title: Diagnosis, microbial epidemiology, and antibiotic treatment of acute otitis media in children: a systematic review.
abstract: BACKGROUND
  Acute otitis media (AOM) is the most common condition for which antibiotics are prescribed for US children; however, wide variation exists in diagnosis and treatment.
  
  
  OBJECTIVE
  To perform a systematic review on AOM diagnosis, treatment, and the association of heptavalent pneumococcal conjugate vaccine (PCV7) use with AOM microbiology.
  
  
  METHODS
  PubMed, Cochrane Databases, and Web of Science, searched to identify articles published from January 1999 through July 2010.
  
  
  METHODS
  Diagnostic studies with a criterion standard, observational studies and randomized controlled trials comparing AOM microbiology with and without PCV7, and randomized controlled trials assessing antibiotic treatment.
  
  
  METHODS
  Independent article review and study quality assessment by 2 investigators with consensus resolution of discrepancies.
  
  
  RESULTS
  Of 8945 citations screened, 135 were included. Meta-analysis was performed for comparisons with 3 or more trials. Few studies examined diagnosis; otoscopic findings of tympanic membrane bulging (positive likelihood ratio, 51 [95% confidence interval {CI}, 36-73]) and redness (positive likelihood ratio, 8.4 [95% CI, 7-11]) were associated with accurate diagnosis. In the few available studies, prevalence of Streptococcus pneumoniae decreased (eg, 33%-48% vs 23%-31% of AOM isolates), while that of Haemophilus influenzae increased (41%-43% vs 56%-57%) pre- vs post-PCV7. Short-term clinical success was higher for immediate use of ampicillin or amoxicillin vs placebo (73% vs 60%; pooled rate difference, 12% [95% CI, 5%-18%]; number needed to treat, 9 [95% CI, 6-20]), while increasing the rate of rash or diarrhea by 3% to 5%. Two of 4 studies showed greater clinical success for immediate vs delayed antibiotics (95% vs 80%; rate difference, 15% [95% CI, 6%-24%] and 86% vs 70%; rate difference, 16% [95% CI, 6%-26%]). Data are absent on long-term effects on antimicrobial resistance. Meta-analyses in general showed no significant differences in antibiotic comparative effectiveness.
  
  
  CONCLUSIONS
  Otoscopic findings are critical to accurate AOM diagnosis. AOM microbiology has changed with use of PCV7. Antibiotics are modestly more effective than no treatment but cause adverse effects in 4% to 10% of children. Most antibiotics have comparable clinical success.
authors.affiliation: Department of Pediatrics, Mattel Children's Hospital, David Geffen School of Medicine at UCLA, Los Angeles, California 90024, USA. tcoker@mednet.ucla.edu
authors.forename: Tumaini R
authors.initials: TR
authors.lastname: Coker
authors.forename: Linda S
authors.initials: LS
authors.lastname: Chan
authors.forename: Sydne J
authors.initials: SJ
authors.lastname: Newberry
authors.forename: Mary Ann
authors.initials: MA
authors.lastname: Limbos
authors.forename: Marika J
authors.initials: MJ
authors.lastname: Suttorp
authors.forename: Paul G
authors.initials: PG
authors.lastname: Shekelle
authors.forename: Glenn S
authors.initials: GS
authors.lastname: Takata
mesh_terms: D000208:Acute Disease; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D002648:Child; D002675:Child, Preschool; D004352:Drug Resistance, Microbial; D006192:Haemophilus Infections / Q000453:epidemiology; D006193:Haemophilus influenzae; D000069443:Heptavalent Pneumococcal Conjugate Vaccine; D006801:Humans; D007223:Infant; D010033:Otitis Media / Q000175:diagnosis / Q000188:drug therapy / Q000453:epidemiology / Q000382:microbiology; D022242:Pneumococcal Vaccines / Q000008:administration & dosage*; D013290:Streptococcal Infections / Q000453:epidemiology
chemical_list: D000900:Anti-Bacterial Agents; D000069443:Heptavalent Pneumococcal Conjugate Vaccine; D022242:Pneumococcal Vaccines