Antimicrobial Agents Available for Treatment of Otitis Media

Penicillins

Amoxicillin

Amoxicillin-clavulanate (Augmentin)

Cephalosporins

Cefaclor (Ceclor) Cefuroxime-axetil (Ceftin) Cefpodoxime (Vantin) Cefixime (Suprax) Ceftibuten (Cedax) Cefdinir (Omnicef) Ceftriaxone (Rocephin)a

Carbapenem

Loracarbef (Lorabid)

Macrolides

Erythromycin Clarithromycin (Biaxin) Azithromycin (Zithromax)

Sulfa combinations

Erythromycin-sulfisoxazole (Pediazole) Trimethoprim-sulfamethoxazole (Bactrim, Septra)

* Includes the oral agents and one parenteral drug available for treatment on an ambulatory basis, whereas there are other parenteral antimicrobial agents effective for treatment of otitis media, usually on an inpatient basis.

a Available only in parenteral form.

azithromycin or clarithromycin, is advocated; as an alternative, one of the newer cephalosporins (e.g., cefuroxime-axetil, cef-podoxime, loracarbef, ceftriaxone) could be used, if the patient does not have hypersensitivity to these agents, and does not have an immediate hypersensitivity reaction to the penicillins. Trimethoprim-sulfamethoxazole is not a desirable alternative, as it has had an unacceptable safety record. A single parenteral dose of ceftriaxone is the most recent antimicrobial agent approved for treatment. The quinolones, such as ciprofloxacin, are not indicated in children below 18 years of age, and efficacy of these antimicrobial agents has not been reported in adults with acute otitis media.

The traditional 10- to 14-day course of therapy is usually recommended, but there has been a recent proposal to shorten the course to 5 to 7 days in an effort to reduce antibiotic usage.13 However, there is some evidence that infants should not be treated for a period of fewer than 10 days.14

Follow-up Visits

Most cases of acute otitis media improve significantly within 48 to 72 h when appropriate antimicrobial therapy is administered. If signs and symptoms of infection progress despite this treatment, i.e., treatment failure, the patient should be reevaluated within 24 h, since a suppurative complication (e.g., acute mastoiditis) or a concurrent serious infection, such as meningitis, may have developed. Persistent or recurrent pain or fever, or both, during treatment would signal the need for tympanocentesis (for Gram stain, culture, and susceptibility testing), selection of another antimicrobial agent, or both. Selection of an antibiotic at this stage would depend upon the results of the culture and susceptibility testing. If amoxicillin was initially administered, one of the alternative antimicrobial agents to amoxicillin would be reasonable as empiric therapy until the results of the culture are available, or if culture is not obtained. In this era of multidrug-resistant otitic pathogenic bacteria, tympanocentesis should be used as often as possible when a patient is considered to be an antibiotic treatment failure, since it is important to document the causative organism. The procedure can be successfully performed in almost all patients without the need for a general anesthetic. Table 78-4 lists the indications for tympanocentesis (needle aspiration for diagnosis) and myringotomy (drainage of the middle ear).

Patients should be reexamined at the end of the course of antibiotic therapy if they still have any signs or symptoms of acute infection, as further evaluation and therapy may be indicated. If the patient is asymptomatic at the end of therapy, the follow-up visit can be delayed until 4 to 6 weeks after the onset of the attack because further treatment is usually not indicated, even if effusion persists in the middle ear.

To Treat or Not to Treat Persistent Middle Ear Effusion with Antibiotics

After antibiotic therapy for an episode of acute otitis media, middle ear effusion persists in approximately 50% of ears. But the presence of asymptomatic effusion does not require further treatment with an antimicrobial agent, since about 90% of these

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