Medical treatment of otitis media

Medical cost coupled with the rise of drug resistant pathogens have led to the reevaluation of otitis media (OM) therapies. OM is a significant generator of antibiotic prescriptions and this has prompted collaboration among the medical professions and government agencies to develop best practice guidelines.

The guidelines developed by various organizations and agencies share common goals and concerns. First among these is safe treatment. Studies indicate that the indiscriminate use of antibiotics by medicine and animal husbandry, has led to widespread antibiotic resistant pathogens. Drug resistant pathogens threaten to eliminate medicine's primary weapons against infectious disease. Drug resistance increases the patient's risk for chronic colonization and invasive disease. Adverse events related to antibiotic therapy also include minor side effects and allergic hypersensitivity. It should be remembered that children often have multiple bouts of OM which can increase their risk for sensitization to antibiotic.

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 from antibiotic treatment of AOM, but it is small. Long term antibiotic treatment of ROM has likewise been shown to confer a small decrease in the number of AOM episodes.

Antibiotics will no doubt remain the primary means of preventing and managing AOM. It is worth noting that no new classes of antibiotics have been approved for the treatment of AOM. Judicious use of the existing antibiotics is therefore in the individual and public interest.

The CDC provides some OM treatment recommendations. Please note that the guidelines are directed toward treatment of the otherwise healthy child and not those children who are immunocompromised or have craniofacial or neurologic abnormalities. The following table is based upon the CDC recommendations.

Acute Otitis Media

Medical interventions should be directed toward decreasing pain and fever, limiting the small potential for serious complications and expediting the resumption of normal activities. This is usually accomplished through some appropriate combination of analgesia, antipyretics and antibiotics.

Antibiotics are very often employed even though as many as 80% of AOM cases will spontaneously clear within 7-14 days when treated only with analgesia. Use of antibiotics increases the cure rate to about 94%.

Guidelines For The Use of Antibiotics For AOM
Pain & Confirmed AOM Pain & Unconfirmed AOM
< 6 mo Antibiotic therapy Antibiotic therapy
6 mo - 2 y/o Antibiotic therapy versus Observation

Antibiotics if:
* no improvement 48-72hrs
* Symptoms worsen
* Moderate to severe pain
* >39 C fever
Observation if:
* Follow-up treatment can be assured.
* Fever <39 C
* Pain mild

>2y Antibiotic therapy if severe illness; observation option possible if nonsevere illness Observation if:
* Follow-up treatment can be assured
* Fever <39 C
* Pain mild

Rocephin (ceftriaxone sodium)
FDA Warning

The drug must not be mixed or administered simultaneously with calcium-containing solutions or products, even via different infusion lines. Additionally, calcium-containing solutions or products must not be administered within 48-hours of the last administration of ceftriaxone.

Selecting an appropriate antibiotics will take into account the following factors:

  • History of allergy or intolerance to an antibiotic or class of antibiotics

  • Streptococcus pneumoniae is most likely the presumed causative organism in a child previously untreated for AOM

  • Antibiotic treatment within the last 30 days may indicate a resistant organism

  • Conjunctivitis/Otitis Syndrome may indicate Haemophilus influenzae infection

  • Compliance issues including taste, dosage regimens and cost.

The duration of antibiotic therapy is usually 10-14 days in length. Children <2 yrs. old have more difficulty clearing the disease and often fail even with a 14 day antibiotic course.

Streptococcus pneumoniae is a common pathogen associated with AOM. Amoxicillin is the initial treatment choice for S. pneumoniae in children who are not allergic to penicillin. For children who fail to improve, amoxicillin-clavulanate or a third generation cephalosporin are preferred second line choices.

For children allergic to penicillin or amoxicillin: Azithromycin or clarithromycin may be prescibed as alternative drugs.

If ß-lactamase-positive Haemophilus influenzae is suspected, amoxicillin/clavulanate is the treatment choice, because it is more effective then amoxicillin alone. (FYI, Clavulanate is a beta-lactamase inhibitor/deactivator that competitively binds with beta-lactamase, allowing more amoxicillin to avoid enzymatic degradation).

Otitis Media with Effusion

Most cases of OME resolve spontaneously. Studies have shown that between 27 and 50 % of effusions actually contain bacterial pathogens. Other studies indicate only a 14% improvement in the resolution of OME is gained by treating with antibiotics.

With this data in mind, a practitioner must weigh the small advantage gained by use of antibiotics over the potential harm cause by exposing a patient to the antibiotic. A recent study showed that children treated with antibiotics are at increased risk of becoming a carrier of drug resistant pneumococci.

It is important to remember that OME is most often a result of AOM. The fluid that remains is the result of the inflammatory process. It can take a long time to clear all the signs and symptoms of OME. If significant hearing loss persists bilaterally for 3 months or unilaterally for 6 months, referral to an ENT specialist may be appropriate.

If surgery is anticipated the CDC suggests that a single 10-14 day trial course of antibiotics can be offered when parents are resistant to surgical treatment.

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Antibiotic treatment is the suggested therapy for children <6 mo. old with AOM symptoms

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