Incidence, microbiology and management of acute otitis media and ear discharge in primary care

Abstract

Acute otitis media (AOM) is a common childhood infection, often leading to doctor visits and antibiotic prescriptions. Approximately 15-20% of children with AOM experience ear discharge due to a spontaneous tear or perforation of the eardrum (AOMd). Contrary to widespread beliefs, acute ear discharge as a presenting symptom of AOM does not mean that the infection is improving. Children with AOMd have similar levels of ear pain and feel worse at first presentation than those without ear discharge. The main aim of this thesis was therefore to provide insight in the incidence, microbiology and management of AOM, and in particular AOMd, in primary care. Chapter 2.1 reports the impact of the COVID-19 pandemic on otitis media in Dutch children. During the pandemic, general practitioner (GP) consultations for AOM, OME (otitis media with effusion), and ear discharge decreased by 63%, 57%, and 54% respectively. Chapter 2.2 shows that the incidence of AOM in adults remained stable between 2015 and 2018, with an incidence of 5.3 episodes per 1,000 person-years. Chapter 3 reports that Streptococcus pneumoniae, Haemophilus influenzae, Staphylococcus aureus, and Streptococcus pyogenes are globally the most common bacteria present in the ear discharge of children with AOMd. Antimicrobial resistance (AMR) data were sparse and mainly limited to S. pneumoniae. There was no significant shift in bacterial prevalence or AMR over time. Chapter 4 reports the results of our randomized controlled trial (RCT) comparing antibiotic-corticosteroid eardrops versus oral antibiotics for children with AOMd. Due to slow accrual the trial was prematurely ended with 58 of a planned 350 children included. We were unable to determine non-inferiority of antibiotic-corticosteroid eardrops to oral antibiotics, but our findings in a small group of children, requiring confirmation, suggest that that oral antibiotics may be more effective in resolving symptoms, and shortening the duration of ear discharge than antibiotic-corticosteroid eardrops in children with AOMd. Chapter 5 reports on a study assessing the differential impact of topical and systemic antibiotics on the gut microbiota composition and antibiotic resistance genes for children with AOMd. The study found no significant differences in gut microbiota composition or antibiotic resistance gene abundance between the two treatment groups. In chapter 6 the thesis’ main findings, including our trial’s recruitment challenges, and their implications for future primary-care based research, are discussed.