Cohen R, Bingen E, Levy C, Benani M, Thollot F, Klink Z, Schlemmer C, Elbez A, Varon E
Association clinique et thérapeutique infantile du Val-de-Marne (ACTIV), 27, rue Inkermann, 94100 Saint-Maur-des-Fossé, France.
Arch Pediatr. 2011 Aug;18(8):926-31. doi: 10.1016/j.arcped.2011.05.001. Epub 2011 Jun 12.
The choice of antibiotics (ATB) to treat acute otitis media (AOM) has to take into account the level of resistance of bacteria species implicated. The aim of this study was to evaluate in France, ATB resistance of pneumococci and H. influenzae isolated from the nasopharyngeal flora, in children with AOM, vaccinated with 7 valent pneumococcal conjugate vaccine (PCV7).
From 2006 to 2010, 66 pediatricians performed nasopharyngeal specimens of children 6 to 24 months with AOM. Demographic characteristics, history, vaccination status and symptoms were reported on a case report form transmitted to ACTIV.
Of the 3,501 children included (mean age 13.5 ± 5 months), over 98% were PCV7 vaccinated and 41.1% were cared in day care center. A total of 47.3% of children had received ATB within 3 months before inclusion (cephalosporins, 22.6% and amoxicillin clavulanate, 19.2%). Pneumococcus and H. influenzae carriage was respectively 57.9% and 48.2%. Pneumococcal strains with reduced susceptibility to penicillin represented 46.3% of cases (3.9% highly resistant strains and 42.4% intermediate resistant strains). Factors that increased the risk of carrying these strains were: day care center (OR: 1.5, 95% CI: [1.2, 1.9]) and two courses or more of ATB before inclusion (OR: 2.6 (95% CI: [2.0, 3.4]). For H. influenzae strains the proportion of ßlactamases+ producing strains was 17.1% and those with reduced susceptibility due to penicillin binding protein changes (BLNAR+ strains+) accounted for 7.7% of cases. Three factors increased the risk of carriage BLNAR+ ßlactamase+ producing strains: age equal or greater than 12 months (OR: 3.5, 95% CI: [1.2, 10.3]), cephalosporin use (OR: 2.5, 95% CI: [1.0, 6.1]) and two courses or more of ATB before inclusion (OR: 3.1, 95% CI: [1.2, 8.0]).
The data in this study (reduction of ßlactamase producing H. influenzae strains and increase of intermediate penicillin pneumococcal strains) should help to change the choice of antibiotics for AOM in children in France, by reducing the role of oral cephalosporins and secondly, by giving frontline amoxicillin ± clavulanic acid.
治疗急性中耳炎（AOM）时抗生素（ATB）的选择必须考虑相关细菌种类的耐药水平。本研究的目的是在法国评估接种7价肺炎球菌结合疫苗（PCV7）的AOM患儿鼻咽部菌群中分离出的肺炎球菌和流感嗜血杆菌的ATB耐药情况。
2006年至2010年，66名儿科医生采集了6至24个月患AOM儿童的鼻咽部标本。人口统计学特征、病史、疫苗接种状况和症状通过病例报告表上报给ACTIV。
纳入的3501名儿童（平均年龄13.5±5个月）中，超过98%接种了PCV7，41.1%在日托中心接受护理。共有47.3%的儿童在纳入研究前3个月内接受过ATB治疗（头孢菌素，22.6%；阿莫西林克拉维酸，19.2%）。肺炎球菌和流感嗜血杆菌携带率分别为57.9%和48.2%。对青霉素敏感性降低的肺炎球菌菌株占病例的46.3%（3.9%为高度耐药菌株，42.4%为中度耐药菌株）。携带这些菌株风险增加的因素有：日托中心（比值比：1.5，95%置信区间：[1.2, 1.9]）和纳入研究前接受过两疗程或更多疗程的ATB治疗（比值比：2.6（95%置信区间：[2.0, 3.4]）。对于流感嗜血杆菌菌株，产β-内酰胺酶菌株的比例为17.1%，因青霉素结合蛋白改变导致敏感性降低的菌株（BLNAR+菌株）占病例的7.7%。三个因素增加了携带BLNAR+产β-内酰胺酶菌株的风险：年龄等于或大于12个月（比值比：3.5，95%置信区间：[1.2, 10.3]）、使用头孢菌素（比值比：2.5，95%置信区间：[1.0, 6.1]）和纳入研究前接受过两疗程或更多疗程的ATB治疗（比值比：3.1，95%置信区间：[1.2, 8.0]）。
本研究中的数据（产β-内酰胺酶流感嗜血杆菌菌株减少，中度青霉素肺炎球菌菌株增加）应有助于改变法国儿童AOM的抗生素选择，一是减少口服头孢菌素的使用，二是将一线用药改为阿莫西林±克拉维酸。
