Epidemiology Of Otitis Media In Children

Understanding Otitis media in children

Discuss about the Epidemiology Of Otitis Media In Children.

Otitis media is referred as middle ear infection where there is building up of fluid in the middle ear. It is also known as childhood illness that is common among this age group having symptoms like fever and earache. Acute Otitis media occurs in children between ages 6 to 18 months up to 4 years of age. More than 65% of infections occur in children at least once by the age of 3 years. Children complain of ear pain that are diagnosed with Otitis media having symptoms including restlessness, irritability, fever and disrupted sleep. The eardrum ruptures and there is discharge from the affected ear. Viral or bacterial infection is the greatest risk factor for Otitis media among children. According to (1) Otitis media occurs in majority of children below the age of six years with high prevalence in developing countries posing a significant burden of disease in these settings. It is a major cause of morbidity and a frequent reason for antibiotic administration among children. A large cross-sectional survey conducted by (2) depicted the fact that Otitis media is a major concern and burden in clinical practice and empirical treatment with antibiotics is considered the first line of treatment (3). Therefore, the rationale for choosing this topic is that Otitis media has emerged as a common medical problem among paediatricians, caregivers and for the children who visit doctors regularly with this condition. As a result, the normal routine is disrupted where adequate treatment is not provided to them on time that fails to provide relief to the children from pain and discomfort. Long-term sequelae can result in permanent middle ear damage or hearing loss in children that need to be lessened with appropriate antibacterial treatment.

Antibiotics are prescribed to the children diagnosed with Otitis media; however, they develop resistance causing a failure in first line medicines. The recommended first line of therapy in Otitis media is high-dosage amoxicillin (80 to 90 mg per kg per day), however children develop resistance or if the child is having a history of hypersensitivity to penicillin or amoxicillin. There is recent antibiotic pressure and pneumococcal conjugate vaccine due to the emergence of Haemophilus influenza (beta-lactamase production). The current Academy of Pediatrics endorse that amoxicillin is the preferred medication for Otitis media treatment, however with increasing amoxicillin-resistant H influenza, it is not considered preferred treatment (4).There is increase in isolates with beta-lactamase producing capability and this resulted in decreased efficacy of amoxicillin with greater stability for Otitis media treatment. Considering this situation, some studies supported the fact that Cefuroxime, a second-generation medicine is effective in resolving Otitis media in cases where children develop amoxicillin resistance (5).

Symptoms of Otitis media

There is an ongoing debate between the efficacies of amoxicillin and cefuroxime in the treatment of children with Otitis media. According to a recent US data, cefuroxime has 80% efficacy against S pneumonia as compared to 90% efficacy of amoxicillin (6). In vitro, the efficacy of cefuroxime is 98% against H influenzae as compared to amoxicillin having 58% efficacy (7). H influenzae also develop resistance against antibiotic, amoxicillin and hypersensitivity reactions develop among children with Otitis media.

The investigation of efficacies of these two antibiotics is important to provide timely treatment to children with Otitis media with decrease in symptoms and related to the discipline and line of research, medicine. Moreover, this investigation would help in reducing physical suffering, emotional distress and behavioural problems that greatly affect the quality of life of children diagnosed with Otitis media (8). Therefore, the aim of the assignment is to develop a PICO question and conduct literature review to investigate the efficacies of the above-mentioned antibiotics in Otitis media treatment among children.

PICO question is a specialized framework that is used to formulate a research question through the conduction of literature review. A clinical question should be relevant to patient or health problem in a way that is helpful in facilitating search or reach an answer. PICO makes this search process easier and important part of a clinical question.

PICO question is:

In children with otitis media (P), is cefuroxime (I) as compared to amoxicillin (C) is more effective in reducing symptoms (O)?

Search strategy is the process that is defined by methodology focusing on research question. Literature review is conducted that provide an opportunity to understand the PICO question and gain in-sight into Otitis media antibiotic treatment. This also appropriately answers the formulated research question so that one can have successful outcomes (9). The studying of efficacy of these antibiotics can be helpful in providing effective treatment to children with Otitis media. An exploration of pool of vast literature is linked to research topic where qualitative approach in systematic literature review is conducted that helps in enhancing the mechanism of action of these drugs so that appropriate treatment can be given to children diagnosed with OM. This section will illustrate the steps involved in systematic literature review to find relevant articles. The keywords, databases, bibliographic aids, research approach and design, inclusion and exclusion criteria, data collection and outcomes are explained in this section.

Risk factors for Otitis media in children

Research design refers to the framework adopted for the data collection and use of appropriate methodology (10). In this systematic review, qualitative approach will be used that focuses on understanding the efficacy of drugs, Cefuroxime and amoxicillin in reducing symptoms of Otitis media in children. Peer-reviewed journals will be explored and reviewed that can be beneficial in fulfilling the research question (PICO). Relevant data will be collected about antibiotic treatment on Otitis media in children to obtain an insight into the mentioned drugs efficacies in reducing symptoms fulfilling the PICO question.  In this research design, the published articles will be evaluated against pre-determined criteria

Secondary research and systematic review will be conducted for the current research that explores the literature available on antibiotic treatment in Otitis media among children. Otitis media is a significant burden for the practitioners as amoxicillin administration gradually develops resistance that is not preferred as a first line of treatment. Cefuroxime is the second-generation treatment that is showing better efficacy to resistance. Therefore, this assignment will derive themes from the collected data and use them to draw conclusions and give recommendations. Secondary research method is used as it cost-effective. It involves analysing existing information the research process and collection of evidence is rapid (11).

The overall search strategy is three-step approach for the data extraction and synthesis of evidence. The search strategy will be restricted to the databases, Google, scholar, CINAHL, and Medline and University library databases. The search was conducted using the Boolean operators OR and AND.

The search was based on these keywords and -was looked for them in the title and abstract. Based on the relevancy of the articles found the full text papers were extracted. After screening for the relevancy the keywords were also searched in the reference list to further find evidence pertaining to PICO question.  

Data collection is the process of gathering evidence systematically to address the research question and evaluate the search outcomes. In this assignment secondary data collection was preferred. The primary study conducted using surveys, trials are used to analyse the evidence. The synthesis of the data is based on the identification of the publications, selection of the relevant publications, and lastly combination of the results from different evidences found (12).  

After extracting the data, the papers are critically analysed to ensure the reliability and validity of the study. Validity and reliability are the key criteria to assess the quality of the research articles. Validity determines the importance of the concepts and reliability gives measure of the consistency and accuracy of the data (12).

Antibiotic resistance in Otitis media treatment

For the data collection PRISMA tool was used. The rationale for using this tool is its efficacy and contains minimum number of items needed to report in systematic review. PRISMA is beneficial in determining the benefits and harms of the health care intervention. It is useful tool for maintaining transparency in reporting the systematic review (9).

Appropriate keywords are required before commencing with the database search.  These words must be related to the research question, covering the key aspects. It will help identify the relevant articles. The keywords used for the search are otitis media, children, cefuroxime, amoxicillin, efficacy, reduced symptoms, hypersensitive to amoxicillin, and effectiveness.

Inclusion and exclusion criteria are required to narrow down the search so that relevant articles are extracted that can address the PICO question. Searching the databases using the keywords such as “otitis media in children” will yield broad results. Use of inclusion and exclusion criteria will help restrict the articles to PICO question and its aspects. It will help eliminate irrelevant articles not pertaining to investigation (13).

The inclusion criteria for the search are the extraction of the papers published in English language and published in the year 2005-2018. Further research conducted with children was taken into consideration. Only peer reviewed articles were included in the study. The evidence will be collected from both qualitative and quantitative studies. Studies published in the languages other than English are excluded. The search excluded expert review papers. Further, the duplicate records, book chapters, editorials and those not addressing the PICO question are excluded. The articles published beyond 2005 are excluded.

 When using Google scholar using the keywords search results obtained were 1170. It appeared that there was a wide pool of literature available on the area of interest. There was also a grey literature available that mainly comprise of the government reports and other antibiotics other than amoxicillin- clavulanate, and cefuroxime. Therefore, the inclusion criteria were applied and the search results were reduced to 820 articles.  Further articles were analysed for its fulfilment of inclusion criteria. The search results were further reduced by removing the duplicates. Further screening was performed by scrutinising titles and abstracts. Some of the articles were excluded as they dealt with the resistance mechanism of the beta lactams in Haemophilus influenza, bacterial profile and clinical implications of antibiotic resistance. It then gave search results as 87. Few more studies were excluded as they focused on the bacterial and respiratory viral interactions and etiology of the disease in HIV patients. Some were only case reports and literature reviews and were not containing key aspects of the PICO question.  It further reduced the number of studies to 50. On further screening for the key aspects of the PICO question and the eligibility for inclusion in study, few more were excluded. Further, editorials and newspapers were excluded leaving with only 5 articles that were relevant to the study.

Comparing the efficacy of Cefuroxime and Amoxicillin in treating Otitis media

There might be several inconsistencies and limitations in regards to studies involved. Sample size, and poor generalisability was major limitations.  Another limitation is lack of sufficient data focussing on cefuroxime and its impact on treatment of otitis media in children. Therefore, small study bias is the key limitation. Bias in other included studies may affect the summary as one may form any opinion as per personal interpretation from evidences (14).  

In the prospective epidemiological study by (15) antimicrobial susceptibility was tested in children receiving treatment for otitis media. The microorganisms predominant in the cultures are Streptococcus pneumoniae and Haemophilus influenza. It was found that both were resistant to cefuroxime only 2% when compared to other antibiotics like ampicillin. The results are indicating that cefuroxime may be effective in treating children with otitis media. However, the results are limited as it does not consider if there are any side effects of cefuroxime.  Also the study was conducted in the public clinical setting where the sample of Chilean children does not represent the Chilean population completely.

This result was contradicted by the findings of (16), that evaluated the antimicrobial susceptibility of the non-typeable Haemophilus influenzae (NTHi) in otitis media. The author evaluated the role of the agent in pediatric otitis media. A positive correlation was obtained between NTHi and complex OM. According to author, amoxicillin/clavulanate should be the first line therapy for otitis media. As per the study findings based on samples of ear fluids collected of children <18 years from 2010-2015, the susceptibility of the NTHi to amoxicillin/clavulanate was higher (82.0%) than the cefuroxime (77%).  However, the study is limited as there was limited access to the patent’s history use of antibiotics.  There might be referral bias in the study as data is taken from single hospital.

In the cohort study conducted by (17) the accuracy of the amoxicillin treatment was assessed in children with otitis media having complains of allergy. The children suspected with the amoxicillin allergy were assessed for immediate and non-immediate reactions to subsequent use of amoxicillin at the time of illness. It was determined through graded provocative challenge and followed up to check any life threatening reactions. As per the findings a true amoxicillin allergy is revealed by longer duration of cutaneous symptoms. Graded provocative challenge gave accurate confirmatory test for skin-related reactions. In the sample population only 10% developed non-immediate cutaneous reactions to amoxicillin. The immediate reactions were observed where rashes developed within 5 minutes of exposure to the intervention. The immediate and non immediate reactions were present in almost all the children involved in study through graded proactive challenge. The study is however restricted because false negative results were not determined.  

PICO Question

In the case report by (18) the anaphylactic reactions due to cefuroxime was assessed in child with otitis media. The child had tolerated the drug exposure earlier. However, the child developed reactions like swelling tongue, itchy throat, and dyspnea. After 24 hours the patent was asymptomatic. A positive result was obtained from the skin prick test performed with the cefuroxime. On the other hand it was found that the child well tolerated the amoxicillin upto therapeutic dosage. This study is limited as only in few cases the Cefuroxime was found to cause anaphylactic reactions and deaths were reported. In the pathogenic mechanism the IgE-mediated responses were evident. Therefore, the avoidance of cephalosporin is recommended as well as induction of drug tolerance is suggested provided patients have no alternate drugs available.    

In a comparative efficacy and safety evaluation study by (19) cefuroxime/cefaclor was compared to the amoxycilln-clavulanate in children with otitis media. Both were found to show significant improvement in the children after treating for 10 days However, the reduction of the symptoms was more in case of cefuroxime as compared to other antibiotic. The clinical success was 98% for cefuroxime when compared to 85% with amoxicillin+clav.  In addition, cefuroxime was well tolerated and was concluded as superior to amoxicillin+clav. As it was multicentric prospective trial there were less limitations than earlier studies.

As per the findings both amoxicillin and cefuroxime were reported to generate anaphylactic reactions as well as significantly reduce the symptoms of otitis media in children. There are contradictory results obtained on efficacy of amoxicillin clavulanate on children with otitis media.  In some studies bacterial susceptibility was found to be higher in amoxicillin whereas in some studies. Cefuroxime was considered to be superior. However, there was bulk of literature available on the amoxicillin both recent and latest. On the other hand the literature on cefuroxime was scarce with little reliability. It can be interpreted that amoxicillin is more effective in improving outcomes in children when compared to cefuroxime as it helps reduce symptoms despite allergic reactions. The conclusion may be subjected to bias as there are non- conclusive evidence in regards to degree of effectiveness of amoxicillin over cefuroxime.   There is less number of randomised control trials and systematic reviews in this area. There is very old literature published beyond 2005, on treatment failure and recurring of otitis media in children. Hence, there is more research required for conclusive evidence.

It is suggested to conduct more research in regards to effectiveness of amoxicillin and possibility of allergic reactions as there many studies that lacks generalisability. There is need of more randomised control trials and systematic reviews with metaanalysis in this area without the issue of generalisability. Further, it is suggested that the nurses must involve in evidence based practice to implement the best evidence for treating otitis media. They must research the efficacy of latest antibiotics against otitis media and evaluate the outcomes for it application in clinical setting. The nurses must advocate the child’s family members about the anaphylactic reactions caused by amoxicillin and instruct them to report immediately.   The clinicians and researchers are recommended to conduct intense research on the efficacy of cefuroxime and if there is serious anaphylactic reactions.   

References

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