title: Empiric first-line antibiotic treatment of acute otitis in the era of the heptavalent pneumococcal conjugate vaccine.
abstract: OBJECTIVE
  Our goal was to estimate the local prevalence of Streptococcus pneumoniae nonsusceptible to penicillin and amoxicillin after widespread use of the heptavalent pneumococcal vaccine and to revise community-specific recommendations for first-line antibiotic treatment of acute otitis media.
  
  
  METHODS
  We conducted serial prevalence surveys between 2000 and 2004 in the offices of community pediatricians in St Louis, Missouri. Study participants were children <7 years of age with acute upper respiratory infections. Children treated with an antibiotic in the past 4 weeks were excluded. S pneumoniae was isolated from nasopharyngeal swabs using standard techniques. Isolates with a penicillin minimum inhibitory concentration >2 microg/mL were considered to be S pneumoniae nonsusceptible to amoxicillin.
  
  
  RESULTS
  There were 327 patients enrolled in the study. Between 2000 and 2004, vaccine coverage with > or =3 doses of heptavalent pneumococcal vaccine increased from 0% to 54%, but nasopharyngeal carriage of S pneumoniae was stable at 39%. The prevalence of S pneumoniae nonsusceptible to penicillin fell from 25% to 12% among patients, did not vary if <2 years of age, was reduced in children with > or =3 doses of heptavalent pneumococcal vaccine, and increased in child care attendees but reduced in attendees who had > or =3 doses of heptavalent pneumococcal vaccine. The prevalence of S pneumoniae nonsusceptible to amoxicillin in patients remained <5%.
  
  
  CONCLUSIONS
  In our community, widespread use of heptavalent pneumococcal vaccine has reduced the prevalence of S pneumoniae nonsusceptible to penicillin, and the prevalence of S pneumoniae nonsusceptible to amoxicillin remains low (<5%). If antibiotic treatment is elected for children with uncomplicated acute otitis media, we recommend treatment with standard-dose amoxicillin (40-45 mg/kg per day) for children with > or =3 doses of heptavalent pneumococcal vaccine, regardless of age and child care status. High-dose amoxicillin should be used for children with <3 doses of heptavalent pneumococcal vaccine and those treated recently with an antibiotic.
authors.affiliation: Division of General Medical Sciences, Washington University School of Medicine, St Louis, Missouri, USA. jgarbutt@im.wustl.edu
authors.forename: Jane
authors.initials: J
authors.lastname: Garbutt
authors.forename: Isabel
authors.initials: I
authors.lastname: Rosenbloom
authors.forename: Jenny
authors.initials: J
authors.lastname: Wu
authors.forename: Gregory A
authors.initials: GA
authors.lastname: Storch
mesh_terms: D000208:Acute Disease; D000658:Amoxicillin / Q000494:pharmacology; D000900:Anti-Bacterial Agents / Q000494:pharmacology / Q000627:therapeutic use*; D002675:Child, Preschool; D024881:Drug Resistance, Bacterial; D005260:Female; D000069443:Heptavalent Pneumococcal Conjugate Vaccine; D006801:Humans; D008297:Male; D022401:Meningococcal Vaccines / Q000008:administration & dosage*; D009666:Nose / Q000382:microbiology; D010033:Otitis Media / Q000188:drug therapy* / Q000382:microbiology*; D010403:Penicillin Resistance; D010614:Pharynx / Q000382:microbiology; D011008:Pneumococcal Infections / Q000188:drug therapy*; D022242:Pneumococcal Vaccines / Q000008:administration & dosage*; D013296:Streptococcus pneumoniae / Q000187:drug effects / Q000302:isolation & purification; D018074:Vaccines, Conjugate / Q000008:administration & dosage*
chemical_list: D000900:Anti-Bacterial Agents; D000069443:Heptavalent Pneumococcal Conjugate Vaccine; D022401:Meningococcal Vaccines; D022242:Pneumococcal Vaccines; D018074:Vaccines, Conjugate; D000658:Amoxicillin