Medical Management Options for Otitis Media Antibiotics

Antimicrobial therapy has continued to be a mainstay of therapy for patients with otitis media. Recently, there has been evidence that over usage of antimicrobial therapy has led to an increased incidence of bacterial resistance in common pathogens related to otitis media. Most notably, St. pneumoniae, H. influenzae, and M. caterrhalis.15 Children frequently presenting to primary physicians with viral upper respiratory tract infections may be treated with antimicrobials, whether or not the patient has simultaneously developed otitis media.4 We know from prior microbiologic studies13,14 that a significant number of middle ear effusion cultures contain predominantly viruses that would not benefit from antimicrobial therapy. It is apparent from these prior studies that many children with otitis media may not benefit from antimicrobial agents, as the cause of otitis media in many cases is nonbacterial, or some cases of bacterial otitis media may resolve without pharmacologic therapy. Approximately 60% of cases of acute otitis media may resolve sponta neously; however, spontaneous resolution is less common in cases of S. pneumoniae, approximately 20%.21'22 Although there are advocates of withholding antimicrobial therapy in cases of otitis media,17 this management strategy is not recommended because of the 20 to 40% incidence of persistent otitis, often caused by S. pneumoniae in nontreated cases. In addition, in cases of untreated otitis media, there is a risk of development of intratemporal or intracranial complications.

Currently, approximately 16 approved antimicrobials may be used for the treatment of otitis media.23 The recommended first line antibiotic for treatment of otitis media continues to be amoxicillin.24'25 In situations of treatment failures or drug allergy to amoxicillin, other antimicrobials should be considered. In cases where agents which have high activity against b-lactamase-producing H. influenzae and M. caterrhalis-effective antimicrobials include amoxicillin and clavulanate potassium, cefixime, cefpodoxime proxetil, and cefuroxime axetil. In cases in which resistant Pneumococcus is suspected or has been diagnosed, high-dose amoxicillin may be beneficial with doses ranging from 60 to 90 mg/kg/day. This regimen may also be used in combination with amoxicillin/shill clavulanate. Obviously, without tympanocentesis, it is difficult to obtain a true diagnosis of the bacteriologic agents in any specific case of otitis media. Unfortunately, tympanocentesis continues as a rather invasive and often uncomfortable procedure that may be difficult to perform in the office setting. A child's parents may also be quite resistant to the possibility of performing this procedure, especially if they are aware of the alternative of empirical antimicrobial treatment. In the future, it may be that as more resistant bacteria emerge from the continued overusage of antimicrobials in our society, there may be an increased role for tympanocentesis for more bacterial-specific treatment for cases of otitis media. Currently, we reserve the role of tympanocentesis for children who have extreme symptomatology and need decompression for immediate relief, for treatment failures, or for children with underlying immunologic disorders who require specific bacteriologic assessment before treatment.

A patient with physical diagnostic findings of acute purulent otitis media with significant symptomatology and fever should be treated with antimicrobial therapy. By contrast, a patient, with a viral upper respiratory tract illness, with evidence of middle ear effusion that is nonpurulent with insignificant otologic symptomatology may initially be treated symptomati-cally without antimicrobial therapy. If progression of symptoms occurs, antimicrobials could be initiated subsequently.

The duration of treatment with antimicrobials for otitis media has traditionally been 7 to 10 days. However, with the advent of newer antibiotics, such as azithromycin, 5-day treatment courses have been advocated.26 Therapy of shorter duration with other antibiotics has also been recommended by some investigators.1,27,28 Single-dose therapy with ceftriaxone has also demonstrated efficacy.29,30

A controversial area in the treatment of otitis media involves chemoprophylaxis with antimicrobial agents in otitis-prone children. Otitis-prone children who tend to completely clear middle ear effusion after appropriate medical therapy for acute otitis media and have no suspected significant hearing loss are candidates for chemoprophylaxis, typically using low-dose amoxicillin and sulfasoxazole. Numerous studies have looked at this issue with no definite conclusions having been determined.31 Williams et al.31 performed a meta-analysis of prior chemoprophylaxis studies, specifically looking at the efficacy of chemoprophylaxis in otitis media. The study did demonstrate a small short-term benefit for the management of recurrent otitis media. However, there did not appear to be any long-term benefit to this treatment strategy. Paradise16'32 stated that physicians should reexamine the role of chemoprophylaxis and the treatment of recurrent otitis media due to the increased incidence of bacterial resistance. He advocates refraining from administration of chemoprophylaxis altogether, or possibly limiting the role of chemoprophylaxis in otitis-prone children just during upper respiratory tract infections.

Children who have significant problems with recurrent acute otitis media requiring multiple courses of antimicrobials may be candidates for chemoprophylaxis. This is a treatment modality that should be individualized to the patient and should be pursued after consultation with the patient's primary care physician. Because of increasing antimicrobial resistance, early placement of tympanostomy tubes may be preferable to long-term chemoprophylaxis.

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