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M E Pichichero

Publications and source records attributed to M E Pichichero.

At least 19 recordsLinked to original sources
PubMed2003

Diagnostic accuracy of otitis media and tympanocentesis skills assessment among pediatricians.

The comparative study presented here evaluated pediatricians from Italy, Greece, South Africa, and a reference group in the USA to determine (i) their ability to accurately diagnose acute otitis media (AOM) and otitis media with effusion (OME) using otoscopy, (ii) their knowledge of antibiotics, and (iii) their technical competence in performing tympanocentesis. The participants included 66 pediatricians from Italy, 115 from Greece, 36 from South Africa and 2,190 from the USA (reference group). Each pediatrician viewed nine video-recorded otoscopic examinations of tympanic membranes, after which their ability to differentiate AOM, OME and normal was ascertained. Questions were posed regarding appropriate, pathogen-directed antibiotic selection for AOM. A mannequin model was used to assess the technical proficiency of each pediatrician in performing tympanocentesis. Results were recorded for each group as the mean percentage +/- standard deviation. The correct diagnosis was made by each group of pediatricians in the following frequencies: Italy, 54+/-27% (range, 18-94%); Greece, 36+/-12% (range, 23-56%); South Africa, 53+/-21% (range, 22-88%); and the USA, 51+/-11% (range, 29-72%). The difference between results from Greece and the US reference group was statistically significant ( P=0.002). Pediatricians from each group over-diagnosed AOM with the following frequencies: Italy, 18+/-19% (range, 2-49%); Greece, 34+/-13% (8-50%); South Africa, 23+/-14% (7-44%); and the US reference group, 26+/-19% (7-51%). Pediatricians correctly selected an antibiotic recommended for treatment of AOM caused by drug-resistant Streptococcus pneumoniae as follows: Italy, 89%; Greece, 77%; South Africa, 82%; and the USA, 80%. For treatment of beta-lactamase-producing Haemophilus influenzae, the results were: Italy, 90%; Greece, 70%; South Africa, 81%; and the USA, 77%. Tympanocentesis was optimally performed by >/=86% of all pediatricians. The results indicate that pediatricians may often misdiagnose OME as AOM, but they select appropriate antibiotics about 80% of the time and can be trained to accurately perform tympanocentesis.

Anti-Bacterial Agents↗
PubMed2003

Acute otitis media disease management.

A first step in management decisions regarding otitis media must focus on accurate diagnosis to distinguish normal from acute otitis media (AOM) from otitis media with effusion (OME) or a retracted tympanic membrane without middle ear effusion. There are several classification schemes for AOM that may impact management decisions: patients with acute, persistent, recurrent, or chronic AOM may have a different distribution of bacterial pathogens and a different likelihood of success from antimicrobial therapy. Patient age, prior treatment history and daycare attendance are other important variables. The natural history of AOM without antibiotic treatment is generally favorable; however, from the few studies available, this is difficult to quantitate because the diagnosis was infrequently confirmed by tympanocentesis leaving the possibility that many patients entered into these trials may not have had bacterial AOM. Antibiotic choices should reflect pharmacokinetic/pharmacodynamic data and clinical trial results demonstrating effectiveness in eradication of the most likely pathogens based on tympanocentesis sampling and antibiotic sensitivity testing. Thereafter, compliance factors such as formulation, dosing schedule and duration of treatment and accessibility factors such as availability and cost should be taken into account. The increasing prevalence of antibiotic resistance among AOM pathogens and the changing susceptibility profiles of these bacteria should be considered in antibiotic selection. Current best practice recommends amoxicillin for uncomplicated AOM; continuing or switching to an alternative antibiotic based on clinical response after 48 hours of therapy; and selection of second line antibiotics as first line choices when the patient has already been on an antibiotic within the previous month or is otitis prone. Preferred second-line agents frequently noted in various guidelines include amoxicillin/clavulanate, cefdinir, cefpodoxime, cefprozil, and cefuroxime. Three injections of ceftriaxone or gatifloxacin (when approved) or diagnostic/therapeutic tympanocentisis (when approved) become a third-line treatment option. No single antibiotic or management strategy is ideal for all patients.

Acute Disease↗
PubMed2001

Assessing diagnostic accuracy and tympanocentesis skills in the management of otitis media.

BACKGROUND: The distinction between acute suppurative otitis media (AOM) and otitis media with effusion (OME) is important for antibiotic treatment decisions. Tympanocentesis may be useful in the diagnosis of AOM in selected patients. OBJECTIVES: To assess physician accuracy in diagnosing AOM and OME from physical examination findings and technical competence in performing tympanocentesis. DESIGN AND SUBJECTS: Five hundred fourteen pediatricians and 188 otolaryngologists viewed 9 different videotaped pneumatic otoscopic examinations of tympanic membranes during a continuing medical education course. Diagnostic differentiation of AOM, OME, and a normal tympanic membrane was ascertained. An infant mannequin model was used to assess the technical proficiency of performing tympanocentesis on artificial tympanic membranes. RESULTS: Overall, the average correct diagnosis by pediatricians was 50% (range, 25%-73%) and by otolaryngologists was 73% (range, 48%-88%). Pediatricians and otolaryngologists correctly recognized the absence of normality 89% to 100% and 93% to 100% of the time, respectively, but overdiagnosed AOM in 7% to 53% (mean, 27%) and in 3% to 23% (mean, 10%) of examinations. Performance of tympanocentesis was optimally performed by 89% of otolaryngologists and by 83% of pediatricians. CONCLUSIONS: The use of video-presented examinations to assess diagnostic ability suggests that AOM and OME may be misdiagnosed often. Interactive continuing medical education courses with simulation technology may enhance skills and improve diagnostic accuracy and treatment paradigms.

Clinical Competence↗
PubMed2001

Open-Label, parallel-group, multicenter, randomized study of cefprozil versus erythromycin in children with group A streptococcal pharyngitis/tonsillitis.

BACKGROUND: Cefprozil and erythromycin are acceptable alternatives to penicillin in the treatment of pharyngitis/tonsillitis due to group A beta-hemolytic streptococcus (GABHS). OBJECTIVE: The purpose of this trial was to determine the relative efficacy and tolerability of cefprozil and erythromycin in the treatment of pediatric pharyngitis/tonsillitis due to GABHS. METHODS: This trial compared the bacteriologic and clinical efficacy of erythromycin and cefprozil in children 2 to 12 years of age with culture-documented GABHS pharyngitis/ tonsillitis. Children who were allergic to penicillin, cefprozil, or erythromycin were excluded. Patients were prospectively randomly assigned to receive 10 days of oral therapy with either cefprozil suspension 15 mg/kg per day in 2 divided doses or erythromycin ethylsuccinate suspension 30 mg/kg per day in 3 divided doses. Primary efficacy end points were bacteriologic and clinical response 2 to 8 days after treatment ended. The frequency and severity of adverse events and their relationship to treatment were also assessed. RESULTS: A total of 199 patients were enrolled and treated (cefprozil, 99; erythromycin, 100); 12 patients in the cefprozil group and 15 in the erythromycin group were not evaluable. The GABHS eradication rate was significantly higher with cefprozil (95%) than with erythromycin (74%) (P = 0.001). The posttreatment carrier rate was lower in the cefprozil group (5%) than in the erythromycin group (18%) (95% CI, -22.3 to -3.8). Clinical cure rate was 90% (78/87) with cefprozil and 91% (77/85) with erythromycin (P = 0.95) (treatment group difference, -0.93; 95% CI, -9.9% to 8.0%). The overall incidence of drug-related adverse events was not significantly different in the 2 groups (11% with cef- prozil, 18% with erythromycin). The most common adverse events were diarrhea and vomiting. Two patients in the erythromycin group discontinued therapy because of adverse events. CONCLUSIONS: The bacteriologic eradication rate was significantly greater with cefprozil compared with erythromycin in children with pharyngitis/tonsillitis. Both cefprozil and erythromycin produced a clinical cure in >90% of patients.

Anti-Bacterial Agents↗
PubMed2001

A prospective observational study of 5-, 7-, and 10-day antibiotic treatment for acute otitis media.

OBJECTIVE: To compare 5-, 7- and 10-day duration of antibiotic therapy for acute otitis media (AOM) in children. STUDY DESIGN AND SETTING: Prospective nonrandomized 1-year evaluation of 3 treatment durations for AOM in a private pediatric setting. Outcomes assessed at 14 +/- 4 days after start of therapy with clinical response categorized as cure, improvement, or failure. RESULTS: A total of 2172 children were studied; 46.4% were < or =2-years-old. Antibiotics used were amoxicillin (61.9% of patients), trimethoprim/sulfamethoxazole (11.7%), cephalosporins (14.2%), amoxicillin/clavulanate (5.2%), and macrolides/azalides (4.8%). No overall difference in outcome was observed comparing the 5-day (n = 707), 7-day (n = 423), or 10-day (n = 1042) treatments, including children < or =2-years-old. However, in the subset who had an episode of AOM in the preceding month, outcome differed; 5-day treatment was followed by more frequent failure than 10-day treatment (P < 0.001). In logistic regression analysis, variables identified as contributing to a cure were: >2-years-old (P < 0.0001), no AOM in the preceding month (P = 0.07), or preceding 12 months (P = 0.03). CONCLUSIONS: Our study supports the transition from 10 to 5 days for standard AOM antibiotic treatment duration in most patients. A 10-day regimen may be superior in children who have experienced an episode of AOM within the preceding month, a known risk factor for resistant bacterial infection in the otitis-prone patient.

Acute Disease↗
PubMed2001

Low baseline antibody level to diphtheria is associated with poor response to conjugated pneumococcal vaccine in adults.

Joining polysaccharide antigens to protein increases immunogenicity in infants. In older adults, using conjugation to protein carriers to improve the immune response to pneumococcal polysaccharide vaccine has thus far proved disappointing. Low immunity to the carrier protein in the elderly may explain the failure of conjugated vaccines to elicit a T-cell-dependent response. We immunized 49 older adults (ages 60-78) and 50 younger adults (ages 18-45) with either 23-valent pneumococcal polysaccharide (PS) vaccine or 5-valent CRM197-conjugated pneumococcal oligosaccharide. Sera obtained before and after vaccination were analyzed for antibody to pneumococcal serotypes 14 and 6B and diphtheria toxin by ELISA. Baseline diphtheria toxin antibody level was lower in older adults than in younger adults (0.31 and 0.88 IU/ml, respectively; p < 0.0001). Adults with higher diphtheria antibody level had a higher antibody level to PS type 6B after vaccination than those with lower diphtheria antibody level (9.9 vs. 3.5 microg/ml, respectively; p = 0.01). Antibody level to PS type 14 was higher, but differed by baseline anti-diphtheria antibody level only when the older group was evaluated alone. Low levels of antibody to diphtheria protein may explain some of the lower responses to conjugate pneumococcal vaccine in older adults.

Adult↗
PubMed2001

Fifth vaccination with dipthteria, tetanus and acellular pertussis is beneficial in four- to six-year-olds.

OBJECTIVE: Diphtheria, tetanus and pertussis serum antibody titers were assessed before a fifth dose of diphtheria-tetanus-acellular pertussis (DTaP) or diphtheria-tetanus-whole cell pertussis (DTwP) vaccination at age 4 to 6 years. METHODS: Healthy children who had participated in a series of National Institutes of Health-sponsored trials assessing DTwP and DTaP vaccines provided prevaccination sera before a fifth dose of DTwP or DTaP. The trial design was prospective, randomized and double blind. Diphtheria, tetanus and pertussis antibody titers were measured by enzyme-linked immunosorbent assay. Pertussis results are expressed in enzyme-linked immunosorbent assay units/ml based on US Food and Drug Administration reference sera. Tetanus and diphtheria toxin concentrations are expressed in IU/ml with a WHO international reference sera as a standard. RESULTS: For diphtheria 100% of the children had antibody titers above the minimum protective level of 0.01 IU/ml and 86 to 100% (depending on prior vaccine product) had titers >0.1 IU/ml. However, only 0 to 40% of the children had antibody titers > or =1.0 IU/ml, a titer associated with more certain durable protection. For tetanus none of the children had an antibody titer below 0.01 IU/ml, and 93 to 100% had titers > or =0.1 IU/ml, a titer associated with more certain, durable protection. For pertussis the geometric mean concentrations of antibody before booster were uniformly very low, and the percentage of children exceeding the minimum detectable titer of antibody by 4-fold was also low. CONCLUSION: Before a 4- to 6-year-old booster, a large proportion of children have titers of antibody to diphtheria below the certain, durable protective level. Because serologic correlates and minimum protective titers of antibody to pertussis antigens have not been established, the relevance of the low titers determined in the current study is unknown but a potential concern.

Antibodies, Bacterial↗
PubMed2001

Assessing diagnostic accuracy and tympanocentesis skills by nurse practitioners in management of otitis media.

PURPOSE: To assess healthcare provider accuracy in recognizing the physical examination findings of acute otitis media (AOM) and otitis media with effusion (OME) and technical competence in performing tympanocentesis using a simulation model. DATA SOURCES: A descriptive study of 1,271 pediatricians and 206 nurse practitioners (NPs) who viewed 9 different video-recorded pneumatic otoscopic examinations of tympanic membranes (TMs) during a continuing medical education (CME) course. Diagnostic differentiation of AOM, OME and normal was ascertained. A mannequin model of a one-two year old child was used to assess technical proficiency of performing tympanocentesis on artificial tympanic membranes. CONCLUSIONS: Overall, the average correct diagnosis by all healthcare providers was 46% (range = 25% to 71%); by pediatricians it was 50% (25% to 71%) and by NPs 42% (25% to 68%). Pediatricians and NPs correctly recognized the absence of normality 86% to 99% and 68% to 99% of the time; they over-diagnosed AOM in 7% to 58% (average 27%) and 10% to 65% of examinations (average 31%), respectively. Performance of tympanocentesis was optimally performed by 73% of NPs. IMPLICATIONS FOR PRACTICE: The distinction between AOM and OME is important for antibiotic management decisions; tympanocentesis may be useful in diagnosis of AOM in selected patients. Healthcare providers may misdiagnose AOM and OME with some frequency. Nurse practitioners and pediatricians have the skills to be trained in the tympanocentesis procedure. Interactive CME courses with simulation technology may enhance skills and lead to a willingness to change and improve diagnostic accuracy and treatment paradigms.

Clinical Competence↗
PubMed2001

Are follow-up throat cultures necessary when rapid antigen detection tests are negative for group A streptococci?

The frequency of obtaining false-negative Group A Streptococcal (GAS) rapid antigen detection (RAD) tests utilizing currently available kits in a private practice setting and the cost effectiveness of requiring follow-up throat cultures were studied. Laboratory records of the Elmwood Pediatric Group (EPG), Rochester, NY, were retrospectively reviewed to identify all patients with pharyngeal RAD tests for GAS performed from January 1996 through May 1999. From January 1996 through October 1997 (study period 1), EPG physicians used either a RAD test or a throat culture to identify GAS; from November 1997 through May 1999 (study period 2), RAD tests were used as the primary test on all patients. Rapid antigen detection test negative results were confirmed with culture. During the 3-year study 11,427 RAD tests were performed. 8,385 (73.4%) were negative and 3,042 (26.6%) were positive. In study period 1, 3,547 (73.2%) were negative and 1,299 (26.8%) were positive; in study period 2 4,837 (73.5%) were negative and 1,743 (26.5%) were positive. Of the 8,385 negative tests, 8,234 (98.2%) were followed up with throat cultures. Of these, 200 (2.4%) were identified to have been negative RAD tests that were throat culture positive (132 [3.8%] of 3,474 in study period 1 and 68 [1.4%] of 4,764 in study period 2). A cost analysis was performed for study period 2, which showed that abandoning throat culture confirmation would generate a cost saving of $13,521 per year to the practice. Throat culture confirmation of RAD test negative results in pharyngitis patients may not be medically necessary for most patients with currently available RAD tests and is costly.

Adolescent↗
PubMed2000

Human immune response to streptococcal inhibitor of complement, a serotype M1 group A Streptococcus extracellular protein involved in epidemics.

Streptococcal inhibitor of complement (Sic) is a highly polymorphic extracellular protein made by serotype M1 group A Streptococcus strains that contributes to bacterial persistence in the mammalian upper respiratory tract. New variants of the Sic protein arise very rapidly by positive selection in human populations during M1 epidemics. The human antibody response to Sic was analyzed. Of 636 persons living in diverse localities, 43% had anti-Sic serum antibodies, but only 16.4% had anti-M1 protein serum antibody. Anti-Sic antibody was also present in nasal wash specimens in high frequency. Linear B cell epitope mapping showed that serum antibodies recognized epitopes located in structurally variable regions of Sic and the amino terminal hypervariable region of the M1 protein. Phage display analyses confirmed that the polymorphic regions of Sic are primary targets of host antibodies. These results support the hypothesis that selection of Sic variants occurs on mucosal surfaces by a mechanism that involves acquired host antibody.

Adolescent↗
PubMed2000

Acute otitis media: part II. Treatment in an era of increasing antibiotic resistance.

Antibiotic resistance is increasing among the pathogens that commonly cause acute otitis media. This development may merit changes in the traditional antibiotic treatment of acute otitis media. Risk factors for resistant pathogens include recent antibiotic treatment of acute otitis media, children in day care facilities, wintertime infections and acute otitis media in children less than two years of age. Amoxicillin remains the antibiotic of first choice, although a higher dosage (80 mg per kg per day) may be indicated to ensure eradication of resistant Streptococcus pneumoniae. Oral cefuroxime or amoxicillin-clavulanate and intramuscular ceftriaxone are suggested second-line choices for treatment failure. Compliance with antibiotic regimens is enhanced by selecting agents that require less frequent dosing (such as one or two times a day) and by prescribing shorter (five days or less) treatment courses. Selective use of tympanocentesis if the patient does not respond to empiric therapy can help confirm the diagnosis and guide effective therapy.

Acute Disease↗
PubMed2000

Acute otitis media: Part I. Improving diagnostic accuracy.

Acute otitis media is overdiagnosed. Symptoms are neither sensitive nor specific for the diagnosis of otitis media; fever and ear pain are present in only one half of patients. Undue reliance on one feature--redness of the tympanic membrane--and failure to assess tympanic membrane mobility with pneumatic otoscopy contribute to inaccurate diagnoses. Adequate visualization of the tympanic membrane is often impaired by low light output from old otoscope bulbs and blockage of the ear canal by cerumen. Distinguishing acute otitis media from otitis media with effusion is clinically important because antibiotics are seldom indicated for the latter condition. A key differentiating feature is the position of the tympanic membrane: it is usually bulging in acute otitis media and in a neutral position or a retracted position in otitis media with effusion. Tympanometry and acoustic reflectometry can be useful adjunctive tools to confirm the presence of fluid in the middle ear. Selective use of tympanocentesis in cases of refractory or recurrent middle ear disease can help guide appropriate therapy and avoid unnecessary medical or surgical interventions.

Acute Disease↗
PubMed2000

Fewer symptoms occur in same-serotype recurrent streptococcal tonsillopharyngitis.

BACKGROUND: Most patients with acute rheumatic fever report no antecedent pharyngitis. OBJECTIVE: To determine the clinical and microbiological characteristics of recurrent group A beta-hemolytic streptococcal (GABHS) tonsillopharyngitis. DESIGN: Prospective randomized trial. SUBJECTS: Symptoms were recorded and throat cultures were obtained at 4 to 6, 18 to 21, and 32 to 35 days following the start of treatment. A subset of 60 patients with subsequent GABHS episodes occurring were evaluated for a 0.2-or greater log rise in either antistreptolysin O or anti-deoxyribonuclease B titer to confirm a bona fide recurrence. RESULTS: Sixteen (27%) of 60 patients had recurrent GABHS tonsillopharyngitis of the same serotype that occurred 21 days or longer following the onset of the initial GABHS infection and was associated with a 0.2- or greater log rise in either antistreptolysin O or anti-deoxyribonuclease B titer, indicating bona fide recurrent infection; these recurrences all occurred within 55 days. Fewer patients with recurrent GABHS pharyngitis of the same serotype had headache (P =.02), sore throat (P =.006), fever (P =. 008), pharyngeal erythema (P<.001), pharyngeal edema (P<.001), pharyngeal exudate (P =.04), and adenitis (P =.03) compared with the initial episode. Chills, stomachache, scarlatina, tonsillar enlargement, and palatal petechiae were similar for both episodes. CONCLUSIONS: Fewer symptoms occur during recurrent GABHS pharyngitis of the same serotype compared with the initial infection. These patients may be less likely to seek physician attention, yet their infections put them at risk for sequelae.

Adolescent↗
PubMed2000

New combination vaccines.

Physicians can achieve full vaccination at each of the recommended visits by administering three or four injections, but for infants, four injections seem to be a maximum in light of the size of the infant thigh, which is the preferred injection site. Thus, physicians must make room for all of the new vaccines on the horizon. To accomplish that task, combinations will be necessary. Progress toward that goal is occurring.

Antibodies, Viral↗
PubMed2000

Diminution of the anti-polyribosylribitol phosphate response to a combined diphtheria-tetanus-acellular pertussis/Haemophilus influenzae type b vaccine by concurrent inactivated poliovirus vaccination.

BACKGROUND: Prelicensure studies of Haemophilus influenzae type b vaccines (Hib) and diphtheria-tetanus-acellular pertussis vaccines (DTaP) were evaluated with concurrent oral poliovirus vaccine (OPV). However, inactivated poliovirus vaccine (IPV) is now recommended. A trial was conducted in which infants received a DTaP and Hib vaccine, separately (+) or combined (/), with either all OPV, all IPV or sequential IPV-OPV for the primary series of vaccinations. METHODS: In this protocol 567 infants were equally randomized to receive one of the following: Reference Arm A, DTaP + Hib + OPV; Treatment Arm B, DTaP/Hib + OPV; Treatment Arm C, DTaP/Hib + IPV at 2 and 4 months and OPV at 6 months; or Treatment Arm D, DTaP/Hib + IPV. antibodies against all administered antigens were measured at 7 months of age. Children with an antibody response to Hib (anti-polyribosylribitol phosphate (anti-PRP) <0.15 microg/ml had an antibody titer repeated after the toddler booster immunization. RESULTS: A significant diminution in the anti-PRP response was observed at 7 months of age in children given two or three doses of IPV concurrently with DTaP/Hib, compared with the groups given OPV. The geometric mean concentration of anti-PRP, percentage of children with > or = 0.15 microg/ml and percentage of children with > or = 1.0 microg/ ml, respectively, were: A, 4.4, 98%, 81%; B, 3.2, 94%, 78%; C, 1.3, 86%, 58% and D, 1.2, 84%, 53%. CONCLUSION: In this trial concurrent IPV appeared to interfere with the anti-PRP response to DTaP/Hib vaccine, suggesting that introduction of new vaccines may require evaluation of immune responses to all concurrently administered vaccines.

Adhesins, Bacterial↗
PubMed2000

A high degree of natural immunologic priming to the capsular polysaccharide may not prevent Haemophilus influenzae type b meningitis.

BACKGROUND: A current debate is whether the immunologic priming of infants with Haemophilus influenzae type b (Hib) conjugate vaccines would be protective in the absence of circulating antibody to the capsular polysaccharide (PS). Data from the prevaccine era on the PS antibody responses of older children to Hib meningitis may be informative on this issue. METHODS: PS antibody was assayed by radioantigen binding in sera taken in the first month postadmission in 47 children ages 2 to 136 months with culture-proved Hib meningitis. RESULTS: Sera obtained on admission had very low antibody concentrations, and the subsequent response during convalescence was age-dependent. The major finding is that some patients, including 10 of 11 children older than 2 years, had substantial antibody elevations within a few days of admission, increases resembling the response to PS vaccine in infants primed with PS-protein conjugate vaccines. CONCLUSIONS: In this group of patients with Hib meningitis, natural priming did not prevent infection. Hib may have the ability to invade despite the capacity for a vigorous antibody response.

Age Factors↗
PubMed2000

Recurrent and persistent otitis media.

Recurrent acute otitis media occurs during the first several years of life in approximately 20 to 30% of the pediatric population. A clinical challenge closely related to recurrent otitis media is persistent otitis media, manifested by persistence during antimicrobial therapy of symptoms and signs of middle ear infection (treatment failure) and/or relapse of acute otitis media within 1 month of completion of antibiotic therapy. Recurrent and persistent otitis media infections are early childhood problems with identifiable risk factors. Differentiation of these infections from otitis media with effusion is important in avoiding misdiagnosis and overtreatment with antibiotics. The predominant pathogens of recurrent and persistent acute otitis media are antibiotic-resistant Streptococcus pneumoniae and beta-lactamase-producing Haemophilus influenzae. A working group convened by the Centers for Disease Control recommended three antibiotics for the treatment of recurrent and persistent acute otitis media: (1) amoxicillin/clavulanate in combination with amoxicillin (high dose amoxicillin regimen, 80 to 90 mg/kg/day); (2) cefuroxime axetil (standard dose, 30 mg/kg/day); and (3) ceftriaxone (possibly requiring up to three injections to optimize clinical success). Other antibiotics were considered suboptimal or had accumulated insufficient data upon which to base a judgment. Conclusions. Optimal management of recurrent and persistent acute otitis media is a clinical challenge. Accurate diagnosis of acute otitis media is the first step in optimal management. Selection of appropriate antibiotic therapy should take into account the major pathogens (S. pneumoniae, H. influenzae and Moraxella catarrhalis) and the occurrence of antibiotic resistance.

Adolescent↗