ANTIMICROBIAL AGENTS AND CHEMOTHERAPY, Aug. 1996, p. 1889–1892 Vol. 40, No.

8
0066-4804/96/$04.0010
Copyright q 1996, American Society for Microbiology

Efficacy of Clarithromycin Treatment of Acute Otitis Media Caused by

Infection with Penicillin-Susceptible, -Intermediate, and -Resistant
Streptococcus pneumoniae in the Chinchilla
CUNEYT M. ALPER,* WILLIAM J. DOYLE, JAMES T. SEROKY, AND CHARLES D. BLUESTONE
Department of Pediatric Otolaryngology, Children’s Hospital of Pittsburgh, and Department of Otolaryngology,
University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
Received 18 March 1996/Returned for modification 14 May 1996/Accepted 11 June 1996

Because of the increasing frequencies of recovery of penicillin-resistant Streptococcus pneumoniae from the
middle ears of children with acute otitis media, non-beta-lactam antibiotics are being explored as treatment
alternatives to amoxicillin. In this study, the efficacy of a 10-day course of clarithromycin was evaluated with
chinchillas. After the pharmacokinetic profiles for clarithromycin were established, 180 animals were assigned
to one of three susceptibility groups (n 5 60/group; penicillin-susceptible, -intermediate, and -resistant S.
pneumoniae), and the right middle ear was infected with the appropriate strain of S. pneumoniae. Equal
numbers of animals in each group were treated orally beginning on day 2 with a 10-day course of clarithro-
mycin (15 mg/kg of body weight; given twice a day) or amoxicillin as a control (20 mg/kg twice a day). On days
4, 9, and 13, otomicroscopy and tympanometry were performed, and on day 13, the middle ears were cultured
for bacteria. The results showed 100% eradication of the challenge organism in both treatment groups for the
susceptible strains of S. pneumoniae. Cultures were negative in 87 and 74% (P > 0.05) of the animals challenged
with the intermediate resistant strains and in 100 and 56% (P < 0.05) of the animals challenged with the
resistant strains and treated with clarithromycin and amoxicillin, respectively. There were no differences
between treatments in the diagnosis of effusion for any group. These results support the use of the chinchilla
to evaluate drug efficacy in the treatment of acute otitis media and show clarithromycin to be effective in
sterilizing the middle ears of animals challenged with penicillin-susceptible, -intermediate, and -resistant
strains of S. pneumoniae.

Acute otitis media (AOM) is a common infectious disease of
infants and children. Clinical studies document a bacterial eti-
ology for most cases of AOM, with Streptococcus pneumoniae,
Haemophilus influenzae, and Moraxella catarrhalis representing
the species most frequently recovered from the middle ears of
children with the disease (7). The results of a recent meta-
analysis of clinical studies (26) confirms the efficacy of antimi-
crobial treatment of AOM, and empirical therapy with antibi-
otics remains the mainstay of treatment. Amoxicillin is the
first-line treatment for AOM in the United States (6). How-
ever, increasing frequencies of recovery of S. pneumoniae
strains that are resistant to penicillin have been observed in
recent years (3, 9, 14, 20, 27, 28). Unlike the mechanism of
resistance for H. influenzae and M. catarrhalis, that of S. pneu-
moniae is not associated with plasmid-mediated production of
b-lactamase but rather involves structural modifications under
genomic control (16). Thus, developed strategies to counter
the penicillin resistance of H. influenzae and M. catarrhalis are
not applicable to S. pneumoniae, and new approaches need to
be explored (5, 11, 22). These approaches include development
of effective pneumococcal vaccines, altered dosing regimens
for the first-line antimicrobial agents (4, 22), and development
of secondary agents that have broad coverage with respect to
the various strains of S. pneumoniae (2, 5, 21, 24).
Regarding the latter, clarithromycin is a 14-membered mac-
rolide antimicrobial agent that has activity against the most
common bacterial species cultured from middle ear effusions
(MEEs), concentrates well in tissues, and has pharmacokinetic
* Corresponding author. Mailing address: Department of Pediatric
Otolaryngology, Children’s Hospital of Pittsburgh, 3705 Fifth Ave.,
Pittsburgh, PA 15213. Phone: (412) 692-6962. Fax: (412) 692-6074.
profiles that offer the possibility of twice daily (BID) dosing. In
clinical trials, clarithromycin has been shown to be as effective
as amoxicillin-clavulanate in the treatment of AOM, though in
those studies, few pneumococcal isolates were resistant to pen-
icillin (13, 15, 17). Because clinical trials of antimicrobial
agents for AOM caused by resistant organisms are difficult to
perform given the high natural rate of clinical cure, the inci-
dent frequency of recovery of the target organism, and at
present, the rather low frequency of penicillin-resistant S.
pneumoniae in AOM (19), we attempted to develop an animal
model of the disease with the chinchilla (1). Previously, a
chinchilla model of AOM caused by b-lactamase-producing
H. influenzae has been successfully used to evaluate the efficacy
of new antimicrobial agents in the treatment of that disease (8,
10, 18, 25).
Therefore, the purposes of this study were as follows: (i) to
develop, using the chinchilla, an animal model of AOM sec-
ondary to infection with S. pneumoniae strains of different
susceptibilities to penicillin; (ii) to determine pharmacokinetic
profiles for blood and MEE samples following single-dose oral
administration of clarithromycin in the chinchilla; and (iii) to
determine if a 10-day standard course of clarithromycin is
effective in eradicating the challenge organism and resolving
the MEE in chinchillas infected transbullarly with penicillin-
susceptible, -intermediate, or -resistant strains of S. pneu-
moniae.
MATERIALS AND METHODS
Pharmacokinetic experiment. A total of 30 adult chinchillas were purchased
and enrolled in this study. The middle ears were challenged bilaterally via a
transbullar approach with 50 mg of Escherichia coli endotoxin in 0.1 ml of sterile
saline to create acute inflammation and effusion. Four days after challenge, the
animals were randomly assigned to one of three equal groups and then admin-

1889
1890 ALPER ET AL.
TABLE 1. Summary of the results of this study
Group and Sample size
Mortality
treatment Posttreatment
Entry rate (%)
subgroup (day 13)
Group S
Clarithromycin 28 8 71
Amoxicillin 28 9 68
Group I
Clarithromycin 30 16 47
Amoxicillin 30 19 37
Group R
Clarithromycin 30 19 37
Amoxicillin 30 18 40
a
Percentage of ears that were cured at day 13 on the basis of the results of culture, otomicroscopy, tympanometry, and effusion recovery for all surviving animals
in the six categories.
b
Significantly different from the value obtained with clarithromycin (P , 0.05 by chi-square test).
istered a single oral dose of clarithromycin at 7.5 (group A), 15 (group B), or 30
(group C) mg per kg of body weight. Blood samples and MEEs were collected
from animals in each group over a 12-h period after dosing. Two MEE samples
from either side (if present), and three or four blood samples were obtained from
each animal according to a random hourly schedule. Samples were processed in
a microbiological assay (done in triplicate) of clarithromycin concentrations by
protocols and methods supplied to our laboratories by Abbott Laboratories (12).
In the analysis of these data, the median value of the triplicate measurements was
used as an estimate of serum or MEE clarithromycin concentration for each
animal at each time point.
Efficacy experiment. A total of 180 adult chinchillas were purchased from local
ranches and randomly assigned to one of three equal groups (n 5 60) (groups S,
I, and R). Both ears of all animals were examined by otomicroscopy and tym-
panometry to document healthy middle ear status. Then, the right middle ears
were inoculated via the transbullar approach with 0.1 ml of phosphate-buffered
saline containing approximately 10 CFU of one of three (n 5 20/strain) penicil-
lin-susceptible strains (group S), -intermediate-resistant strains (group I), or
-resistant strains (group R) of S. pneumoniae. Two days after inoculation, ani-
mals challenged with the different strains in each group were randomly assigned
to one of two equal subgroups for treatments with amoxicillin (control) or
clarithromycin (experimental). Beginning on that day and continuing for a total
of 10 days, antibiotics (supplied by Abbott Laboratories) were administered by
mouth BID. The total daily dose of amoxicillin was 40 mg/kg/day, and the total
daily dose of clarithromycin was 30 mg/kg/day.
Animals were reexamined under ketamine (20 mg/kg; given intramuscularly)
sedation at 4, 9, and 13 days postinoculation by tympanometry and otomicros-
copy, and then the animals were killed by barbiturate overdose (324 mg of
pentobarbital given intracardiac). The right middle ear bullae were opened, and
effusions were recovered into sterile traps. These effusions were swabbed and
cultured onto chocolate plates for detection of S. pneumoniae. Bullae lacking
effusion were washed with phosphate-buffered saline, and the recovered wash
fluid was cultured for S. pneumoniae by standard microbiological techniques.
Culture results were coded on a five-point scale (no growth [rating of 0] to heavy
growth [rating of 4]). All procedures were performed by personnel blinded to the
group and subgroup assignment of the animals. The protocol was approved by
the Animal Care and Use Committee at the Children’s Hospital of Pittsburgh.
The nine strains of S. pneumoniae were originally isolated from the middle ears
of children with AOM. These strains corresponded to three different levels of
penicillin susceptibility as documented by standard microbiological assay per-
formed by the clinical microbiology laboratory at the Children’s Hospital of
Pittsburgh and included three susceptible strains (group S; MIC # 0.1 mg/ml),
three intermediate strains (group I; 1.0 mg/ml $ MIC . 0.1 mg/ml), and three
resistant strains (group C; MIC $ 2.0 mg/ml). At the end of the experiment and
before the group and subgroup assignments of the animals were revealed, all
strains were submitted to Abbott Laboratories for blinded microbiological assay
of susceptibility to amoxicillin and to clarithromycin (23).
Otomicroscopy was performed with a Zeiss operating microscope at 6 power.
Disease status with respect to AOM was categorized as present or absent on the
basis of observation of an air-fluid level and/or bulging of the tympanic mem-
brane. Tympanometry was performed with a clinical instrument (model AE-105;
American Electronics Corp.) previously validated in our laboratories. The pres-
ence of effusion was diagnosed if the middle ear pressure was less than 2100 mm
H2O and/or the recorded compliance of the tympanic membrane was less than or
equal to 0.5 cm3 (1).
The primary outcome measure was sterility of the middle ear after a 10-day
course of treatment. Secondary outcomes included mortality, disease course, and
ANTIMICROB. AGENTS CHEMOTHER.
Cure rate (%)a
Culture Otomicroscopy Tympanometry MEE recovery
100 38 88 63
100 44 56 56
87 50 38 50
74 37 42 63
100 47 47 53
56b 33 33 61
resolution of effusion. Analysis of the data was performed independently for each
of the three groups. The frequencies for the outcomes related to sterility, mor-
tality, and presence of effusion were compared between subgroups by a chi-
square test evaluated at a 5 0.05. Data summarizing the results of this study are
presented in Table 1.
RESULTS
Pharmacokinetic experiment. Measurable serum and MEE
clarithromycin concentrations were observed following admin-
istration of all three clarithromycin doses. For the 7.5-mg/kg
dose, a peak average serum clarithromycin concentration of
0.33 6 0.22 mg/ml was observed at 2 h with no measurable
concentrations documented at 6 h after dosing. Concentrations
in MEE as high as 0.55 mg/ml were measurable for up to 9 h
after dosing. The 15-mg/kg dose resulted in a peak level in
serum at 2 h of 1.88 6 .55 mg/ml and a peak level in MEE of
0.78 mg/ml at 9 h after dosing. Detectable antibiotic concen-
trations in these fluids could be measured over the 12-h fol-
low-up period. Doubling that dose to 30 mg/kg did not have an
appreciable effect on the measured serum drug concentrations
(peak 1.6 6 1.7 mg/ml at 7 h) but did appear to increase the
peak effusion drug concentration (2.75 mg/ml at 10 h). Com-
parable concentrations in serum to those documented for chil-
dren following a single oral clinical dose of 7.5 mg/kg were
achieved at the 15-mg/kg dose in the chinchillas. Therefore, in
the efficacy experiment, clarithromycin was administered BID
at a dose of 15 mg/kg.
Efficacy experiment. (i) Mortality. In developing the proto-
col, we estimated from past experience with S. pneumoniae
infection, a mortality rate of between 30 and 40% by day 13,
and this was approximated in the groups challenged with the
penicillin-intermediate (group I, 42%) and -resistant (group R,
39%) S. pneumoniae strains. There were no significant differ-
ences in mortality between these groups or between treatments
within these groups. However, for group S, both treatment
subgroups experienced a high mortality rate (clarithromycin
subgroup, 71%; amoxicillin subgroup [control], 68%). This
mortality rate was significantly greater than those for groups R
and I and was heterogeneous with respect to the challenge
strain (mortalities of 60, 85, and 50% for groups S, R, and I,
respectively). The data analysis reported below considers only
the animals that survived to study day 13.
(ii) Culture results. Table 1 reports, for each group and
subgroup, the sample size (day 13) available for analysis of
bacterial cultures and the percentage of surviving animals in
VOL. 40, 1996
which the challenge organism was not recovered. All ears
(100%) in both treatment subgroups of group S animals were
sterile for the challenge organism on day 13. For group I
animals, 14 ears (87%) in the clarithromycin-treated group and
14 ears (74%) in the amoxicillin-treated subgroup were culture
negative for S. pneumoniae, while in group R animals, 19 ears
(100%) in the clarithromycin-treated subgroup and 10 ears
(56%) in the amoxicillin subgroup were culture negative. Be-
tween-treatment differences in culture negativity were signifi-
cant for group R.
Both ears with recoverable S. pneumoniae on day 13 in the
clarithromycin-treated subgroup were challenged with the
same strain of intermediate resistant S. pneumoniae. The col-
ony count rating of the two samples representing clarithromy-
cin treatment failures was 4 (heavy growth). The clarithromy-
cin susceptibility (MIC) of this strain was 4 mg/ml, suggestive of
resistance to the test drug. In contrast, clarithromycin suscep-
tibilities of the other eight strains were less than 0.015 mg/ml.
Amoxicillin susceptibilities for the strains were as follows: 8,
2, and 0.5 mg/ml for the penicillin-resistant strains; 0.5, 0.06,
and 0.03 mg/ml for the penicillin-intermediate-resistant strains,
and 0.03, ,0.015 and ,0.015 mg/ml for the penicillin-suscep-
tible strains. The colony count ratings were 4 in three ears and
1 in two ears of group I animals and 4 in six ears and 1 in two
ears of group R animals. Subdividing this data set on the basis
of measured MICs for amoxicillin showed positive cultures in
1 of 21 ears (5%) for strains with MICs of ,0.06 mg/ml, 5 of 10
ears (50%) for strains with MICs of 0.5 mg/ml, 2 of 8 ears
(25%) for strains with MICs of 2.0 mg/ml, and 5 of 7 ears (71%)
for strains with MICs of 8 mg/ml.
(iii) Clinical cure. Clinical cure was defined on the basis of
fluid recovery on day 13, and on the results of otomicroscopic
and tympanometric examinations for that day. The percent-
ages of ears cured for the two treatment subgroups of each
group are reported in Table 1. MEE was recovered from be-
tween 50 and 63% of the ears in the various groups, with no
obvious differences noted between groups or between treat-
ment subgroups of any group. Similar results are reported for
cure rates on the basis of otomicroscopic examinations and
tympanometric measurements. The percentage of ears with
disease as diagnosed by otomicroscopy and tympanometry in
each group and subgroup on each day of observation was
examined. On treatment day 2 (study day 4), otomicroscopy
diagnosed disease in almost all of the animals (94 to 100%) in
the different groups. There was no significant heterogeneity in
the temporal pattern of disease expression, as diagnosed by
either otomicroscopy or tympanometry that was attributable to
group or subgroup assignment.
DISCUSSION
S. pneumoniae remains the major pathogen in AOM, and
antimicrobial therapy should target this microorganism (7).
Amoxicillin is recommended as the primary drug of choice for
this disease (6), but recent reports from a number of centers
and geographical areas have described an alarming increase in
the frequency of recovery of penicillin-resistant strains of S.
pneumoniae (3, 9, 14, 20, 27, 28). To control the infections
caused by these resistant organisms, a variety of options have
been suggested including increasing the dose of the first-line
amoxicillin therapies or including alternative antibiotics for
primary treatment failures (4, 5, 11, 22). In that regard, some
evidence supports the usefulness of the first approach (4, 22),
while current clinical practice includes the second approach
(5). Evaluations of the clinical efficacy of the various treatment
options would clearly benefit from the development of an an-
CLARITHROMYCIN TREATMENT OF AOM 1891
imal model of AOM caused by penicillin-resistant strains of
S. pneumoniae that mimics the human condition (19). Previ-
ously, the chinchilla has been used to evaluate antibiotic effi-
cacy with regard to AOM caused by b-lactamase-producing
H. influenzae, and therefore, one of the purposes of this study
was to extend that model to penicillin-resistant S. pneumoniae
(8, 10, 18, 25).
All nine challenge strains used in this experiment resulted in
acute infection and the development of AOM in the chinchilla.
One of the penicillin-susceptible strains of S. pneumoniae cho-
sen for study was unexpectedly virulent and associated with a
high mortality rate (85%), while the mortality rates for the
other strains were lower and varied between 35 and 60%. On
the basis of the behavoral signs exhibited by the animals prior
to death which included head tilt, abnormal gait, labored
breathing, and lethargy, the mortality documented in this study
was attributed to disseminated infection causing labrynthitis,
meningitis, and sepsis. Previously, differences in mortality us-
ing the chinchilla as a model of AOM were reported for dif-
ferent S. pneumoniae strains and mortalities in untreated con-
trol groups were unacceptably high for all strains tested (1).
The high rates of mortality secondary to S. pneumoniae infec-
tion of the middle ear documented in the chinchilla are not
representative of the human condition and represent a signif-
icant limitation of the model. This limitation may be obviated
by a careful screening in the chinchilla of a large number of S.
pneumoniae strains to identify strains that induce disease ex-
pression in the absence of significant mortality. However, for
ethical reasons, the use of a placebo control group in this
model is not justified because the high expected mortality in
the untreated control group would significantly limit the power
of any comparisons between treatment groups.
Prior to evaluating the efficacy of clarithromycin in treating
the AOM caused by the different strains of S. pneumoniae, the
pharmacokinetics of clarithromycin was studied in chinchillas
with acute middle ear inflammation caused by endotoxin. The
data showed that single-dose oral administration of clarithro-
mycin at 15 mg/kg to the chinchilla resulted in good serum
levels and appreciable MEE drug levels. The sustained con-
centrations documented for up to 12 h suggested that BID
dosing would result in higher MEE levels than those docu-
mented following a single dose. Thus, these data show that
clarithromycin rapidly penetrates the inflamed middle ear in
this animal model.
For reasons discussed above, a strict negative-control group
was not included in the efficacy study design. Rather, the re-
sults for animals treated with clarithromycin were compared
with those for animals treated with amoxicillin. To maintain
the researcher’s ignorance of the group and subgroup assign-
ment of animals in the present study, an amoxicillin dose of 20
mg/kg was administered BID and at the same times as the
clarithromycin doses. In a previous study, amoxicillin adminis-
tered three times a day for 10 days to chinchillas at a compa-
rable total dose (39 mg/kg/day) resulted in negative culture
rates of 76, 68, and 60% compared with negative culture rates
of 21, 38, and 25% for placebo treatments in middle ears
infected with a penicillin-susceptible, -intermediate, and -re-
sistant S. pneumoniae strain, respectively. Assay of amoxicillin
concentration in the MEEs at different times following admin-
istration of the final drug dose showed mean (6 standard
deviation) concentrations of 0.7 6 1.0 (n 5 3), 8 6 12 (n 5 5),
5.4 6 2.2 (n 5 2), 3.1 6 4.1 (n 5 5), 9.5 6 9.5 (n 5 2), and 0
(n 5 1) mg/ml for effusions collected at 0.5, 1, 2, 3, 4, and 6 h,
respectively (1). These data show that 10 days of treatment
with a total daily amoxicillin dose of 39 mg/kg achieves signif-
1892 ALPER ET AL.
icant concentrations of the antibiotic in the MEEs and is more
effective than the placebo in sterilizing the middle ear cleft.
The efficacy data from the present study show that both anti-
biotic treatments were equally effective in eradicating penicil-
lin-sensitive strains of the challenge organism. For the interme-
diate resistant strains, clarithromycin treatment was associated
with fewer treatment failures (positive middle ear cultures)
than amoxicillin treatment, but the difference between treat-
ment subgroups was not significant. In contrast, none of the
animals challenged with resistant strains of S. pneumoniae and
treated with clarithromycin was considered a treatment failure
compared with approximately 46% of the animals treated with
amoxicillin. For both antibiotics, a relationship between drug
susceptibility and effectiveness was supported by the data. How-
ever, the clinical significance of the higher cure rate for clarith-
romycin than for amoxicillin should be interpreted with cau-
tion. Specifically, the serum and effusion amoxicillin concen-
trations achieved at the dosing schedule utilized in this study
were not measured and may not be comparable to those
achieved in humans administered clinically effective doses of
that antibiotic. However, the data from the earlier study dis-
cussed above showing efficacy in the chinchilla model of com-
parable doses of amoxicillin suggest that the amoxicillin dose
utilized represents a reasonable positive control for demonstrat-
ing clarithromycin efficacy. Thus, these results support the use
of clarithromycin in treating AOM caused by S. pneumoniae.
As reported previously, effective eradication of the challenge
organism was not associated with a resolution of the middle ear
inflammation as judged by presence of effusion and tympano-
metric and otomicroscopic evaluations of signs (8, 10, 18, 25).
Thus, there were no apparent differences between treatment
subgroups in the resolution of the inflammation at the end of
the 10-day course of treatment. This may be attributable to the
relatively short follow-up period for animals in this study. Res-
olution of inflammation may occur over a period of weeks
following eradication of the infection, and this possibility
should be evaluated in a future study.
In summary, the results of this study show that the chinchilla
offers a reasonable animal model for evaluating treatment
strategies for AOM caused by penicillin-resistant S. pneumo-
niae. In the model, cure rates defined on the basis of sterili-
zation of the middle ear cleft correlated with the measured
susceptibilities of the challenge strains to each of the two anti-
biotics tested. The primary disadvantage of the model is the
relatively high mortality rate documented for these infections,
an outcome not reported for the disease in humans. Accepting
that limitation, clarithromycin treatment was demonstrated to
be effective in sterilizing the middle ears of animals infected
with different strains of S. pneumoniae that were sensitive,
intermediate, and resistant to penicillin. However, the docu-
mented resistance to clarithromycin of 1 in 9 (11%) randomly
chosen pneumococcal strains used in this study may reflect a
relatively high rate of clarithromycin resistance of S. pneu-
moniae strains in children with otitis media with effusion. This
rate should be determined for a significant number of S. pneu-
moniae strains recovered from MEEs from children with AOM
to establish the potential limitations of clarithromycin therapy.
ACKNOWLEDGMENTS
We thank Brenda Kerber, Jean Betch, and Melissa Garret for pro-
viding technical assistance with this study.
This study was supported in part by Abbott Laboratories.
REFERENCES
1. Alper, C. M., W. J. Doyle, J. T. Seroky, and C. D. Bluestone. 1996. Ampicillin
and amoxicillin treatment of acute otitis media caused by penicillin sensitive,
ANTIMICROB. AGENTS CHEMOTHER.
intermediate and resistant S. pneumoniae infection in the chinchilla. In D.
Lim, C. D. Bluestone, and M. L. Casselbrant (ed.), Proceedings of 6th
International Symposium on Recent Advances in Otitis Media. B. C.
Decker, Inc., Toronto.
2. Aspin, M. M., A. Hoberman, J. McCarty, et al. 1994. Comparative study of
the safety and efficacy of clarithromycin and amoxicillin-clavulanate in the
treatment of acute otitis media in children. J. Pediatr. 125:136–141.
3. Baquero, F., and E. Loza. 1994. Antibiotic resistance of microorganisms
involved in ear, nose and throat infections. Pediatr. Infect. Dis. J. 13(Suppl.
1):9–14.
4. Barry, B., M. Muffat-Joly, P. Gehanno, and J. J. Pocidalo. 1993. Effect of
increased dosages of amoxicillin in treatment of experimental middle ear
otitis due to penicillin-resistant Streptococcus pneumoniae. Antimicrob.
Agents Chemother. 37:1599–1603.
5. Bluestone, C. D. 1992. Current therapy for otitis media and criteria for evalu-
ation of new antimicrobial agents. Clin. Infect. Dis. 14(Suppl. 2):197–203.
6. Bluestone, C. D., and J. O. Klein. 1995. Otitis media in infants and children,
2nd ed. W. B. Saunders, Philadelphia.
7. Bluestone, C. D., J. S. Stephenson, and L. M. Martin. 1992. Ten-year review
of otitis media pathogens. Pediatr. Infect. Dis. J. 11(Suppl.):7–11.
8. Chan, K. H., J. D. Swarts, W. J. Doyle, K. Tanpowpong, and D. R. Kar-
datzke. 1988. Efficacy of a new macrolide (azithromycin) for acute otitis
media in the chinchilla model. Arch. Otolaryngol. 114:1266–1269.
9. Chesney, P. J. 1992. The escalating problem of antimicrobial resistance in
Streptococcus pneumoniae. Am. J. Dis. Child. 146:912–916.
10. Diven, W. F., R. W. Evans, C. M. Alper, et al. 1995. Treatment of experi-
mental acute otitis media with ibuprofin and ampicillin. Int. J. Pediatr.
Otorhinolaryngol. 33:127–139.
11. Faden, H., J. Bernstein, L. Brodsky, J. Stanievich, and P. L. Ogra. 1992.
Effect of prior antibiotic treatment on middle ear disease in children. Ann.
Otol. Rhinol. Laryngol. 101:87–91.
12. Fernandes, P. B., N. Ramer, R. A. Rode, and L. Frieberg. 1988. Bioassay for
A-56268 (TE-031) and identification of its major metabolite, 14-hydroxy-6-
o-methyl erythromycin. Eur. J. Clin. Microbiol. Infect. Dis. 7:73–76.
13. Fraschini, F., F. Scaglione, G. Pintucci, et al. 1991. The diffusion of clar-
ithromycin and roxithromycin into nasal mucosa, tonsil and lung in humans.
J. Antimicrob. Chemother. 27(Suppl. A):61–65.
14. Friedland, I. R., and G. H. McCracken. 1994. Management of infections
caused by antibiotic-resistant Streptococcus pneumoniae. Drug Ther. 331:
337–382.
15. Guay, D. R. P. 1992. Pharmacokinetics of new macrolides. Infect. Med.
9(Suppl. A):31–38.
16. Guenzi, E., A. M. Gasc, M. A. Sicard, and R. Hakenbeck. 1994. A two-
component signal-transducing system is involved in competence and peni-
cillin susceptibility in laboratory mutants of Streptococcus pneumoniae. Mol.
Microbiol. 12:505–515.
17. Hardy, D., D. R. P. Guay, and R. N. Jones. 1992. Clarithromycin, a unique
macrolide. A pharmacokinetic, microbiological, and clinical overview. Diagn.
Microbiol. Infect. Dis. 15:39–53.
18. Hotaling, A. J., W. J. Doyle, and E. I. Cantekin. 1987. Efficacy of a new
cephalosporin for acute otitis media. Arch. Otolaryngol. 113:370–373.
19. Marchant, C. D., S. A. Carlin, C. E. Johnson, et al. 1992. Measuring the
comparative efficacy of antibacterial agents for acute otitis media: the “Pol-
lyanna phenomenon.” J. Pediatr. 120:72–77.
20. Mason, E. O., Jr., S. L. Kaplan, L. B. Lamberth, and J. Tillman. 1992.
Increased rate of isolation of penicillin-resistant Streptococcus pneumoniae in
a children’s hospital and in vitro susceptibilities to antibiotics of potential
therapeutic use. Antimicrob. Agents Chemother. 36:1703–1707.
21. McCarty, J. M., A. Phillips, and R. Wiisanen. 1993. Comparative safety and
efficacy of clarithromycin and amoxicillin/clavulanate in the treatment of
acute otitis media in children. Pediatr. Infect. Dis. J. 12:122–127.
22. McCracken, G. H., Jr. 1987. Selection of antimicrobial agents for treatment
of acute otitis media with effusion. Pediatr. Infect. Dis. J. 6:985–988.
23. National Committee for Clinical Laboratory Standards. 1993. Methods for
dilution antimicrobial susceptibility tests for bacteria that grow aerobically:
approved standard M7-A3, 3rd ed. National Committee for Clinical Labo-
ratory Standards, Villanova, Pa.
24. Pukander, J. S., J. P. Jero, E. A. Kaprio, and M. J. Sorri. 1993. Clarithro-
mycin vs amoxicillin suspensions in the treatment of pediatric patients with
acute otitis media. Pediatr. Infect. Dis. J. 12(Suppl. 3):118–121.
25. Rosenfeld, R. M., W. J. Doyle, J. D. Swarts, J. T. Seroky, and I. Green. 1993.
Efficacy of ceftibuten for acute otitis media caused by Haemophilus influ-
enzae: an animal study. Ann. Otol. Rhinol. Laryngol. 102:222–226.
26. Rosenfeld, R. M., J. E. Vertrees, J. Carr, et al. 1994. Clinical efficacy of
antimicrobial drugs for acute otitis media: metaanalysis of 5400 children
from thirty-three randomized trials. J. Pediatr. 124:355–367.
27. Spika, J. S., R. R. Facklamm, B. D. Plikaytis, and M. J. Oxtoby. 1991.
Antimicrobial resistance of Streptococcus pneumoniae in the United States
1979–1987. J. Infect. Dis. 163:1273–1728.
28. Zenni, M. K., S. H. Cheatham, J. M. Thompson, et al. 1995. Streptococcus
pneumoniae colonization in the young child: association with otitis media and
resistance to penicillin. J. Pediatr. 127:533–537.