Piglansky Lolita, Leibovitz Eugene, Raiz Simon, Greenberg David, Press Joseph, Leiberman Alberto, Dagan Ron
Pediatric Infectious Disease Unit, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.
Pediatr Infect Dis J. 2003 May;22(5):405-13. doi: 10.1097/01.inf.0000065688.21336.fa.
High dose (70 to 90 mg/kg/day) amoxicillin is recommended as first line therapy of acute otitis media (AOM) in geographic areas where drug-resistant Streptococcus pneumoniae is prevalent. Information on the bacteriologic efficacy of high dose amoxicillin treatment for AOM is limited.
To evaluate the bacteriologic and clinical efficacy of high dose amoxicillin as first line therapy in AOM.
In a prospective study 50 culture-positive patients ages 3 to 22 months (median, 9 months; 77% <1 year) were treated with high dose amoxicillin (80 mg/kg/day three times a day for 10 days) No antibiotics were administered 72 h before enrollment. Twenty-four (48%) patients presented with their first episode of AOM. Middle ear fluid was cultured by tympanocentesis at enrollment and on Days 4 to 6 of therapy. Additional middle ear fluid cultures were obtained if clinical relapse occurred. Bacteriologic failure was defined by positive cultures on Days 4 to 6 and clinical failure by no change or worsening of AOM signs and symptoms and requirement for additional antibiotics during therapy and/or at end of therapy. Patients were followed until Day 28 +/- 2. Susceptibility to penicillin and amoxicillin was measured by E-test.
Sixty-five organisms were recovered at enrollment: Haemophilus influenzae (38), Streptococcus pneumoniae (24), Streptococcus pyogenes (2) and Moraxella catarrhalis (1). Eighteen (75%) S. pneumoniae were nonsusceptible to penicillin (MIC > 0.1 microg/ml). All 24 S. pneumoniae isolates had amoxicillin MIC < or = 2.0 microg/ml. Thirteen (34%) of the 38 H. influenzae were beta-lactamase producers. Eradication was achieved in 41 (82%) patients for 54 of 65 (83%) pathogens: 22 of 24 (92%) S. pneumoniae, 21 of 25 (84%) beta-lactamase-negative H. influenzae, 8 of 13 (62%) beta-lactamase-positive H. influenzae, 2 of 2 S. pyogenes and 1 of 1 M. catarrhalis. Seven organisms not initially present were isolated on Days 4 to 6 in 5 patients: 3 beta-lactamase-positive H. influenzae; 1 beta-lactamase-negative H. influenzae; 2 S. pneumoniae; and 1 M. catarrhalis. In total 14 of 50 (28%) patients failed bacteriologically on Days 4 to 6 (persistence + new infection), of whom 9 (64%) had beta-lactamase-positive H. influenzae. Three (33%) of the 9 patients with bacteriologic failure (2 beta-lactamase-positive H. influenzae, 1 S. pneumoniae) failed also clinically on Days 4 to 6.
The predominant pathogens isolated from children with AOM failing high dose amoxicillin therapy were beta-lactamase-producing organisms. Because its overall clinical efficacy is good, high dose amoxicillin is still an appropriate choice as first line empiric therapy for AOM, followed by a beta-lactamase-stable drug in the event of failure.
在耐青霉素肺炎链球菌流行的地区，推荐大剂量（70至90毫克/千克/天）阿莫西林作为急性中耳炎（AOM）的一线治疗药物。关于大剂量阿莫西林治疗AOM的细菌学疗效的信息有限。
评估大剂量阿莫西林作为AOM一线治疗药物的细菌学和临床疗效。
在一项前瞻性研究中，对50例年龄在3至22个月（中位数9个月；77%小于1岁）、培养阳性的患者给予大剂量阿莫西林治疗（80毫克/千克/天，每日3次，共10天）。入组前72小时未使用抗生素。24例（48%）患者为首次发生AOM。在入组时以及治疗的第4至6天通过鼓膜穿刺术采集中耳液进行培养。如果发生临床复发，则额外采集中耳液进行培养。细菌学失败定义为治疗第4至6天培养阳性，临床失败定义为AOM体征和症状无变化或恶化，且在治疗期间和/或治疗结束时需要额外使用抗生素。对患者随访至第28±2天。通过E试验测定对青霉素和阿莫西林的敏感性。
入组时分离出65株细菌：流感嗜血杆菌（38株）、肺炎链球菌（24株）、化脓性链球菌（2株）和卡他莫拉菌（1株）。18株（75%）肺炎链球菌对青霉素不敏感（最低抑菌浓度＞0.1微克/毫升）。所有24株肺炎链球菌分离株的阿莫西林最低抑菌浓度≤2.0微克/毫升。38株流感嗜血杆菌中有13株（34%）产β-内酰胺酶。41例（82%）患者的65株（83%）病原体被清除：24株肺炎链球菌中的22株（92%）、25株β-内酰胺酶阴性流感嗜血杆菌中的21株（84%）、13株β-内酰胺酶阳性流感嗜血杆菌中的8株（62%）、2株化脓性链球菌中的2株以及1株卡他莫拉菌中的1株。在5例患者的治疗第4至6天分离出7株最初不存在的细菌：3株β-内酰胺酶阳性流感嗜血杆菌；1株β-内酰胺酶阴性流感嗜血杆菌；2株肺炎链球菌；1株卡他莫拉菌。总共50例患者中有14例（28%）在治疗第4至6天细菌学失败（持续感染+新感染），其中9例（64%）有β-内酰胺酶阳性流感嗜血杆菌。9例细菌学失败的患者中有3例（33%）（2例β-内酰胺酶阳性流感嗜血杆菌，1例肺炎链球菌）在治疗第4至6天也出现临床失败。
从大剂量阿莫西林治疗失败的AOM患儿中分离出的主要病原体是产β-内酰胺酶的细菌。由于其总体临床疗效良好，大剂量阿莫西林仍是AOM一线经验性治疗的合适选择，若治疗失败，可选用对β-内酰胺酶稳定的药物。
Zotero 插件