Pathogens isolated during treatment failures in otitis

OBJECTIVES: A prospective study in the Paris region to evaluate the clinical and bacteriologic epidemiology of acute otitis media in infants in whom oral antibiotic therapy resulted in clinical failure. METHODS: The study included 186 children with a mean age of 17.5 +/- 13.1 months. Two-thirds of them attended a day-care center and 40.8% had a history of recurrent otitis media. The most frequently prescribed prior antibiotics were amoxicillin-clavulanic acid (43% of cases), an oral third generation cephalosporin (22.6%), erythromycin-sulfisoxazole (11.8%) and a first generation cephalosporin (10.2%). The average duration of antibiotic therapy was 6.9 +/- 2.65 days. Specimens for bacterial cultures included 188 samples of middle ear fluid obtained by tympanocentesis and 37 collected from otorrhea fluid. RESULTS: One hundred forty-one samples (62.7%) from 126 children yielded 170 bacterial isolates. In 60 children (32.3%) the culture of the ear pus was sterile. Among the 170 bacterial isolates: 67 (39.4%) were Streptococcus pneumoniae (59 patients), of which 77.6% had reduced susceptibility to penicillin (PRSP with penicillin MIC > or = 0.125 mg/l); 61 (35.9%) were Haemophilus influenzae (56 patients) of which 49.2% were beta-lactamase producers; and 8 were Moraxella catarrhalis (8 patients), of which 87.5% were beta-lactamase producers. Thirty-six patients were infected by S. pneumoniae with penicillin MIC > or =1 mg/l. In our study attending day-care center (P = 0.04), temperature >38 degrees C with signs of otalgia (P = 0.02), age <2 years (P = 0.048) and prior antibiotic treatment with erythromycin-sulfisoxazole (P = 0.006) were independently predictive risk factors for patients infected with penicillin-resistant S. pneumoniae. Pneumococcal serogroups 23, 14 and 19 were predominant (25.4, 25.4 and 23.8%, respectively). Penicillin resistance was mainly associated with serogroups 23 and 14. CONCLUSIONS: Penicillin-resistant S. pneumoniae isolates are frequently responsible for therapeutic failure in cases of acute otitis media in the Paris region.     

Strategies in the treatment of penicillin-resistant Streptococcus pneumoniae

The epidemiology, resistance mechanisms, susceptibility testing, treatment, prevention, and clinical importance of penicillin-resistant Streptococcus pneumoniae (PRSP) infection are discussed. PRSP is an established presence in the United States, with some geographic areas reporting decreased susceptibility in up to half of isolates. The mechanism of resistance to beta-lactam antibiotics in S. pneumoniae is genetic changes resulting in decreased binding of drug to the bacterial cell wall. Emerging PRSP strains have necessitated testing as a tool in selecting drugs for treating life-threatening infections. Opinions differ on how to treat these infections empirically. Non-life-threatening infections, such as otitis media, are still often treated successfully with amoxicillin, amoxicillin-clavulanate potassium, or a third-generation cephalosporin. Currently recommended initial treatment of pneumococcal pneumonia in otherwise healthy patients requiring hospitalization consists of cefuroxime, ceftriaxone, or cefotaxime; some authors continue to emphasize injectable penicillin. Once the mainstay of empirical treatment of pneumococcal meningitis, penicillin has largely been abandoned in favor of cefotaxime or ceftriaxone. Vaccination remains an underutilized strategy in atrisk populations. The clinical importance of penicillin resistance among pneumococci is still uncertain. Changing patterns in the susceptibility of S. pneumoniae to penicillin make selection of appropriate therapy increasingly difficult. Key considerations are the site of infection and the level of resistance.     

Lifetime use of alternative therapy: a study of Florida residents

OBJECTIVE: To determine the bacteriologic efficacy of ceftriaxone in nonresponsive acute otitis media in children. METHODS: In a prospective study 92 patients ages 3 to 36 months (median, 11 months) with culture-proved nonresponsive acute otitis media were studied from January, 1995, through August, 1997. The patients were treated with intramuscular ceftriaxone (50 mg/kg/l/day) for 3 days. Middle ear fluid was aspirated for culture by tympanocentesis on day of enrollment (Day 1); a second tap was performed on Days 4 to 10. Additional middle ear fluid cultures were obtained if clinical relapse occurred. Bacteriologic failure was defined by positive culture on Days 4 to 10. Patients were followed until Day 17+/-2. Susceptibility was measured by E test. RESULTS: The main drugs administered before enrollment were amoxicillin (38%), amoxicillinclavulanate (25%) and cefaclor (20%). Organisms recovered (n=105) were: Haemophilus influenzae, 54; Streptococcus pneumoniae, 47; Moraxella catarrhalis, 2; and Streptococcus pyogenes, 2. Thirty-four (72%) of the 47 S. pneumoniae isolates were intermediately resistant to penicillin (MIC 0.1 to 1.0 microg/ml), but all were susceptible to ceftriaxone (MIC < 0.5 microg/ml). Bacteriologic eradication was achieved in 100 of 105 (95%) cases: 54 of 54 (10O%) H. influenzae, 43 of 47 (92%) S. pneumoniae, 1 of 2 (50%) M. catarrhalis and 2 of 2 (100%) S. pyogenes. Bacteriologic success (with no relapse) occurred in 13 of 13 (100%) penicillin-susceptible S. pneumoniae vs. 28 of 34 (82%) S. pneumoniae intermediately resistant to penicillin (4 cases of bacteriologic failure and 2 cases of relapse). CONCLUSION: A 3-day intramuscular ceftriaxone regimen is efficacious for the treatment of nonresponsive acute otitis media. The optimal duration of treatment in cases of nonresponsive acute otitis media and whether ceftriaxone is efficacious for the treatment of nonresponsive otitis media caused by S. pneumoniae highly resistant to penicillin is yet to be determined.     

Microbiology of common infections in the upper respiratory tract

The management of upper respiratory tract infections has become more difficult because of the recent increase in the number of penicillin-resistant organisms. The bacteria that predominate in otitis media and sinusitis can resist penicillin through the production of the enzyme beta-lactamase (Haemophilus influenzae and Moraxella catarrhalis in acute infections and Staphylococcus aureus and Prevotella and Fusobacteria spp in chronic infections) or through changes in penicillin-binding sites (Streptococcus pneumoniae). beta-lactamase-producing bacteria can express their pathogenicity directly through their ability to cause infections and indirectly by production of the enzyme, thus protecting penicillin-susceptible pathogens from penicillins. This phenomenon may explain penicillin's failure in the treatment of Group A beta-hemolytic streptococcal (GABHS) tonsillitis. An additional cause for penicillin failure is the absence among the normal tonsillar bacterial flora of streptococcal species that are capable of interfering with the growth of GABHS. Proper use of antimicrobial therapy, including those therapies that are effective against penicillin-resistant bacteria, is the cornerstone of management of upper respiratory tract infections.     

Vancomycin in meningitis caused by penicillin G resistant Streptococcus pneumoniae

We report two cases of penicillin G-resistant pneumococcal meningitis in adults, with clinical and bacteriological failure of amoxicillin and negative or incomplete response to third generation cephalosporins. Meningitis occurred in a man treated for myeloma and in an elderly woman under prolonged intermittent amoxicillin therapy for chronic otitis. Such situations are known as exposing to pneumococcal meningitis and to resistance of the strain involved to penicillin G. Both patients were cured by vancomycin in continuous infusion associated with rifampicin or fosfomycin. Contrary to third generation cephalosporins, which have higher minimal inhibitory concentrations, vancomycin and rifampicin are still fully active against penicillin G-resistant pneumococcal strains. Thus, vancomycin administered in continuous infusion and associated with rifampicin and fosfomycin deserves to be tried as first-line treatment of pneumococcal meningitis in patients at risk of resistance to penicillin G.     

Multivariate analysis of risk factors for infection due to penicillin-resistant and multidrug-resistant Streptococcus pneumoniae: a multicenter study

Pneumococcal disease was studied prospectively to determine the risk factors associated with resistance to penicillin and other antibiotics. One hundred twelve clinically significant pneumococcal isolates were recovered from 95 patients. Approximately one-half (49.47%) of the cases were due to penicillin-resistant strains. Multivariate analysis showed that previous use of beta-lactam antibiotics (odds ratio [OR], 2.81; 95% confidence interval [CI], 0.95-8.27), alcoholism (OR, 5.22; 95% CI, 1.43-19.01), and noninvasive disease (OR, 4.53; 95% CI, 1.54-13.34) were associated with penicillin resistance, whereas intravenous drug use (OR, 0.14; 95% CI, 0.03-0.74) was not. Statistical analyses of the variables associated with resistance to multiple antibiotics detected age of younger than 5 years (OR, 16.79; 95% CI, 1.60-176.34) or of 65 years or older (OR, 4.33; 95% CI, 1.42-13.21) and previous use of beta-lactam antibiotics by patients with noninvasive disease (OR, 7.92; 95% CI, 1.84-34.06) as parameters associated with increased risk. We conclude that multivariate analysis provides clues for empirical therapy for pneumococcal infection.     

Pneumococci with diminished sensitivity to penicillin in pneumopathies. Clinical consequences

INCREASING PREVALENCE: Since 1988, French clinicians have been faced with an increasing prevalence of penicillin-resistant pneumococcal pneumonia. In 1996, the percentage of strains with reduced susceptibility to penicillin reached more than 40% and the number of multiresistant strains has increased steadily. CLINICAL IMPACT: Despite this apparently alarming situation, the clinical impact is not obvious. Different clinical studies have demonstrated that mortality due to pneumococcal pneumonia has not been affected by the development of resistant strains, eventually because the strains involved belong to less invasive serotypes than penicillin susceptible pneumococci. HYPOTHESIS: The preferential distribution of penicillin resistance among less invasive serotypes might explain the development of resistance in carriage strains more often exposed to antibiotic selection and the greater risk for immunodepressed subjects to acquire these strains. PRACTICAL CONSEQUENCES: To date, first-line antibiotic therapy with amoxicillin at the dose of 3g/24 h remains valid for the great majority of cases. Use of much higher dosages or other antibiotics for pneumococcal pneumonia would only be rational when penicillin minimum inhibitory concentrations are above 2 mg/l.     

Prenatal diagnosis by FISH of a 22q11 deletion in two families

OBJECTIVE: To investigate the predictive value of an intravenous fluid bolus during tilt table testing on clinical outcome and to evaluate of oral therapy is an effective treatment for patients with vasodepressor syncope. DESIGN: Retrospective cohort. SETTING: Regional pediatric cardiology outpatient clinic. PATIENTS: Patients (N = 58) with a positive baseline tilt table testing result who were treated with oral fluid therapy between February 1991 and March 1996. INTERVENTIONS AND MAIN OUTCOME MEASURES: Patients with a positive tilt table test result were given an intravenous bolus of isotonic saline solution. Responders were identified as having a negative tilt table test result after the bolus. Patients were prescribed a protocol of oral fluid therapy. Data were obtained from the medical record and a mailed survey. RESULTS: Of the 58 subjects, 90% had no recurrent syncope while receiving oral fluid therapy. During tilt table testing, the mean decrease in mean arterial pressure seen with symptomatic events was lower after the intravenous fluid. The heart rate, which dropped during the initial test, increased during the rests after the intravenous bolus. In the nonresponders, symptomatic episodes occurred significantly later in the tilt table test when given fluids. The response to intravenous fluid bolus had positive predictive value of 92% and negative predictive value of 11% of clinical outcome. CONCLUSIONS: Our data suggest that oral fluid therapy is an effective treatment for vasodepressor syncope in our population. Fluid bolus response during tilt table testing has a high positive but a low negative predictive value of response to oral fluid therapy. We now recommend oral fluid therapy as a primary intervention and reserve tilt table testing for oral fluid therapy failures.     

Storage of trachea for X-ray microanalytical studies of tracheal submucosal glands

Previous studies have suggested that penicillin-resistant pneumococcal isolates (especially those with MIC > 1 microgram/mL) usually are clonally related. To test this hypothesis, the molecular epidemiology of 29 clinical isolates of penicillin-resistant pneumococci (of which 83% were also resistant to either cefotaxime or ceftriaxone) collected in central Taiwan was investigated by pulsed field gel electrophoresis. Twenty-seven distinct patterns were identified. Our results indicate that an increase in penicillin-resistant S. pneumoniae between April 1993 and June 1994 in central Taiwan is not due to the clonal dissemination of a limited number of epidemic strains.     

Dynamics of pneumococcal nasopharyngeal colonization during the first days of antibiotic treatment in pediatric patients

BACKGROUND: Nasopharyngeal (NP) carriage of antibiotic-resistant Streptococcus pneumoniae was shown to be associated with recent antibiotic treatment. To date no studies have evaluated early dynamics of pneumococcal NP carriage during antibiotic treatment. OBJECTIVES: To observe changes in NP pneumococcal carriage within 3 to 4 days after initiation of antibiotic treatment in acute otitis media (AOM). METHODS: Patients ages 3 to 36 months with AOM treated with various antibiotics were prospectively followed. Nasopharyngeal culture for S. pneumoniae was obtained before (Day 1) and 72 to 96 h after initiation of treatment (Days 4 to 5). Antibiogram and serotyping were performed in all isolates as was also the MIC of penicillin. The disappearance and persistence of the initial isolates as well as the appearance of isolates with new serotype or with new antibiotic susceptibility patterns were investigated. RESULTS: A total of 120 patients were studied: 106 received beta-lactam antibiotics and 14 received azithromycin. Among the initial 76 pneumococcal isolates 63, 37 and 13% were resistant to > or =1, > or =2 and > or =3 antibiotic drugs. After 3 to 4 days of treatment with various beta-lactam drugs, 45, 63 and 100% of isolates with MIC values of <0.1 microg/ml, 0.125 to 0.25 microg/ml and 0.38 to 1.0 microg/ml, respectively, persisted in the NP (P = 0.038). There was a difference between the various beta-lactam drugs in their effect on NP colonization: a drug with lower MIC values (cefuroxime-axetil) had a better eradication rate of penicillin-susceptible organisms than a less active one (cefaclor), but neither significantly reduced carriage of penicillin nonsusceptible isolates. Azithromycin eliminated carriage of macrolide-susceptible organisms but increased the carriage of macrolide-resistant ones. In 19 of 120 (16%) patients a new S. pneumoniae isolate was recovered 3 to 4 days after initiation of treatment. Of those 16 (84%) were resistant to the drug the patient was receiving. CONCLUSION: A rapid selection of nonsusceptible NP pneumococcal isolates during antibiotic treatment for AOM is common. This phenomenon may contribute to the spread of resistant pneumococci.     

Dysuria associated with urethral caruncle in the dog

Activity of CP 99,219 (trovafloxacin), clinafloxacin, ciprofloxacin, sparfloxacin, lomefloxacin and cefuroxime against 4 penicillin-susceptible, 2 penicillin-intermediate and 4 penicillin-resistant pneumococci was tested by MIC and time-kill methodology. Bacteriostatic values for all three groups did not differ significantly with all compounds tested except cefuroxime, and were lowest for trovafloxacin and clinafloxacin, followed by sparfloxacin, ciprofloxacin and lomefloxacin; cefuroxime yielded values which increased in line with those of penicillin G. The test compounds were bactericidal (i.e. they reduced original counts by > or = 3 log10 cfu/mL at one dilution above bacteriostatic levels) in most cases, though some strains showed slightly greater discrepancies between bacteriostatic and bactericidal levels of all compounds tested. Trovafloxacin, clinafloxacin and sparfloxacin yielded MIC and time-kill results which point to possible efficacy in treatment of penicillin-susceptible and -resistant pneumococcal infections.     

The place of Mitrofanoff neourethra in the repair of exstrophy-epispadias complex

BACKGROUND: Wegener's granulomatosis is an immunepathogenic disease of unknown origin. The histopathological picture shows granulomatous inflammation with epitheloid cells, granulomas, and general vasculitis. The diagnosis of Wegener's granulomatosis is made on the basis of the clinical picture, serum cANCA, and histologic examination of biopsies. PATIENT: We present the case of a 57-year-old white male patient who was admitted to our ENT Hospital with a six weeks' history of otalgia and incomplete ipsilateral facial palsy since the day before admission. The patient had clinical features of acute otitis media without signs of mastoiditis. Despite a ten days' course of intravenous antibiotic treatment, the intensity of facial palsy progressed and the general condition of the patient worsened. A mastoidectomy and decompression of the facial nerve were performed, demonstrating sclerosis of the mastoid cells. Three weeks after release from the hospital, the patient was admitted again with recurrent fever, cephalea, loss of weight, and arthritic pain. There were no signs of recurrent otitis media or mastoiditis, and sigmoid sinus thrombosis was ruled out. Even under aggressive, intravenous antibiotic treatment the general physical condition continued to worsen; septic temperatures and signs of beginning renal failure occurred. The patient was transferred to the ICU with the diagnosis of sepsis of unknown origin. There bloodtests were positive for cANCA, which is highly specific for Wegener's granulomatosis. Under therapy with cyclophosphamide and i.v. corticosteroid, the patient recovered with 14 days. CONCLUSION: The lack of symptoms in the upper respiratory tract in our patient was unusual, indicating that in patients with recurrent otitis media, facial palsy, mastoiditis, or external otitis Wegener's granulomatosis should be ruled out as differential diagnosis.     

Clindamycin in persisting streptococcal pharyngotonsillitis after penicillin treatment

239 patients with streptococcal pharyngotonsillitis completed treatment with phenoxymethyl penicillin 12.5 mg per kg body weight b.i.d. for 10 days. At examination after completing therapy, throat specimens from 53 patients (22%) yielded growth of group A streptococci of the same. T-type as the initial culture (bacterial treatment failure). 20 of these 53 (38%) had symptoms and signs of tonsillitis (clinical and bacterial treatment failure). 48 of the patients with bacterial failure were randomly allocated to phenoxymethyl penicillin or clindamycin in an open design; 22 of them received a second course of phenoxymethyl penicillin for 10 days and 26 were given clindamycin, 6.5 mg per kg body weight b.i.d. (children) or 300 mg t.i.d. (adults) for 10 days. After completing their treatment, 14 of 22 patients (64%) given phenoxymethyl penicillin harboured the same T-type as in the previous two cultures, while group A streptococci were not recovered from any of the 26 patients receiving clindamycin. In patients with clinical failure after phenoxymethyl penicillin treatment, a new course with this drug is not motivated. In that situation clindamycin seems to be an efficient choice.     

Pharmacokinetics and pharmacodynamics of new and old antimicrobial agents for acute otitis media

Selection of appropriate antibiotic treatment for children with acute otitis media (AOM) is challenging. Although the diagnosis is relatively easy for experienced clinicians, the distinction between AOM and otitis media with effusion is often more subtle. In general therapy is empiric and the pathogen causing disease in a given patient remains unknown. However, this situation is made even more difficult by the dynamic nature of the pathogenesis of AOM. Both the proportion of patients infected with one of the three primary pathogens, Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis, and the antimicrobial susceptibility patterns of these pathogens are changing. Currently there are 16 antibiotics labeled for use in AOM. Only 2 are reliably effective against penicillin-resistant pneumococcus: high dose amoxicillin (80 to 100 mg/kg/day) and im ceftriaxone. Among the others all are beta-lactamase-stable and have proven clinical effectiveness in AOM patients infected with H. influenzae or M. catarrhalis. Even with the high spontaneous resolution rate reported for AOM, antimicrobial therapy remains the standard of care in the United States. Recognition of the fundamental determinants of effective therapy should permit rational antibiotic selection for each patient.     

Early switch from intravenous to oral cephalosporins in the treatment of hospitalized patients with community-acquired pneumonia

BACKGROUND: Switch therapy is defined as the early transition from intravenous to oral antibiotics during treatment of infection. This study was designed to evaluate the clinical outcome and length of stay of hospitalized patients with community-acquired pneumonia treated with an early switch from intravenous to oral third-generation cephalosporins. METHODS: Patients with a new roentgenographic pulmonary infiltrate and at least two symptoms (cough, fever, or leukocytosis) were enrolled in this study and treated with intravenous ceftizoxime sodium (1 g every 12 hours) or ceftriaxone sodium (1 g every 24 hours). Patients were switched to oral cefixime (400 mg every 24 hours) as soon as they met the following criteria: (1) resolution of fever; (2) improvement of cough and respiratory distress; (3) improvement of leukocytosis; and (4) presence of normal gastrointestinal tract absorption. RESULTS: Of the 120 patients enrolled, 75 (62%) had clinical data evaluated. Long-term follow-up showed that 74 patients (99%) were cured; one patient required readmission for further intravenous therapy. Mean duration of hospital stay was 4 days. CONCLUSIONS: This investigation demonstrated that an early switch to oral cefixime may be reasonable in hospitalized patients with community-acquired pneumonia who have already shown a good clinical and laboratory response to therapy with intravenous third-generation cephalosporins. This approach is clinically effective and minimizes hospital stay.     

Endocarditis due to penicillin-sensitive and -resistant pneumococci: the current perspectives on the disease

BACKGROUND: To evaluate the clinic characteristics and therapeutic aspects of endocarditis by Streptococcus pneumoniae sensitive and resistant to penicillin. METHODS: Twelve cases of pneumococcal endocarditis evaluated in 4 Spanish hospitals over the last 10 years were studied, analyzing their clinical characteristics and the existence of resistance to penicillin. The features were compared with a series of 98 cases found in a review of the literature. RESULTS: All the patients were males, most being alcoholics. The course of the disease was acute (2 weeks) in all the cases and evolved with great aggressivity: cardiac failure (9 patients), myocardial abscess (7 patients), multiple arterial embolisms (5 patients), septic arthritis (4 patients). Three patients had simultaneous pneumococcal meningitis but only one had pneumonia. The valve most affected was the aortic (9 cases). Three cases were due to strains of Streptococcus pneumoniae with moderate resistance to penicillin (CMI 0.5-1 micrograms/ml). Global mortality was 42%. All the patients receiving inadequate antibiotic treatment died. Vancomycin and cefotaxime appear to be effective in the treatment of cases produced by strains of pneumococcus with intermediate sensitivity to penicillin. There were no apparent differences in mortality between the cases of endocarditis by pneumococcus sensitive or moderately resistant to penicillin. CONCLUSIONS: Pneumococcal endocarditis continues to condition a high mortality similar to that produced in previously made series. The classic relation with meningitis and pneumonia is infrequent today. The appearance of strains resistant to penicillin may increase the incidence of this infection and further worsen prognosis.     

Intramuscular ceftriaxone compared with oral amoxicillin-clavulanate for treatment of acute otitis media in children

Two hundred and fifteen children aged 4 months 6 years with acute otitis media (AOM) were randomized to be treated either by a single i.m. injection of ceftriaxone, 50 mg/kg, with a second dose in the event of unsatisfactory response after 48 h or a history of recurrent AOM (109 patients) or amoxicillin clavulanate 12.5 mg tid (106 patients). The failure rate was similar in children treated by ceftriaxone and amoxicillin clavulanate, 4.6% and 4.7%, respectively (standard error for intergroup difference -2.87%, 95% confidence interval -5.62% to 5.87%). No significant differences between the groups were found in the dynamics of the resolution of the acute symptomatology, otoscopy findings, relapse rate at 30 days or tympanographic evidence of middle ear effusion at the scheduled visits on days 30, 60 and 90. Recurrence of AOM between days 31 and 90 was observed significantly in more children treated with amoxicillin clavulanate than with ceftriaxone--25 out of 84 (29.4%) versus 11 out of 81 (13.6%) (P = 0.012). Conclusion: Ceftriaxone injection(s) is as efficient at least as 10-day oral amoxicillin clavulanate for treatment of acute otitis media in children. Although not recommended as routine, ceftriaxone can be considered in the management of acute otitis media under special circumstances, particularly in cases when the ability to tolerate or absorb oral drugs is compromised, in children refusing or unable to take oral therapy or when the compliance is questionable.     

Intratemporal complications of acute otitis media in infants and children

We reviewed our experience with 100 children admitted to Children's Hospital of Pittsburgh between 1980 and 1995 with an intratemporal complication of acute otitis media. Seventy-two patients were treated for acute mastoiditis. Of these 72 children, 54 (75.0%) were treated conservatively with broad-spectrum intravenous antibiotics and myringotomy. Eighteen (25.0%) required mastoidectomy for treatment of a subperiosteal or Bezold's abscess or cholesteatoma, or because of poor response to conservative therapy. Twenty-two children presented with facial paralysis, complete in 5 (22.7%) and incomplete in 17 (77.3%). Eighteen (81.8%) were treated conservatively, but four required mastoid surgery. Nineteen patients had adequate follow-up; of these, 15 recovered normal facial function but 4 were left with partial paralysis. Three patients presented with serous labyrinthitis and recovered completely with conservative therapy. Of the two patients who presented with suppurative labyrinthitis, one was treated conservatively, but the other required tympanomastoidectomy with cochleotomy; both patients had permanent, profound sensorineural hearing loss in the affected ear. Four patients presented with acute petrositis, and in all four it resolved with mastoidectomy. In the antibiotic era, intratemporal complications of acute otitis media still occur in otherwise healthy children, often after inadequate treatment of acute otitis media.     

Rapid increase of pneumococcal resistance to beta-lactam and other antibiotics in isolates from the respiratory tract (Nagasaki, Japan: 1975-1994)

The susceptibility of 101 pneumococcal isolates from the respiratory tract during 1991-1994 was examined and compared with the susceptibility of isolates over the period of 1975-1990. A rapid increase of resistance was seen not only to penicillin but also other antimicrobial agents. During 1991-1994, 38% of all the isolates were resistant to penicillin. The rates of resistance during this period were 16-23% for three newer cephalosporins, 18% for imipenem, 69% for tetracycline, 31% for erythromycin, 20% for chloramphenicol and 9% for clindamycin. The use of antibiotics within one month prior to pneumococcal isolation was correlated with penicillin resistance (P < 0.05). Serotyping of the isolates by antiserum revealed differences in predominant types between penicillin-resistant (19F, 23F,4) and -susceptible isolates (15, 4, 11A). Our data suggests that anti-pneumococcal antibiotics should be carefully chosen on the basis of susceptibility tests.