Mastoiditis Medication

The principal medications used in the treatment of mastoiditis are antibiotics. Other medications include analgesics, antipyretics, and topical antibiotic-steroid combinations.

If open mastoid surgery is not undertaken, use of single, high-dose intravenous (IV) steroids is warranted to decrease mucosal swelling and promote natural drainage through the aditus ad antrum into the middle ear.

A study done by Roddy et al showed that in the post-pneumococcal vaccine era, ceftriaxone nonsusceptibility was seen in 30% of post-pneumococcal conjugate vaccine S pneumoniae isolates, compared with 7% of pre-pneumococcal conjugate vaccine isolates.^[10] We can conclude that ceftriaxone alone is insufficient for empiric antimicrobial therapy in the post-pneumococcal conjugate vaccine era.

Class Summary

Culture and sensitivity results ultimately govern the selection of specific antibiotic agents. A third-generation cephalosporin or the combination of a penicillinase-resistant penicillin and an aminoglycoside is recommended. If a patient is allergic to penicillin (history of anaphylaxis), clindamycin can be considered instead. If a Pseudomonas species is suspected, an antipseudomonal penicillin should be used.

Until microbiologic information is available, the following principles should guide antibiotic selection: (1) the antimicrobial must be appropriate to cover the most common invasive strains of bacteria in acute otitis media (AOM), (2) the selected antibiotic should cross the blood-brain barrier, and (3) the selected therapeutic spectrum should include consideration of MDRSP organisms that are prevalent in the individual's community. Coverage for anaerobic bacteria, as well as gram-negative aerobic bacteria and S aureus including methicillin-resistant S aureus, are important in chronic mastoiditis.

After identification of the organism, antibiotic coverage can be narrowed. Patients should be afebrile for 48 hours before intravenous antibiotics are discontinued. Oral antibiotics should then be administered for an additional 14 days.

Linezolid (Zyvox)

Culture and sensitivity results ultimately govern the selection of specific antibiotic agents. A third-generation cephalosporin or the combination of a penicillinase-resistant penicillin and an aminoglycoside is recommended. If a patient is allergic to penicillin (history of anaphylaxis), clindamycin can be considered instead. If a Pseudomonas species is suspected, an antipseudomonal penicillin should be used.

Until microbiologic information is available, the following principles should guide antibiotic selection: (1) the antimicrobial must be appropriate to cover the most common invasive strains of bacteria in acute otitis media (AOM), (2) the selected antibiotic should cross the blood-brain barrier, and (3) the selected therapeutic spectrum should include consideration of MDRSP organisms that are prevalent in the individual's community. Coverage for anaerobic bacteria, as well as gram-negative aerobic bacteria and S aureus including methicillin-resistant S aureus, are important in chronic mastoiditis.

After identification of the organism, antibiotic coverage can be narrowed. Patients should be afebrile for 48 hours before intravenous antibiotics are discontinued. Oral antibiotics should then be administered for an additional 14 days.

Cefepime (Maxipime)

Cefepime is a fourth-generation cephalosporin. It has gram-negative coverage comparable to that of ceftazidime but has better gram-positive coverage (comparable to that of ceftriaxone). Cefepime is a zwitter ion; it rapidly penetrates gram-negative cells. This agent is the best beta-lactam for intramuscular administration. Cefepime's poor capacity to cross the blood-brain barrier precludes the drug's use for the treatment of meningitis.

Vancomycin (Vancocin)

Because an increasing proportion of invasive strains of S pneumoniae are multidrug-resistant and owing to the increased role of methicillin-resistant S aureus, beginning therapy with vancomycin is appropriate. After surgical or culture and sensitivity results confirm pathogenic sensitivity to other medications, medications that do not require the same degree of monitoring may be used instead. In patients with sensitivity to vancomycin, high-dose ceftriaxone or cefotaxime may be used. Rifampin is also effective in managing MDRSP.

Ceftriaxone (Rocephin)

Ceftriaxone is a third-generation cephalosporin; it arrests bacterial growth by binding to 1 or more penicillin-binding proteins. Initiate ceftriaxone treatment with a high dose to adequately treat potential penicillin-resistant pneumococcal infection. Ceftriaxone has a broad gram-negative spectrum, lower efficacy against gram-positive organisms, and higher efficacy against resistant organisms.

Meropenem (Merrem)

Meropenem is a bactericidal, broad-spectrum carbapenem antibiotic that inhibits cell-wall synthesis. It is effective against most gram-positive and gram-negative aerobic and anaerobic bacteria. Meropenem has slightly increased activity against gram-negative organisms and slightly decreased activity against staphylococci and streptococci, compared with imipenem.

Clindamycin (Cleocin)

Because an increasing proportion of invasive strains of S pneumoniae are multidrug-resistant and because of the increased role of methicillin-resistant S aureus, beginning therapy with clindamycin is appropriate. This agent is a lincosamide that is effective against S aureus, aerobic streptococci (except enterococci), and anaerobic bacteria. It inhibits bacterial growth, possibly by blocking dissociation of peptidyl transfer ribonucleic acid (tRNA) from ribosomes, causing RNA-dependent protein synthesis to arrest.

Piperacillin and tazobactam sodium (Zosyn)

This drug combination consists of an antipseudomonal penicillin plus a beta-lactamase inhibitor and is effective against aerobic and anaerobic gram-positive and gram-negative bacteria. It inhibits biosynthesis of cell-wall mucopeptide and is effective during the stage of active multiplication.

Oxacillin

Oxacillin is a bactericidal antibiotic that inhibits cell-wall synthesis; it is used in the treatment of infections caused by penicillinase-producing staphylococci. Oxacillin may be used to initiate therapy when a staphylococcal infection is suspected. It should be employed in combination with an aminoglycoside.

Class Summary

After a tympanostomy tube is placed, with or without mastoidectomy, a pH-balanced solution or suspension of an antibiotic and a corticosteroid is useful to decrease mucosal swelling and to deliver topical antibiotics to the middle ear and mastoid. The drops should be continued until otorrhea has ceased and the view through the tube shows healing mucosa without swelling or obstruction. Several combinations are available; the best are those thin enough to apply through the tube into the middle ear.

Hydrocortisone/neomycin/polymyxin otic (Cortisporin Otic Suspension, Cortomycin)

This is an antibacterial and anti-inflammatory suspension for otic use. It is used to treat superficial bacterial infections in the external auditory canal.

Dexamethasone/tobramycin (TobraDex, TobraDex ST)

Tobramycin interferes with bacterial protein synthesis by binding to 30S and 50S ribosomal subunits, which results in a defective bacterial cell membrane. Dexamethasone decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and reducing capillary permeability. Sterile ophthalmic drops are also commonly used for otic infections.

Gentamicin/betamethasone (Garasone)

This is a sterile ophthalmic solution available only in Canada. It is commonly used for otic infections. Gentamicin is an aminoglycoside antibiotic used for gram-negative bacterial coverage. Betamethasone decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reducing capillary permeability.

Class Summary

These agents may be considered following tympanostomy tube placement to treat acute or chronic otitis media.

Ofloxacin otic solution

This inhibits bacterial growth by inhibiting deoxyribonucleic acid (DNA) gyrase.

Class Summary

These agents are used for patient comfort.

Acetaminophen (Tylenol, Acephen, Feverall, Cetafen)

Acetaminophen is the drug of choice for treatment of pain in patients with documented hypersensitivity to aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) and in patients diagnosed with upper GI disease or who are taking oral anticoagulants. It reduces fever by direct action on hypothalamic heat-regulating centers, which increases dissipation of body heat via vasodilation and sweating.