RESUMO
OBJECTIVE: To reconcile conflicting published reports concerning the absolute and comparative clinical efficacy of antimicrobial drugs for acute otitis media in children. STUDY SELECTION: Articles were identified by MEDLINE search, Current Contents, and references from review articles, textbook chapters, and retrieved reports. Randomized, controlled trials of therapeutic antimicrobial drugs used in the initial empiric therapy for simple acute otitis media were selected by independent, blinded observers, and scored on 11 measures of study validity. Thirty English and three foreign-language articles met all inclusion criteria. DATA EXTRACTION: Data were abstracted for an end point of complete clinical resolution (primary control), exclusive of middle ear effusion, within 7 to 14 days after therapy started. DATA SYNTHESIS: The spontaneous rate of primary control--without antibiotics or tympanocentesis--was 81% (95% confidence interval, 69% to 94%). Compared with placebo or no drug, antimicrobial therapy increased primary control by 13.7% (95% confidence interval, 8.2% to 19.2%). No significant differences were found in the comparative efficacy of various antimicrobial agents. Extending antimicrobial coverage to include beta-lactamase-producing organisms did not significantly increase the rates of primary control or resolution of middle ear effusion. Pretreatment tympanocentesis was positively associated with individual group primary control rates, negatively associated with the ability to detect differences in clinical efficacy and unassociated with resolution of MEE. CONCLUSIONS: Antimicrobial drugs have a modest but significant impact on the primary control of acute otitis media. Treatment with beta-lactamase-stable agents does not increase resolution of acute symptoms or middle ear effusion; initial therapy should be guided by considerations of safety, tolerability, and affordability, and not by the theoretical advantage of an extended antibacterial spectrum.
Assuntos
Antibacterianos/uso terapêutico , Otite Média/tratamento farmacológico , Doença Aguda , Pré-Escolar , Feminino , Humanos , Lactente , Masculino , Análise Multivariada , Ensaios Clínicos Controlados Aleatórios como Assunto , Sensibilidade e EspecificidadeRESUMO
The aggressive nature of childhood cholesteatoma has generated much controversy regarding the optimal management of this challenging disorder. To identify potential predictors of residual-recurrent disease, we studied 232 children (244 ears) treated with 427 surgical procedures between 1973 and 1990. Cause of the primary cholesteatoma was congenital in 43 patients (18%), acquired in 83 (36%), and unknown in 106 (46%). Of 90 patients with residual-recurrent disease, 21 (23%) instances were detected during a second-look surgical exploration. The 3- and 5-year residual-recurrence rates were 48% and 57%, respectively. Development of residual-recurrent disease was associated with ossicular erosion (Cox regression) but not with status of the canal wall (up vs down) during tympanomastoidectomy. This study suggests a need for intense and prolonged postoperative follow-up of children with cholesteatoma, especially those with ossicular erosion.
Assuntos
Colesteatoma/patologia , Colesteatoma/cirurgia , Otopatias/patologia , Otopatias/cirurgia , Orelha Média , Recidiva Local de Neoplasia , Adolescente , Fatores Etários , Criança , Pré-Escolar , Colesteatoma/mortalidade , Otopatias/mortalidade , Ossículos da Orelha/patologia , Orelha Média/cirurgia , Feminino , Seguimentos , Previsões , Humanos , Lactente , Masculino , Processo Mastoide/cirurgia , Reoperação , Análise de SobrevidaRESUMO
There is concern that third-generation cephalosporins may not be effective in the treatment of acute otitis media due to Streptococcus pneumoniae. Using the chinchilla animal model, we compared two third-generation cephalosporins, cefixime (Suprax) and ceftibuten (investigational), with ampicillin and saline controls in an investigator-blinded, randomized trial. Whereas the saline controls performed worse than all other groups, no significant differences were detected among the three antibiotics regarding the time required to sterilize the middle ear cleft, or the prevalence of positive cultures after 10 days of therapy. The statistical power of the comparisons of cefixime and ceftibuten with ampicillin were 98% and 67%, respectively. The results of this in vivo animal study fail to support the contention that the two third-generation cephalosporins investigated are not effective in the treatment of pneumococcal acute otitis media. Caution is advised when extrapolating these results to the general clinical setting.