Sharon Ovnat Tamir

Changing Trends of Acute Otitis Media Bacteriology in Central Israel in the Pneumococcal Conjugate Vaccines Era

Background: The widespread use of 7-valent pneumococcal conjugate vaccine (PCV7) has changed acute otitis media (AOM) bacteriology. Only scattered data with regard to this effect of PCV13 have been published so far. Methods: We retrospectively identified children <6 years of age who presented to our hospital with AOM, and had middle ear fluid (MEF) cultures obtained during tympanocentesis or from spontaneous otorrhea during 2008–2013, when PCV7 (2009) and PCV13 (2010) were gradually introduced in the Israeli National Immunization Program. Data were extracted for demographics, clinical and microbiologic parameters, according to vaccination status. Results: Of the 295 eligible AOM episodes reported in 279 children, 224 (76%) had MEF cultures from tympanocentesis and 71 (24%) from spontaneous otorrhea. Boys and children <2 years of age contributed 178 (60%) and 219 (74%) AOM episodes, respectively. Acute mastoiditis complicated 58 (20%) of these episodes. None of the children were PCV immunized in 2008, but >90% had received ≥1 PCV dose(s) by 2011 or later. Of the 106 (36%) MEF cultures which tested positive for otopathogens, Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis and multiple bacteria grew in 60 (57%), 39 (37%), 2 (2%) and 5 (5%) episodes, respectively. S. pneumonia-positive MEF culture rate in unimmunized children (31, 69%) was significantly higher than in PCV7-immunized children (22, 59%) or PCV13-immunized children (12, 50%), P = 0.04 and P = 0.02, respectively. Conclusion: PCV7 and PCV13 implementations in the Israeli National Immunization Program were associated with a rapid reduction of “severe” pneumococcal AOM episodes.

Acute mastoiditis in the pneumococcal conjugate vaccine era.

ABSTRACT Following the introduction of the 7- and 13-valent pneumococcal conjugate vaccines, we observed an inverse relationship between the increasing rate of immunized children and the proportion of middle ear fluid cultures collected during acute mastoiditis episodes that tested positive for Streptococcus pneumoniae among a subset of children 0 to 6 years old who had initially presented with severe acute otitis media and had bacterial cultures collected during tympanocentesis or from spontaneous otorrhea.

Acute otitis media guidelines in selected developed and developing countries: uniformity and diversity

Background Acute otitis media (AOM) is a common childhood disease, with an enormous economic and healthcare-related burden. Guidelines and consensus papers for AOM diagnosis and management were published in many countries. Our objective was to study the differences and similarities between these protocols in developing and developed countries. Methods The keywords: ‘acute otitis media’ AND ‘children’ AND [‘treatment’ or ‘management’] AND [‘guideline’ or ‘consensus’] were used in various electronic databases between 1 January 1989 through 31 December 2015. Overall, 99 sources from 62 countries were retrieved: 53 from 22 developed countries, and 46 from 40 developing countries. Representative guidelines from America (the USA, Argentina), Europe (Italy, Moldova), Africa (South Africa, Tanzania, Ethiopia), Asia (Japan, Afghanistan, Sri Lanka),and Oceania (South Australia, Fiji) were compared. Results Paediatric societies publish guidelines in most developed countries; in developing countries, the Ministry of Health usually initiates guideline formulation. Most guidelines use the same diagnostic criteria and offer watchful waiting in mild–moderate scenarios. Amoxicillin is the suggested first-line antibiotic, whereas options for second-line and third-line therapies vary. Duration of therapy varies and is usually age dependent: 5–7 days for children <2 years and 10 days for children >2 years in developed countries, while duration and age groups vary greatly in developing countries. Reduction of AOM risk factors is encouraged in developed countries, but rarely in developing countries. Conclusions Guidelines for AOM from developing and developed countries are similar in many aspects, with variation in specific recommendations, due to local epidemiology and healthcare accessibility. Formulation of regional guidelines may help reduce AOM burden.

The effect of immunization with pneumococcal conjugated vaccines on Streptococcus pneumoniae resistance patterns in acute otitis media

Following the introduction of 7- and 13-pneumococcal conjugate vaccines (PCVs) in Israel, we demonstrated that within Streptococcus pneumoniae (Sp) positive middle ear cultures, obtained from young children with severe acute otitis media (AOM) episodes, there were more penicillin-susceptible and less multi-drug resistant Sp isolates in PCV immunized children.

Impact of Pneumococcal Conjugate Vaccines on Selected Head and Neck Infections in Hospitalized Israeli Children.

Background: Streptococcus pneumoniae is a major pathogen of pediatric head and neck infections (HNIs), for example, acute otitis media (AOM), acute mastoiditis, acute bacterial sinusitis and meningitis. The aim of this study was to characterize the epidemiology of pneumococcal HNIs (pHNIs) before, during and after the introduction of pneumococcal conjugate vaccines (PCVs). Methods: Children 0–16 years of age, who were hospitalized with HNIs in the pediatrics department in a general hospital between January 1, 2007, and December 31, 2014, were retrospectively identified. Study years were categorized according to the PCV introduction timeline: 2007–2008: “pre-PCV years”; 2009–2011: “transition years” and 2012–2014: “post-PCV years.” pHNIs episodes were defined if pneumococcal culture or urine antigen was positive. Children who received ≥2 doses of PCV7/PCV13 were considered as immunized. All other children were considered as unimmunized. Results: HNIs accounted for 2.5%–4.7% of the total admissions; 3%–17% of them were pHNIs. Eighty-seven pHNI episodes were identified: AOM (n = 42), acute mastoiditis (n = 28) and meningitis (n = 17). There was a downward trend in the overall incidence of HNIs, and particularly of pHNIs, in the post-PCV years. The average age and hospitalization duration of children with HNIs/pHNIs remained stable during the study years. In 2009–2010, pHNIs incidence sharply decreased, from 7 to 1.74/1000 hospitalized children/year, due to ~55% reduction of pneumococcal AOM episodes. An additional decrease was observed in the post-PCV years (1.62/1000 hospitalized children/year). Immunized children were less likely to present with pHNIs (P = 0.001) but were more likely to undergo surgery (P = 0.042). Conclusion: We observed a reduction in pHNIs incidence after PCV program implementation.

Acute Otitis Media Perspectives in Israel.

1. Tal Marom, MD* 2. Sharon Ovnat Tamir, MD* 1. *Department of Otolaryngology-Head and Neck Surgery, Edith Wolfson Medical Center, Tel Aviv; University Sackler School of Medicine, Holon, Israel. Israel is characterized by its diversity of populations, which differ in many cultural and socioeconomic aspects, despite their geographic proximity in a relatively small country. As such, it can serve as a microcosm when evaluating health-care-related modifications and processes. An illustrative example is the evaluation of different steps that have been implemented in the national health-care system to reduce the acute otitis media (AOM) burden. These include the relatively late introduction of the 7-valent pneumococcal conjugate vaccine (PCV7), only in mid-2009; the timely introduction of PCV13 in the latter part of 2010; …

Effect of general anesthesia and intubation on parathyroid levels in normal patients and those with hyperparathyroidism

Induction of general anesthesia and endotracheal intubation may precipitate parathyroid hormone (PTH) elevation in patients with primary hyperparathyroidism (HPT). The purposes of this study were to revisit this observation and to study its impact in healthy patients.

The Middle Ear Cleft Status in a “Natural” Cohort With Eustachian Tube Dysfunction

BACKGROUND The Eustachian tube (ET) has a major role in the middle ear (ME) pressure homeostasis. ET dysfunction is the accepted paradigm for pressure-related ME disorders. We studied the ME status in patients with severely diminished ET opening abilities, and anticipated to find ME disorders in most of them. PATIENTS AND METHODS ME status was evaluated in unconscious adults, who were hospitalized in a rehabilitation center with severe brain damage, requiring tracheotomy and gastrostomy. These patients were unable to swallow, produce valsalva, yawn, and needed oral suctioning. Examination included fiberoptic nasopharyngoscopy, gag reflex and soft palate assessments, otoscopy, and tympanometry. RESULTS Nineteen patients (38 ears) were evaluated: 14 men and 5 women, aged 18 to 93 years (average 59). Duration of gastrostomy and tracheotomy were between 3 months and 18 years. All the patients lacked gag reflex, palatal movements, or supraglottic sensation. Eighteen ears (47%) had otitis media with effusion (OME) (versus ∼3% in the general population, p = 0.00001), none had significant tympanic membrane atelectasis, but 20 (53%) ears were normal. Twenty-two ears (59%) had tympanometry types B/C and 16 (41%) had type A. Cerumen impaction incidence (26 ears, 68%) was significantly higher than in normal adults (10%), mentally retarded (36%), and nursing homes residents (57%). CONCLUSIONS A dysfunctional ET predisposed ME disorders. Yet, ∼50% of the ears were normal, in contrast to the current paradigm. This implies that ME pressure homeostasis is maintained by factors that can compensate for ET dysfunction. Treating cerumen impaction and OME may be beneficial for rehabilitation.

Deep neck infections in cervical injection drug users

To characterize deep neck infections (DNI) in adult intravenous drug users (IDUs) who injected illicit substances to their neck, in comparison to DNI in non‐IDUs.