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The changing guidelines for AOM treatment along with the

growing antibiotic resistance globally may lead to a rise in the number of AOM

complications [23]. The incidence of AM in our 

hospital district has increased relative to earlier data. ifferent

 pathogens cause different clinical findings of AM.

!t is important to ta"e bacterial cultures of the middle ear effusion and to treat the patients according to these results. !n our 

sub#ect pool$ older children had more previous antibiotic

treatment %p & '.'(). This partially e*plains the tendency towards

more culture+negative findings.

,e compared our data with the data published by -es"inen

et al. [] The patients in their study comprised children %'/0(

years) treated for AOM complications at 1elsin"i niversity

entral 1ospital$ epartment of Otorhinolaryngology$ between

0' and 2'''. The incidence of complications was higher in our 

material %0.44 vs. 0.050'' '''5year). 6. pneumoniae %347 vs. 2(7)

and 6. pyogenes %007 vs. 87) were more common$ but 9. aeruginosaless common %007 vs. 227) in our material. Mastoidectomy was

more common in the earlier material %((7 vs. 3:7). The sub#ect

 pools were otherwise similar$ but differed in the number of 08+

year+olds %2 in our study) and in complications other than AM %37

in their study).

6. pneumoniae is "nown to be the predominant pathogen in

children with AM [08$2:]. Our results support this finding. 6.

 pneumoniae wasmore common in younger than in older children. Of 

the typical AOMpathogens$ 6. pneumoniae has been associated with

the greatest virulence [02$0:]. Otalgia and retroauricular symptoms

were common in patients with 6. pneumoniae. Otorrhoea was less

common %p & '.'3) in patients with 6. pneumoniae than in patients of 

other pathogen groups. 9atients with 6. pneumoniae had more

destruction of the mastoid septa %p & '.'() relative to all other 

 pathogen groups.Mastoidectomy was performed in 3:7 of all cases$

most commonly in patients with 6. pneumoniae !5;.

;esistance problems of 6. pneumoniae to penicillin and

cefalosporines have been reported in several countries including

the nited 6tates [0($08] and

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 burden caused by AOM and its complications. This may also

influence the resistance situation [2(]. 9> is "nown to decrease

the incidence of invasive 6. pneumoniae infections [28]. 9> is also

"nown to decrease the incidence of recurrent acute otitis media

[2?] and the need for tympanostomy tube insertions [2?$24].1owever$

no decrease has been reported in the incidence of AM after the introduction of 9> [08$2:]. Moreover$ a decrease in the

incidence after introduction of the vaccination followed by a rapid

return to pre+vaccination levels has been described [2]. Thismay

 be due to pneumococcal serotype replacement [2$3']. A pneumococcal

con#ugate vaccination$ 9>0'$ was introduced to the

=innish national immuni@ation protocol in 6eptember 2'0'. The

effect of these vaccinations on the incidence of AM has not yet

 been estimated in =inland [30]. espite vaccinations$ 6. pneumoniae

must remain our main target when treating AOM and AM.

;esistance problems must be considered and antibiotics chosen

accordingly. nnecessary prescription of antibiotics must beavoided but complicated cases of OM need prompt treatment.

6. pyogenes was the most common isolated pathogen in AOM

in the first half of the 2'th century [32]. AOM caused by

6. pyogenes has been associated with older age in children$ higher 

local aggressiveness and higher rates of tympanic perforations

and mastoiditis [33]. Our findings were similar$ although

 periosteal symptoms and protrusion of the pinna were less

common in the 6. pyogenes group than in other pathogen groups.

9atients with 6. pyogenes had less otalgia and less retroauricular 

symptoms than the other groups. Otorrhoea was found in (?7 of 

 patients with 6. pyogenes. ,e hypothesi@e that otorrhoea may

lead to less otalgia by releasing the tension of the tympanic

membrane. AM caused by 6. pyogenes was more common in older 

children.

9. aeruginosa is an opportunistic ram+negative bacterium

that causes infections when host defences are compromised$ [3:]

for e*ample$ after tympanostomy tube insertion [23]. Ongoing

 pneumococcal infection may protect from and prior pneumococcal

infection predispose to pseudomonas infection [23].

9. aeruginosa has often been associated with mastoiditis caused

 by chronic otitis media$ but has in previous studies been found to be a common pathogen in AM$ especially in children aged older 

than : years [3(]. !n our study$ 9. aeruginosa was found in 007 of 

 patients$ all of whom were older than 2 years. The patients with

AM caused by 9. aeruginosa had mild signs and symptoms of 

infection$ but all had otorrhoea. A clear correlation was found

 between previous tympanostomy tubes and AM caused by

9. aeruginosa %p B '.''0).

Mastoidectomies were significantly more common in patients

who had received a@ithromycin prior to hospitali@ation %p & '.'2).

 Co significant differences emerged in the number of mastoidectomies

 performed between the groups receiving amo*icillin/ clavulanate$ amo*icillin or cephalosporines or in the group of 

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 patients receiving no previous antibiotic treatment. A@ithromycin

should not be used to treat AOM without results from bacterial

culture indicating its use. !n =inland$ the current recommended

dose of amo*icillin in the treatment of AOM is :' mg5"g5day [(]. !n

other countries$ a higher initial dose %4'/' mg5"g5day) is

recommended [2(]. linically$ amo*icillin/clavulanate is a goodchoice in treating AOM. !t has more adverse effects than

amo*icillin$ but has the best antibiotic coverage for all the usual

 pathogens of AOM [2(]. The local antibiotic resistance pattern and

the bacteriology of AOM must be followed also after the launch of 

9> vaccinations$ and future recommendations should be based on

these.

AM is a rare complication of AOM that must be treated

 promptly to avoid potential further complications. Dacterial

cultures must be ta"en and the treatment chosen according to

the causative pathogen. 6. pneumoniae is the most common

 pathogen in AM$ and initial treatment must cover it. 9neumococcalantibiotic resistance should be ta"en into account when treating

AOM and its complications.

(. onclusion

The clinical findings of AM differ according to the causative

 pathogen.

6. pneumoniae$ especially strains with reduced susceptibility for 

common antimicrobials$ causes severe symptoms and leads to

mastoidectomy more often than the other pathogens. 6. pneumoniae

with reduced susceptibility %!5;) was clearly overrepresented

in our mastoiditis children relative to the bac"ground population

%p B '.''0). 6. pyogenes causes less otalgia than the other 

 pathogens.

9. aeruginosa seems to especially affect children with tympanostomy

tubes$ but causes a less aggressive form of disease. =unding

This pro#ect was financially supported by the research funds of 

1elsin"i niversity entral 1ospital and the =innish ;esearch

=oundation for Otology.

onflict of interest

,e have no conflicts of interest to declare.

Ac"nowledgements

The authors