Otorrhea in Kids With Tubes: Which Treatment Is Best?
Otorrhea in Kids With Tubes: Which Treatment Is Best?
Adherence to the regimen was greatest (93%) among those receiving eardrops, compared with 88% among those receiving oral antibiotics and 79% among those in the observation group. The 3 groups had comparable demographic characteristics at enrollment. The mean age at enrollment was 4.5 years, and 58% of the children were boys. At study entry, 17% of the children had otorrhea bilaterally, and the median duration of otorrhea was 3 days. Tympanostomy tubes had been placed for recurrent acute infectious episodes in 43% of the children, and 57% received them for persistent effusion. Among the positive bacterial cultures, 40% grew Haemophilus influenzae, 40% grew Staphylococcus aureus, and 18% grew Pseudomonas aeruginosa. Only 7% grew Streptococcus pneumoniae, and 3% grew Moraxella catarrhalis.
For all outcomes, otic drops proved to be the superior treatment regimen, followed by oral antibiotics. For example, the median duration of otorrhea for the enrollment episode was 4 days in the otic drop group, 5 days in the oral antibiotic group, and 12 days in the observation group. Median days of otorrhea over the 6-month follow-up were highest in the observation group as well. The median number of recurrent episodes during the 6-month follow-up period was 0 for children with otic drops, 1 for those treated with oral antibiotics, and 1 for those treated with observation. For the primary outcome, only 5% of those treated with otic drops had otorrhea at the 2-week follow-up, compared with 44% of those who received oral antibiotics and 55% of those in the observation group.
There were also differences in adverse events between the groups, with 21% of the children in the otic drop group experiencing local discomfort or pain during administration of the ear drops compared with gastrointestinal discomfort in 23% of the children who received oral antibiotics. Van Dongen and collegues concluded that antibiotic-glucocorticoid eardrops were more effective than oral antibiotics in treating an episode of acute otorrhea in children with tympanostomy tubes.
Many pediatric providers will be interested in the results of this study. The study was conducted in The Netherlands, so the particulars of the trial vary somewhat from treatment approaches in the United States. Specifically, the otic drops used are not routinely available in the United States, but the antimicrobial coverage of the preparation most widely used in the United States should be similar to that of the one used in this study. More problematic for US practitioner interpretation is the fact that the amoxicillin dose in the oral antibiotic group is much lower than the currently recommended dose in the United States, and the study authors allude to the lower rate of pneumococcal resistance in The Netherlands as the reason for that choice.
However, the results are probably applicable to US practice for the following reason: The success rate of drop treatment alone was 95%. Even if one were to compare oral antibiotics with an amoxicillin component of 60-80 mg/kg/day, the treatment effectiveness would have to be higher than 95% for oral treatment to be considered superior. Therefore, it seems to me that otic drop treatment should be offered to any family who voices preference for it over oral treatment, but the different side-effect profiles are worth reviewing with parents. I was also struck by the antimicrobial variability, including pathogens that won't respond to amoxicillin only such as Staphylococcus and Pseudomonas. It means that we should remember that children with tympanostomy tubes will be more likely to harbor resistant organisms, and our treatment decisions should account for that.
Abstract
Study Findings
Adherence to the regimen was greatest (93%) among those receiving eardrops, compared with 88% among those receiving oral antibiotics and 79% among those in the observation group. The 3 groups had comparable demographic characteristics at enrollment. The mean age at enrollment was 4.5 years, and 58% of the children were boys. At study entry, 17% of the children had otorrhea bilaterally, and the median duration of otorrhea was 3 days. Tympanostomy tubes had been placed for recurrent acute infectious episodes in 43% of the children, and 57% received them for persistent effusion. Among the positive bacterial cultures, 40% grew Haemophilus influenzae, 40% grew Staphylococcus aureus, and 18% grew Pseudomonas aeruginosa. Only 7% grew Streptococcus pneumoniae, and 3% grew Moraxella catarrhalis.
For all outcomes, otic drops proved to be the superior treatment regimen, followed by oral antibiotics. For example, the median duration of otorrhea for the enrollment episode was 4 days in the otic drop group, 5 days in the oral antibiotic group, and 12 days in the observation group. Median days of otorrhea over the 6-month follow-up were highest in the observation group as well. The median number of recurrent episodes during the 6-month follow-up period was 0 for children with otic drops, 1 for those treated with oral antibiotics, and 1 for those treated with observation. For the primary outcome, only 5% of those treated with otic drops had otorrhea at the 2-week follow-up, compared with 44% of those who received oral antibiotics and 55% of those in the observation group.
There were also differences in adverse events between the groups, with 21% of the children in the otic drop group experiencing local discomfort or pain during administration of the ear drops compared with gastrointestinal discomfort in 23% of the children who received oral antibiotics. Van Dongen and collegues concluded that antibiotic-glucocorticoid eardrops were more effective than oral antibiotics in treating an episode of acute otorrhea in children with tympanostomy tubes.
Viewpoint
Many pediatric providers will be interested in the results of this study. The study was conducted in The Netherlands, so the particulars of the trial vary somewhat from treatment approaches in the United States. Specifically, the otic drops used are not routinely available in the United States, but the antimicrobial coverage of the preparation most widely used in the United States should be similar to that of the one used in this study. More problematic for US practitioner interpretation is the fact that the amoxicillin dose in the oral antibiotic group is much lower than the currently recommended dose in the United States, and the study authors allude to the lower rate of pneumococcal resistance in The Netherlands as the reason for that choice.
However, the results are probably applicable to US practice for the following reason: The success rate of drop treatment alone was 95%. Even if one were to compare oral antibiotics with an amoxicillin component of 60-80 mg/kg/day, the treatment effectiveness would have to be higher than 95% for oral treatment to be considered superior. Therefore, it seems to me that otic drop treatment should be offered to any family who voices preference for it over oral treatment, but the different side-effect profiles are worth reviewing with parents. I was also struck by the antimicrobial variability, including pathogens that won't respond to amoxicillin only such as Staphylococcus and Pseudomonas. It means that we should remember that children with tympanostomy tubes will be more likely to harbor resistant organisms, and our treatment decisions should account for that.
Abstract
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