1. P. Marchisio, S. Esposito, M.Picca, E. Baggi,
PROSPECTIVE EVALUATION OF THE ETIOLOGY AND PATHOGENESIS OF ACUTE OTTIS MEDIA WITH SPONTANEOUS TYMPANIC MEMBRANE PERFORATION
P. Marchisio, S. Esposito, M.Picca, E. Baggi,
A. Orenti, E. Biganzoli, N. Principi
Pediatric Highly Intensive Care Unit,
Department of Pathophysiology and Transplantation,
Fondazione IRCSS Cà Granda Ospedale Maggiore
University of Milan, Milan, Italy

2. BACKGROUND
Spontaneous tympanic membrane perforation (STMP) can occur during an episode of acute otitis media (AOM) and complicate the clinical course of the disease.
Incidence of AOM with STMP varies between 5% and 30%.
Several studies have suggested that AOM with STMP could have some specific characteristics and be differentiated from uncomplicated AOM.

3. OBJECTIVES
To evaluate the microbiology of acute otitis media with otorrhea due to spontaneous tympanic membrane perforation in children living in Italy
To evaluate pneumococcal serotypes

4. prospective, single-center study, Italy
METHODS (1)
prospective, single-center study, Italy
enrollment for 12 months: May 1, 2015 to April 30,
2016
previously healthy children (6 m – 7 yrs)
diagnosis of AOM with spontaneous otorrhea:
(a) middle ear effusion + signs of acute inflammation of the tympanic membrane + acute symptoms and (b) otorrhea (within 12 hours of spontaneous rupture of TM)

5. METHODS (2)
excluded: tubes, midfacial abnormalities, chronic middle ear conditions, including chronic perforation, immunodeficiency, antibiotics in the previous 2 weeks, topical treatment
purulent fluid removed and MEE collected close to the perforation using an extra-thin flexible wire swab (Copan eNAT transport and preservation medium, Brescia, Italy).
bacterial genomic DNA was extracted by clinical specimens by semi-automatic DNA extraction system. The presence of Streptococcus pneumoniae (S.pn) (and its serotypes) , Haemophilus influenzae (Hi), Moraxella catarrhalis (M.cat), group A beta hemolyticus Streptocccus (GABHS) and Staphylococcus aureus was evaluated by means of real-time PCR using specific oligos-probe sets. S.pn. cases were serotyped using primers and probes designed on the basis of the GenBank database sequences (

6. STUDY POPULATION Children N = 177 (%) Sex (males) Age (group)
< 2 years
2 - 4 years
> 5 years
mean age ± SD (years)
History of rAOM
PCV13 fully vaccinated
103 (58.2)
65 (36.7)
70 (39.6)
42 (23.7)
3.5 ± 2.7
100 (56.5)
162 (91.5)

8. PATHOGENS DETECTED ALONE OR AS CO-PATHOGENS
Il patogeno identificato più frequentemente è risultato essere H. influenzae (90 campioni, 50,8% del totale), seguito da M. catarrhalis, S. pneumoniae, S. pyogenes e infine S. aureus.
All H.influenzae strains were non typeable

9. How many children had a positive sample for one or more pathogens?

10. Non typeable H.Influenzae  the most frequent pathogen (70%)
in co-infections (M.catarrhalis  GAS  S.pneumoniae)

11. COMPARISON BETWEEN TIME AND DETECTION METHODS
Il patogeno identificato più frequentemente è risultato essere H. influenzae (90 campioni, 50,8% del totale), seguito da M. catarrhalis, S. pneumoniae, S. pyogenes e infine S. aureus.
PCR – Italian data to 2016 Marchisio P et al., CMI, epub 2017
Culture – Italian data to Marchisio P et al., Infection, 2013

12. Streptococcus pneumoniae positive cases: age distribution

13. Streptococcus pneumoniae positive cases: PCV13 versus non-PCV13 serotypes

14. Streptococcus pneumoniae serotypes
PCV7
PCV13
non PCV13

15. CONCLUSIONS - 1
Non typeable H.influenzae , which is the most frequently pathogen associated with biofilm formation, is predominant in spontaneous otorrhea
Group A Strep is confirmed to be a main cause of otorrhea, especially in older children
M. catharralis seems to be a relevant pathogen
Co-infections are common , especially in children with recurrent AOM and especially for NTHi
The therapeutic approach should be different from that which is usually reported for uncomplicated AOM, taking into account the possible formation of biolfim and the presence of betalactamase producers

16. CONCLUSIONS - 2
S. pneumoniae is still one of the main pathogens despite full immunization with PCV13
most of the pneumococcal cases are associated with serotypes not included in the vaccine. This finding suggests that a significant replacement phenomenon has developed, reducing the potential effect of PCV13 on AOM incidence
periodical monitoring of pneumococcal ST circulation after introduction of PCV with a defined number of ST is needed in order to evaluate replacement phenomenon and the need for new vaccines with greater protective activity

17. Thank you for your attention