Medical treatment of otitis media

There is controversy within the medical community regarding the treatment of children with otitis media (OM). Some of the points of contention include:

Societal costs coupled with the rise of drug resistant pathogens have led to a reevaluation of the standard therapies. Recognizing that otitis media is a primary generator of antibiotic prescriptions, medicine and government have collaborated to develop guidelines which are intended to outline best practices. These clinical guidelines are steadily gaining general acceptance, as evidenced in part by the standardization of terminology related to otitis media.

The guidelines offered by various organizations and agencies have common goals and concerns. First among these is safe treatment. Studies indicate that the indiscriminate use of antibiotics, both in medicine and animal husbandry, has led to widespread antibiotic resistant pathogens. Antibiotic resistance threatens to eliminate medicine's primary weapons against infectious disease. Furthermore, there is evidence that antimicrobial treatment increases the patient's risk for both colonization and invasive disease with nonsusceptible Streptococcus pneumoniae. Additionally, the adverse reactions related to antibiotic therapy, including hypersensitivity, must be always considered. It should be remembered that many children have a number of bouts with OM. Hence, many may be at increased risk of antibiotic sensitization.

Efficacy of treatment is second only to safety. With that in mind, a number of studies have been done to consolidate evidence based practice from US sources and abroad. These studies have shown that, historically, US physicians routinely treated the symptoms of OM with antibiotics. European physicians rarely treated with antibiotics. Instead, their norm is to observe, reserving antibiotics for treatment of complications. Evidence indicates the there is a benefit to antibiotic treatment of OM, but it is small.

Antibiotics will no doubt remain an important tool in the management of OM. It is worth noting that no new classes of antibiotics have been developed in the last decade and no new classes are on the horizon. Judicious use of the existing antibiotics is therefore in the individual and public interest.

 

WASHINGTON DEPARTMENT OF HEALTH

PRACTICE GUIDANCE FOR JUDICIOUS USE OF ANTIBIOTICS
ACUTE OTITIS MEDIA (AOM) (Children)

NON-AOM CONDITIONS
AOM
  • Normal-appearing ear drum
  • Middle ear effusion without inflammation
  • Inflammation of ear canal
  • Pain with mild traction to outer ear
  • Bulging tympanic membrane
  • New onset otorrhea (not due to acute otitis externa)
  • Intense erythema of the tympanic membrane with new onset otalgia

Non-severe AOM is defined as mild otalgia for < 48 hours and temperature < 39°C (102°F).

Severe AOM is defined as moderate or severe otalgia, otalgia for > 48 hours, or temperature > 39°C (102F°).

TREATMENT

The following cases should always be treated with antibiotics:

  • AOM with otorrhea
  • Severe AOM (unilateral or bilateral)
  • Any AOM in infants < 6 months (infants < 2 months may require additional infectious work up)

Consider watchful waiting without antibiotic therapy (see table)

  • When watchful waiting is used, ensure follow-up and begin antibiotic therapy if patient is worsening or not improving within 48-72 hours
Age Bilateral non-severe AOM without otorrhea Unilateral non-severe AOM without otorrhea
6-23 months Antibiotic therapy Watchful waiting or antibiotic therapy
> 23 months Watchful waiting or antibiotic therapy Watchful waiting or antibiotic therapy

SYMPTOMATIC TREATMENT

  • Extra rest, warm drinks, oral hydration
  • Analgesics/antipyretics, as needed
  • Avoid cigarette smoke; offer smoking cessation resources, if indicated

FIRST-LINE ANTIBIOTIC THERAPY

  • Amoxicillin (high-dose)
    NOTE: For children with AOM and concurrent purulent conjunctivitis, use of amoxicillin in prior month, or history of recurrent treatment failures on amoxicillin, prescribe amoxicillin-clavulanate.

SECOND-LINE ANTIBIOTIC THERAPY

  • Amoxicillin-clavulanate (high-dose)
  • Cefdinir, cefpodoxime, cefuroxime, or ceftriaxone

DIFFERENTIAL DIAGNOSIS DETAILS

  • Middle ear effusion without inflammation suggests Otitis Media with Effusion (OME), a collection of non-infected fluid in the middle ear due that may be due to viral URI, allergies, irritant exposure, eustachian tube dysfunction, or resolving AOM.
  • Pain with mild traction to outer ear and normal appearing ear drum may indicate otitis externa.
  • Recurrent AOM (> 2 episodes in 6 months or > 3 episodes in 1 year) in children is an indication for referral for tympanostomy tube placement.

BEST PRACTICES FOR COMMUNICATING WITH PATIENTS

  • Identify and validate patient’s and parent’s concerns
  • Provide clear recommendations including specific symptom treatment and contingency plan for if symptoms worsen
  • Confirm agreement and answer questions
  • Provide education about antibiotic use and associated risks, including bacterial resistance and C. difficile

POTENTIAL HARMS ASSOCIATED WITH ANTIBIOTIC USE

  • May cause significant side effects, such as antibiotic-associated diarrhea and allergic reactions
  • Can increase the risk of carrying a drug-resistant organism which may decrease the effectiveness of antibiotics in the future and make an infection more severe
  • Can result in a diarrheal disease caused by C. difficile which can be severe and even fatal
ANTIBIOTIC THERAPY FOR AOM
DRUG
DOSE
DURATION
Amoxicillin

Child high-dose: 80-90mg/kg/day PO divided in 2 doses, max 2 mg/dose

NOTE: High-dose amoxicillin is recommended for pediatric otitis media because >10% Strep pneumoniae isolates are non-susceptible in Washington.

5-7 days for nonsevere AOM and age > 2 years

10 days for severe AOM or age < 2 years
Amoxicillin-clavulanate

Child high-dose: 90 mg/mg/day (amoxicillin component )PO divided in 2 doses, max 2 gm/dose

NOTE: High-dose amoxicillin-clavulanate is recommended for pediatric otitis media because >10% Strep pneumoniae isolates are non-susceptible in Washington.

Cefdinir Child: 14 mg/kg/day PO divided in 1-2 doses
Cefpodoxime Child: 10 mg/kg/day PO divided in 2 doses
Cefuroxime Infants > 2 months and children: 30mg/kg PO divided in 2 doses (max 500mg per dose)
Ceftriaxone Child: 50 mg/kg IM or IV QD for 1 or 3 days

ANTIBIOTIC ALLERGY

Most patients who report antibiotic allergies, particularly penicillin class allergies, do not have true drug allergies. It is important to carefully evaluate reported drug allergies starting with a history before determining whether an alternative agent is indicated.