes of AM. Age in months n (%)

1–5 7 (3.5)

6–11 38 (19.2)

12–23 82 (41.4)

24–35 31 (15.7)

36+ 40 (20.2)

Gender Male:female

3:4

22:16

51:31

17:14

26:14

7.29

5.34

6.59

5.87

5.37

1

15

41

21

14

92 (47)

0.238

1 SA: 1 (14)

3 SA: 2 (5)

21 SA: 14 (17) EA: 3 (3.5)

2 SA: 2 (6.5) M: 1 (3.2)

3 EA: 1 (2.5)

30 (15.4) SA: 22 (11.1) EA: 4 (2) M: 1 (0.5)

0.0198 0.0217

Duration of admission (mean in days) Preadmission antibiotic CT, n Complications

Total 198 (100)

P

119:79 (male: 60%; female: 40%) 6.01 6 3.33

0.763 0.239

CT, computerized tomography; EA, epidural abscess; M, meningitis; SA, subperiosteal abscess.

decreased utilization of paracentesis in the management of AOM.12 Van Zuijlen et al13 reported an AM incidence of 3.8 cases per 100,000 person-years in The Netherlands, a country with low antibiotic prescription rates for AOM, in contrast to rates of 1.2–2 per 100,000 person-years in United Kingdom, Canada, Australia and the United States, countries with higher antibiotic prescription rates for AOM.14 A retrospective study in southern Israel from 1990 to 20017 found a particularly high incidence of 6.1 per 100,000 population younger than 14 years, with a significant increase in the number of cases over that time period, together with a higher rate of complications. Numbers of cases increased from 36 between 1990 and 1995 to 80 cases between 1996 and 2001. Our annual number of AM cases increased from the mid-1990s to the beginning of 2000 and stayed relatively stable since then (Figure 1). This finding was not accompanied by a high incidence of antibiotic resistance in pneumococcal isolates, contrary to the findings of other studies.14–17 This difference may be

explained by the change in susceptibility breakpoints that was recommended by the Clinical Laboratory Standards Institute for S. pneumonia, over the last few years. We used the new susceptibility breakpoints (minimal inhibitory concentration , 2), which meant that a higher percentage of S. pneumonia was considered susceptible to penicillin. The main pathogen in our series was S. pneumonia followed by Staphylococcus pyogenes, which is consistent with the results of Katz et al.7 Although Staphylococcus pyogenes plays a minor rule in AOM, it is a much more important pathogen in AM because of its virulence and tendency for complications. The lower recovery rates of H. influenza we found were also noted by Ginsburg et al,18 who postulated predilection of this pathogen for mucous and serous membranes versus bone. Complication rates were highest in young children and infants, especially in the 12- to 23-month age group. These results are also similar to those of Katz et al7 and may reflect an immature immune system at this age and may

Table 2. Microbiological results and antibiotic susceptibility in the 62 positive middle ear cultures. Clinical findings

1–5 mo

6–11 mo

12–23 mo

24–35 mo

Protrusion of the ear Postauricular redness Postauricular swelling Pain tenderness over mastoid Irritability

7/7 5/7 4/7 4/7 4/7

35/38 33/38 28/38 20/38 14/38

77/82 74/82 55/82 53/82 30/82

28/21 30/31 23/31 23/31 3/31

(100) (71) (57) (57) (57)

(92) (87) (74) (53) (37)

(94) (90) (67) (65) (37)

(90) (97) (74) (74) (10)

1–35 mo 147/158 142/158 110/158 100/158 51/158

(93) (90) (70) (63) (32)

$36 mo 32/40 32/40 23/40 27/40 1/40

(80) (80) (58) (68) (3)

P* 0.006 0.044 0.072 NS ,0.001

Percentage values are given in parentheses. *,36 months versus .36 months. NS, not significant.

www.americantherapeutics.com

American Journal of Therapeutics (2014) 0(0)

Copyright ª Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

4

Glatstein et al

Table 3. Positive cultures reported in 62 cases. Microorganism

n (%)

Group A Streptococcus 7 (11) Staphylococcus aureus (MSSA) 4 (6) Haemophilus influenza (b-lactamase negative) 1 (2) Streptococcus pneumoniae 32 (51) Penicillin susceptible (MIC , 2) 27 (85) Penicillin resistant (MIC $ 2) 5 (15) Ceftriaxone susceptible (MIC , 1) 32 (100) Pseudomonas aeruginosa 13 (21) Stenotrophomonas maltophilia 3 (5) Other 2 (3)

5.

6.

7.

8.

MIC, minimal inhibitory concentration; MSSA, staphylococcus aureus methicillin susceptible.

9.

suggest that earlier institution of antibiotic treatment is indicated in this age group. Our study has several limitations associated with being a retrospective analysis: there was no standardization in documentation of physical findings, and some findings were missing from charts, or was there a predetermined management protocol for AM. In conclusion, pediatric AM was seen with increased frequency in the decade before the introduction of pneumococcal vaccination in a relatively stable pediatric population despite the availability of effective antibiotics and medical resources. The most prevalent pathogen was S. pneumonia, and penicillin resistance did not seem to play an important role in morbidity. These findings suggest a role for early and effective antibiotic treatment in children with AOM who are not immunized with pneumococcal vaccine especially those in their second year of life.

10.

11.

12.

13.

14.

15.

REFERENCES 1. Tamir S, Schwartz Y, Peleg U, et al. Acute mastoiditis in children: is computed tomography always necessary? Ann Otol Rhinol Laryngol. 2009;118:565–569. 2. Tamir S, Shwartz Y, Peleg U, et al. Shifting trends: mastoiditis from a surgical to a medical disease. Am J Otolaryngol. 2010;31:467–471. 3. Benito MB, Gorricho BP. Acute mastoiditis: increase in the incidence and complications. Int J Pediatr Otorhinolaryngol. 2007;71:1007–1011. 4. Kopes-Kerr CP. Should children with acute otitis media routinely be treated with antibiotics? Yes: routine treatment makes sense for symptomatic, emotional, and economic

American Journal of Therapeutics (2014) 0(0)

16.

17.

18.

reasons. Am Fam Physician. 2013;88:7. Available at: http://www.aafp.org/afp/2013/1001/od1.html. Venekamp RP, Sanders S, Glasziou PP, et al. Antibiotics for acute otitis media in children. Cochrane Database Syst Rev. 2013;1:CD000219. Available at: http://www.ncbi.nlm.nih. gov/pubmed/23440776. Accessed January 31, 2013. Mustafa A, Debry CH, Wiorowski M, et al. Treatment of acute mastoiditis: report of 31 cases over a ten year period. Rev Laryngol Otol Rhinol (Bord). 2004;125:165–169. Katz A, Leibovitz E, Greenberg D, et al. Acute mastoiditis in Southern Israel: a twelve year retrospective study (1990 through 2001). Pediatr Infect Dis J. 2003;22: 878–882. Niv A, Nash M, Slovik Y, et al. Acute mastoiditis in infancy: the Soroka experience: 1990-2000. Int J Pediatr Otorhinolaryngol. 2004;68:1435–1439. Psarommatis IM, Voudouris C, Douros K, et al. Algorithmic management of pediatric acute mastoiditis. Int J Pediatr Otorhinolaryngol. 2012;76:791–796. Thompson PL, Gilbert RE, Long PF, et al. Effect of antibiotics for otitis media on mastoiditis in children: a retrospective cohort study using the United Kingdom general practice research database. Pediatrics. 2009;123: 424–430. Amir AZ, Pomp R, Amir J. Changes in acute mastoiditis in a single pediatric tertiary medical center: our experience during 2008-2009 compared with data for 19832007. Scand J Infect Dis. 2014;46:9–13. Ghaffar FA, Wördemann M, McCracken GH Jr. Acute mastoiditis in children: a seventeen-year experience in Dallas, Texas. Pediatr Infect Dis J. 2001;20:376–380. Van Zuijlen DA, Schilder AG, Van Balen FA, et al. National differences in incidence of acute mastoiditis: relationship to prescribing patterns of antibiotics for acute otitis media? Pediatr Infect Dis J. 2001;20:140–144. Spratley J, Silveira H, Alvarez I, et al. Acute mastoiditis in children: review of the current status. Int J Pediatr Otorhinolaryngol. 2000;56:33–40. Rodríguez Paramás A, Mancheño Losa M, García de Pedro F, et al. Acute mastoiditis in children. A retrospective study and literature review [in Spanish]. Acta Otorrinolaringol Esp. 2006;57:165–170. Dagan R, Givon-Lavi N, Shkolnik L, et al. Acute otitis media caused by antibiotic-resistant Streptococcus pneumoniae in southern Israel: implication for immunizing with conjugate vaccines. J Infect Dis. 2000;181:1322–1329. Available at: http://www.ncbi.nlm.nih.gov/pubmed/ 10753730. Vera-Cruz P, Farinha RR, Calado V. Acute mastoiditis in children—our experience. Int J Pediatr Otorhinolaryngol. 1999;50:113–117. Ginsburg CM, Rudoy R, Nelson JD. Acute mastoiditis in infants and children. Clin Pediatr (Phila). 1980;19: 549–553.

www.americantherapeutics.com

Copyright ª Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

Acute Mastoiditis Before Pneumococcal Vaccination: The Experience of a Large Tertiary Care Pediatric Hospital.

To report the experience of a large tertiary care pediatric center during a period of increasing Streptococcus pneumoniae antimicrobial resistance bef...
121KB Sizes 0 Downloads 8 Views