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.

Please note that the following guidelines are directed toward treatment of the otherwise healthy child and not those children who are immunocompromised or have craniofacial or neurologic abnormalities.

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.

 

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