The most common reason to see a doctor is acute otitis media (OCO) in children. In the United States, this figure rose to 24.5 million in 1990. Aminopenicillins (amoxicillin, ampicillin) are most often used for the treatment of ACC. The emergence and spread of resistance to penicillins and macrolides in pneumococci, as well as an increase in the role of H. influenzae strains producing beta-lactamases, have led to the search for drugs most effective for the empirical antibacterial treatment of acute otitis media.

Acute otitis media is more common in infants and young children with a maximum incidence of 6 to 18 months. This disease is more sensitive to boys than to girls.

Seasonality: ACC occurs at any time of the year, but the highest incidence is observed in the fall-spring, which corresponds to the seasonality of respiratory infectious diseases.

The nature of the diet: when breastfeeding in children, passive immunity is formed and, therefore, it is believed that breastfeeding in the first 3 months of life greatly reduces the risk of OCO disease during the first year.

Kindergarten visit: a number of studies have shown that children attending kindergartens have a higher incidence of CCA and a percentage of surgical procedures for chronic otitis media than children who do attend not.

Sleep: A study of 14,000 children in Bristol, England, found that ACC is more common in children who sleep on their stomachs than those who sleep on their backs.

The microbiological diagnosis of otitis media is based on a bacteriological study of the content of the middle ear obtained by tympanocentesis or tympanopuncture. Studies in the United States, Europe and Japan have shown that the most common causative agent of acute otitis media is S. pneumoniae, in second place, the non-typable strains of H. influenzae, third place - M.catarrhalis. Less than 10% of ACC is caused by other microorganisms, such as group A streptococci and S. aureus. The etiology of ACC cannot be established according to the clinical picture, however, it should be noted that pneumococcal ACC generally progresses more difficult, often leads to the development of complications and is not subject to self- resolution.

Of the 90 serotypes of S. pneumoniae, only a few cause ACC. The most common are: 19, 23, 6, 14, 3 and 18 serotypes. The use of a vaccine containing capsular polysaccharides of the 7 to 8 most common serotypes of S. pneumoniae, can prevent more than 80% of ACC of pneumococcal etiology.

Most strains of H. influenzae that cause TOC are atypical. According to modern data, approximately 20 to 50% of the H. influenzae secreted during ACC produce beta-lactamases.

Antispasmodics and antihistamines relieve patients, but have no noticeable effect on the duration of the disease.

Antibacterial treatment of acute otitis media is based on the choice of an active antibiotic against 3 main pathogens. In addition, the drug should have good tolerance, a practical dosage schedule, low cost and high safety.

Correction of therapy is performed in the event of ineffectiveness, if the selected microorganism is resistant to the prescribed antibiotic or if the patient has adverse reactions. The therapy is considered ineffective in the absence of positive dynamics during the first 72 hours.

Since CCA is permitted in some cases without the use of antibiotics, many authors consider the comparison of the persistence of the microorganism after use of the antibiotic and placebo as the standard. or to determine the efficacy of the treatment (Table 1).

The problem of antibiotic resistance in S. pneumoniae exists worldwide. Resistance to the most commonly used beta-lactam antibiotics is associated with a modification of penicillin-binding proteins - enzymes that play a major role in the synthesis of the microbial wall. In addition, from a clinical point of view, it is important to distinguish between resistance to penicillin at low levels (CPI = 0.1-1.0 g / l) and high (CPI over 2 g / l)..

In the United States and Europe, numerous studies have been conducted to investigate the resistance of S. pneumoniae to antibiotics in CCA. In the United States, the number of resistant strains therefore varied from 20 to 40%, 25 to 50% of them having a high level of resistance.

For the first time, the production of beta-lactamases by the H. influenzae strains was described in the 1970s. The number of these strains, including the use of amoxicillin for the treatment n is no more effective than placebo, since the early 1970s in the USA ranges from 15% to 40%. Thus, in Pittsburgh (1980-1989), the number of CCA caused by strains of H. influenzae producing beta-lactamases increased from less than 20% to more than 40%. The number of strains resistant to H. influenzae amoxicillin (ampicillin) that do not produce beta-lactamases in most European and American centers does not exceed 5% of the total number of resistant strains.

The value of bacterial resistance in the clinical ineffectiveness of antibiotic therapy with CCA can be characterized by the number of infections caused by a particular microorganism with an estimated percentage of resistant strains and the number of cases of the disease. who are able to resolve themselves. Thus, for example, S. pneumoniae is the cause of more than 40% of cases of CCA, approximately 20% of strains (Boston) are resistant to penicillins, and in approximately 20% of cases, it is possible to resolve the infection without antibiotics. Thus, in approximately 8% of CCA cases, treatment with amoxicillin may be clinically ineffective due to resistance. However, approximately 20% of ACC tends to self-recover, and clinical ineffectiveness is observed almost exclusively with a high level of resistance (in Boston, approximately 25% of all resistant strains). It follows from the above that the expected clinical ineffectiveness in the treatment of amoxicillin in Boston is only 1.6%.

A similar approach can be used to determine the role of resistant strains of H. influenzae. Since H. influenzae is the cause of TOC in 25% of the cases, while about 30% of the strains produce beta-lactamases, then 8% of all TOC could be caused by H. influenzae beta-lactamase producing strains. At the same time, 50% of the ACC caused by these microorganisms tends to resolve on their own. Thus, the ineffectiveness of amoxicillin therapy associated with beta-lactamase-producing H. influenzae can only be expected in 4% of cases.

Constant and careful monitoring of resistance is necessary because, despite the fact that in most regions, amoxicillin can still be used as the drug of choice for the treatment of ACC, in areas of high resistance , a review of the treatment should be considered.

Microbiological data shows that far from all cases, children with CCA need antibiotic therapy. In approximately 33% of all CCAs, a bacterial pathogen is not detected, suggesting that there is no effect of antibiotic therapy in these cases. In approximately 20% of children with pneumococcus and 50% with hemophiliac CCA without the use of antibiotics, a positive clinical dynamic and the eradication of the middle ear pathogen are observed. According to Kaleida et al, up to 90% of children with mild OSO recover without antibiotics. By comparing data from a meta-analysis, 33 studies on 5400 children show that in 81% of cases, recovery occurs without prescription of antibiotics, while with active antibiotic therapy, this figure reaches 95%. An increase in the frequency of purulent complications (usually acute mastoiditis) in the absence of antibiotic therapy was noted in 2 studies. At the same time, Kaleida et al. Noted a significantly lower frequency of persistence of middle ear exudation in children after a two-week course of amoxicillin (47%), compared to placebo (63% ).

Since we cannot differentiate children into two groups: those who need antibiotic therapy and who have a high probability of spontaneous recovery, doctors should consider all children with CCA as needing antibiotic therapy.

Experience with the pneumococcal polysaccharide vaccine has shown its effectiveness. However, since polysaccharide antigens do not cause vaccination in children under 2 years of age (a risk group for CCA), the development of more immunogenic vaccines is necessary.