1. SEVERITY OF PNEUMOCOCCAL VS
SEVERITY OF PNEUMOCOCCAL VS. NON-PNEUMOCOCCAL ACUTE OTITIS MEDIA IN CHILDREN Sharon Ovnat Tamir, MD1, Tal Marom, MD2 1Department of Otolaryngology-Head and Neck Surgery, Edith Wolfson Medical Center; 2Department of Otolaryngology-Head and Neck Surgery, Assaf Harofe Medical Center; Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
Good morning. My name is Dr. Tal Marom, on behalf of myself and my colleague, Dr. Sharon Ovnat Tamir, I’d like to overview the indicators for severity of acute otitis media episodes in children.

2. Tel Aviv University
We have nothing to disclose

3. Outline AOM risk factors Severity Scores Conclusion
Assessment of signs
Assessment of symptoms
Assessment of signs and symptoms
Assessment of physical examination findings
Assessment of laboratory findings
Our study –
Materials and methods
Results
Discussion
Conclusion
I will shortly review pneumococcal children, and then present data from the pre-vaccines era, discuss the types of pneumococcal conjugated vaccines available worldwide, and review the effects of these vaccines on acute otitis media (AOM) and acute mastoiditis (AM).

4. Classic Risk Factors for AOM
Factors that can not be modified :
Boys
Age < 2 years
Older siblings
Lack of breastfeeding
Season (fall, winter)
Factors that can be modified:
Pacifier use
Passive smoke exposure
Day care attendance
Low socioeconomic status

5. Risk Factors for Treatment Failure or Recurrence
Antibiotic therapy within the last 1 month
Any AOM diagnosis within the last 1 month
> 3 AOM episodes / last 6 months
Age < 2 years
Age at 1st AOM episode < 6 months
Day care attendance
Bilateral AOM

6. Reports Linking Severity of AOM To Streptococcus Pneumoniae
Coffey et al. reported an association of Streptococcus pneumoniae with bullous myringitis.
Howie et al. reported more pain and fever in children with pneumococcal AOM.
Rodriguez et al. described higher fever and more intensely yellow/red and bulging tympanic membranes (TMs) in AOM associated with S. pneumoniae

7. Acute Otitis Media Severity of Symptoms (AOM SOS) Score
This Score indicates the severity of the following 7 directly observable behaviors:
 Ear tugging
Crying
Fussiness
Disturbed sleep
Decreased play
Eating less
Fever
Children with Pneumococcal AOM had higher scores
Shaikh et al. Acute otitis media severity of symptom score in a tympanocentesis study. PIDJ 2011

8. AOM Facies Score
No correlation stated between AOM –FS and Pneumococcal Disease
Friedman et al. Development of a Practical Tool for Assessing the Severity of Acute Otitis Media. Pediatric Infectious Disease Journal. 25(2): , February 2006.

9. Ear Treatment Group – 5 Items (ETG-5)
Parents use this scale to grade the following:
fever, 0 = <38°C, 4 = 38–39°C or 7 = >39°C
ear ache (tugging), 0 = none, 4 = occasional or 7 = frequent
irritability, 0 = none, 4 = occasional, or 7 = frequent
0 = feeds well, 4 = mild decrease in appetite or 7 = very poor appetite
0 = normal sleep, 4 = somewhat restless sleep or 7 = very poor sleep
Symptom score did not differ between bacterial and non bacterial pathogens
McCormick et al. Otitis media: can clinical findings predict bacterial or viral etiology? Pediatr Infect Dis J. 2000;

10. Otologic System – 8 (OS-8)
0 = normal, or effusion without erythema
1 = erythema only, no effusion
2 = erythema, air fluid level, clear fluid
3 = erythema, complete effusion, no opacification
4 = erythema, opacification with air-fluid level or air bubble(s), no bulging
5 = erythema, complete effusion, opacification and no bulging
6 = erythema, bulging rounded doughnut appearance of the tympanic membrane
7 = erythema, bulging, complete effusion and opacification with bulla formation
In the presence of erythema, complete effusion and opacification (grade 5 or above) physicians were more likely to diagnose and treat with antibiotics. Physical examination rather than history has a major influence on AOM management decisions.
Friedman et al. Development of a Practical Tool for Assessing the Severity of Acute Otitis Media. Pediatric Infectious Disease Journal. 25(2): , February 2006.

11. Tympanic Membrane Bulging
A bulging TM was highly associated with isolation of bacterial pathogens or bacterial/viral combinations as compared with pure viral or negative cultures (P = 0.01).
The finding of a bulging ear predicted a bacterial otitis with a positive predictive value of 74% and a negative predictive value of 45%.
Bulging TMs were also noted somewhat more often in ears infected with S. pneumoniae
McCormick et al. Otitis media: can clinical findings predict bacterial or viral etiology? Pediatr Infect Dis J. 2000;

12. What are we left with in order to differentiate Pneumoccoal Vs Non-Pneumococcal AOM
Risk factors – do not differentiate
Parental scoring systems – do not differentiate
Facial Expressions – do not differentiate
Symptoms and signs scores – do not differentiate
Otoscopic findings – only bulging seems to somewhat differentiate ??

13. Laboratory Findings
In children presenting with AOM, the ability to rely on laboratory findings is of interest and can be pragmatic for decision-making purposes, particularly in order to differentiate pneumococcal and non-pneumococcal AOM.

14. Laboratory Findings
Studies, dating from the pre-pneumococcal conjugate vaccine (PCV) era, found significantly higher WBC counts and neutrophil count in pneumococcal AOM, when compared to Haemophilus influenza positive or in culture-negative AOM
High CRP levels were more frequently associated with AOM caused by a bacterial origin than viral origin
Polachek et al. Relationship among peripheral leukocyte counts, etiologic agents and clinical manifestations in acute otitis media. Pediatr. Infect. Dis. J 2004

15. Laboratory Findings
High CRP levels were more frequently associated with AOM caused by a bacterial origin than viral origin.
However no association was found between the type of bacteria and high CRP levels.
Tejani N.R. et al. (1995) Use of C-reactive protein in differentiation between acute bacterial and viral otitis media. Pediatrics 95

16. Severity of pneumococcal versus non-pneumococcal acute otitis media in children Ovnat Tamir, S. & Marom, T. Clin. Otolaryngol. 2015
To examine the correlation between common laboratory findings and the causative agent(s) of AOM in a subset of young children presenting with ‘severe’ AOM episodes, in an era when PCVs have been gradually implemented in the Israel.

17. Patients and Methods
Children <6 years of age who had MEF cultures obtained during ‘severe’ AOM episodes during 2008–2013 were retrospectively identified.
Episodes were considered as ‘severe’, because tympanocentesis was performed due to:
Lack of clinical improvement despite ≥48 h of oral antibiotic therapy
Signs of AOM-related complications
Or children presented with spontaneous otorrhea

18. Patients and Methods For each AOM episode, we retrieved :
medical records for age, sex, history of current disease
highest body temperature, laterality
recent history of antibiotic treatment
MEF, blood, and cerebrospinal fluid culture
highest WBC count; highest serum CRP level
AOM-related complications [acute mastoiditis (AM), facial nerve palsy, meningitis and intracranial abscess] and AOM-related surgical interventions (ventilating tube insertion and mastoidectomy)
Pneumococcal conjugated vaccine-immunisation data

19. Results
279 children who met the eligibility criteria contributed 295 ‘severe’ AOM episodes
106 (36%) MEF cultures from 103 children tested positive for any of the three otopathogens (S. pneumoniae, nontypeable H. influenzae and Moraxella catarrhalis).
S. pneumoniae group:
single bacterium in 60 (92%) episodes
5 (8%) episodes as a mixed growth with non-typeable H. influenzae.
Non-pneumococcal group:
41 episodes: non-typeable H. influenzae was isolated in 39 (95%) episodes and M. catarrhalis in 2 (5%) episodes.

24. Results
When pneumococcal AOM episodes were stratified according to PCV status at presentation
WBC counts were significantly higher in ‘unimmunised’ children, when compared with ‘PCV13-immunised’ children.
CRP levels did not differ between the three groups.

25. Discussion
WBC counts (and particularly ANCs) and CRP levels were significantly elevated in pneumococcal versus non-pneumococcal AOM episodes.
In the pneumococcal AOM group, WBC counts were higher in ‘unimmunised’ children, when compared to ‘PCV7/PCV13-immunised’ children.
Differences in CRP levels between the three patient groups presenting with pneumococcal AOM were slight.

26. Discussion
With the expected widespread use of PCV13 worldwide, we anticipate that it will be not possible to rely on WBC counts and CRP levels as predictors for pneumococcal AOM.

27. Conclusion