Antimicrobial resistance among organisms that cause acute otitis media (AOM) and new approaches in the prevention and treatment of AOM are discussed. Organisms commonly responsible for causing AOM include Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. The evolution of pneumococcal resistance to penicillins, erythromycin, trimethoprim-sulfamethoxazole, and oral cephalosporins may require treatment with agents such as vancomycin or rifampin in certain patients. H. influenzae and M. catarrhalis are becoming increasingly resistant to penicillins, trimethoprim-sulfamethoxazole, oral cephalosporins, and macrolides. Mechanisms of resistance include changes in penicillin-binding proteins, production of beta-lactamase, alterations in target enzymes, and inhibition of drug access to the site of action. Because of changing resistance patterns and the limited spectra of activity of many currently available antimicrobials, new antimicrobials have been developed in the hope of improving therapy. While amoxicillin and trimethoprim-sulfamethoxazole are appropriate first-line agents, children at risk for resistant infections may be treated initially with cefuroxime axetil, cefpodoxime proxetil, cefprozil, or amoxicillin-clavulanate. After local resistance patterns, patient adherence to therapy, in vitro data, and cost factors have been weighed, other agents to consider include loracarbef, clarithromycin, azithromycin, and ceftriaxone. Along with the efforts to improve treatment, research is focusing on the prevention of otitis media with bacterial and viral vaccines. The emergence of resistant strains of organisms causing AOM has complicated its treatment.
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The pulmonary disposition of cefpodoxime was studied in 12 patients with pulmonary opacities after a single oral dose of 260 mg of cefpodoxime-proxetil, which is equivalent to 200 mg of cefpodoxime. Blood and lung tissue samples were collected during surgery, and bronchoalveolar lavage was carried out 3 h (group A) or 6 h (group B) after drug administration. Urea was used as an endogenous marker for measurement of the volume of epithelial lining fluid (ELF). Concentrations were measured by using a microbiological assay. The mean concentrations of cefpodoxime in plasma, ELF, and lung tissue were, respectively, 1.85 +/- 0.82 mg/liter, 0.22 +/- 0.13 mg/liter, and 0.89 +/- 0.80 mg/kg of body weight in group A and 1.40 +/- 1.25 mg/liter, 0.12 +/- 0.14 mg/liter, and 0.84 +/- 0.61 mg/kg in group B. Concentrations in lung parenchyma 6 h after dosing were at least equal to or above the MICs for 90% of the strains of most organisms commonly found in respiratory tract infections, whereas data for ELF suggest levels of drug insufficient to inhibit bacteria.
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The authors present their experience with antimicrobial treatment with cephalosporin of the third generation, cefpodoxime proxetil, in skin and soft tissue infections in a group of patients treated at the ambulatory department of the Surgical Clinic in Prague 10 in 1995. From the total number antimicrobial treatment was administered to 6 patients with a phlegmon, 5 patients with panaritium, 4 patients with an early infection after laparotomy, 3 with an abscess in the subcutaneous layer, and with cheilitis and bursitis of the olecranon in the remaining two patients. In addition to surgical treatment (incision, evacuation and drainage) cefpodoxime proxetil-200 mg after 12-hour intervals for 6-9 days-was administered to the patients. For microbiological examination a smear from the inflammatory focus and from the nasopharynx was used. The cefpodoxime proxetil serum level was assessed during the 1st-11th hour after administration of the antibiotic. All 20 patients recovered.
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Ninety-three patients with a diagnosis of acute pharyngitis/tonsillitis due to Streptococcus pyogenes were randomly assigned to receive 100 mg of cefpodoxime proxetil orally with food every 12 hours or 250 mg of penicillin V potassium orally on an empty stomach every six hours. Treatment efficacy was evaluated in 30 cefpodoxime-treated and 33 penicillin-treated patients. After 10 days of treatment, S pyogenes was eradicated from the throat culture in 29 of the 30 cefpodoxime-treated patients and in 30 of the 33 penicillin-treated patients. Twenty days after treatment termination, infection recurred in one patient of each treatment group. Clinical cure or improvement was found in 97% of the patients in each group. Adverse medical events occurred in nine of the 48 cefpodoxime-treated patients and in four of the 45 penicillin-treated patients; these were probably related to the study drug in seven and two patients, respectively. The most common adverse events were nausea (in three cefpodoxime and one penicillin patient) and diarrhea (in three and two). No patient showed colitis related to Clostridium difficile. No clinically significant abnormal laboratory test results were found in either treatment group. It is concluded that cefpodoxime proxetil is as effective and safe as penicillin V potassium in the treatment of pharyngitis due to S pyogenes.
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Six pediatric patients who had AOM with otorrhea caused by CA-MRSA.
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twenty patients were selected, based on clinical assessment, to be converted from intravenous ceftriaxone to oral cefpodoxime proxetil. Twenty other comparable patients who would have been appropriate for step-down therapy, did not receive pharmacy intervention and were used as a control group.