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Middle Ear, Acute Otitis Media, Medical Treatment: Treatment & Medication
Updated: Sep 28, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
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Treatment
Medical Care
AOM has been described as a self-limiting disease provided the patient does not develop a complication. This is an old reference, but in the new millennium, practitioners are forced to observe the lessons of history because these may serve as our models of life without effective antimicrobial agents. Presently, a chorus of advocates recommends withholding antibiotic therapy for patients with AOM under terms such as watchful waiting or wait-and-see. As expected from long-known data, most of these children do well, but a recent study from England observes that the rate of mastoiditis increased in children at a rate that is, essentially, the inverse of the decrease in prescriptions for acute otitis.
Despite these advocates, the overwhelming consensus remains that antibiotics are the initial therapy of choice for AOM for 3 very valid reasons. First, after the institution of antibiotic therapy, a marked decline in the suppurative complications of AOM is noted. Second, practitioners cannot predict with certainty which patients will develop complications. Third, studies have demonstrated that the use of antibiotics improves patient outcomes in both the early and late phases of AOM.
Recently, some order has been brought to the discussions of antibiotic use under the auspices of the Centers for Disease Control and Prevention and by the Agency for Health Care Policy and Research, both agencies of the US government. The Centers for Disease Control and Prevention published 6 principles of appropriate antibiotic use in an attempt to bring precepts of good public health and responsible therapy to the discussion while minimizing the selection of resistant strains of bacteria within the community. These principles are listed below.
- Principles for judicious use of antimicrobials in the treatment of AOM
- Classify episodes of OM as AOM or OME.
- Antimicrobials are indicated for treatment of AOM; however, diagnosis requires documented middle ear effusion and signs or symptoms of acute local or systemic illness.
- Uncomplicated AOM may be treated with a 5- to 7-day course of antimicrobials in certain patients older than 2 years.
- Antimicrobials are not indicated for the initial treatment of OME; treatment may be indicated if effusions persist for longer than 3 months.
- Persistent OME after therapy for AOM is expected and does not require re-treatment with antimicrobials.
- Reserve antimicrobial prophylaxis for controlling recurrent AOM, defined as 3 or more distinct, well-documented episodes in 6 months or 4 or more episodes in 12 months.
- Antibiotic therapy
- Selection of an antibiotic, in the absence of culture results obtained from tympanocentesis, should have 2 objectives. First, the antibiotic should cover most of the common bacterial pathogens detailed earlier in this article. Second, the antibiotic must be individualized for the child with regard to allergy, tolerance, previous exposure to antibiotics, cost, and community resistance levels.
- The duration of therapy is also somewhat empiric, and data indicate that significant numbers of children do not receive prescribed antibiotics beyond relief of acute symptoms. Ten to 14 days of therapy has been traditional and is convenient for office scheduling, but it may not necessarily be more efficacious than 5 days of therapy, or even 2 days.
- Studies have demonstrated that short-duration therapy may not be appropriate in children younger than 2 years who appear prone to failure even after 14 days of therapy. Mandel showed that when an effusion-free ear is the prime objective, 20 days of antibiotic therapy achieves improved outcomes versus 10 days of therapy or placebo. However, after 90 days, no difference in the groups existed and recurrence was not prevented by the additional therapy.
- The administration of prescribed antimicrobials may differ from recommendations for the same antibiotic when used for soft tissue infections.
- Pulse-dosing antibiotics, when administered for infections of hollow organs, such as the ear or sinuses, appear to have efficacy due to poorly understood antimicrobial mechanisms, increased compliance on the part of the patient or parent, and slower penetration into and removal from middle ear effusion.
- Subminimal serum levels of antibiotics have been shown to disrupt adhesive bonds between bacteria and mucosal cell walls and to provide a postantibiotic effect, in which the reproduction of bacteria is disrupted for a period of hours after exposure to antibiotics. Similarly, a leukocyte-enhancing action has been demonstrated at these low concentrations. When used in this manner, a marked variation in the effectiveness of individual antibiotics and susceptibility for the various etiologic agents exists.
- Generally, beta-lactam antibiotics are most successful against gram-positive pathogens for both disruption of adhesion and postantibiotic effect.
- Amoxicillin (erythromycin/sulfisoxazole in patients who are allergic to penicillin) remains the initial treatment of choice in children with AOM.
- With the emergence of resistant strains, the practitioner may need to select an alternative antimicrobial therapy from either a broad-spectrum beta-lactamase–resistant cephalosporin or a combination drug such as amoxicillin-clavulanate or trimethoprim-sulfamethoxazole. Combination therapy may help prevent the emergence of resistance by mutation, provided the pathogen is initially sensitive to both components. Efficacy and dosages for selected antimicrobials are provided in the Medication section.
- With the emergence of multidrug-resistant S pneumoniae (MDRSP), oral therapy consisting of amoxicillin and amoxicillin-clavulanate may have efficacy when the total amoxicillin dose reaches 80-100 mg/kg/d.
- If a child does not respond to an antibiotic within 48 hours and concurrently develops local and systemic signs of toxicity, this may indicate resistance to the selected drug. Treatment options include an empirical change of antimicrobial agent or a drainage procedure with culture. Failure to improve with antibiotic therapy may indicate coexistent viral infection in children with prolonged acute symptoms.
- Other medical therapies
- Analgesics and antipyretics have a definite role in the symptomatic management of AOM.
- Decongestants and antihistamines do not appear to have efficacy either early or late in the acute process, although they may relieve coexistent nasal symptoms.
- Systemic steroids have no demonstrated role in the acute phase.
Surgical Care
Tympanocentesis and myringotomy are the procedures used to treat AOM.
- Tympanocentesis, in its purest form, is a diagnostic procedure that gives the clinician access to acute or chronic middle ear effusions for culture and other evaluations.
- Generally, perform tympanocentesis without anesthesia, after sterilization of the ear canal with isopropyl alcohol or povidone-iodine solution (Betadine). Insert a needle through the anterior portion of the tympanic membrane, and aspirate the contents of the middle ear into a sterile trap for identification of microbes and their properties.
- Consider tympanocentesis in (1) children who are immunosuppressed or immunocompromised, (2) neonates with AOM (they are more likely to have an unusual or more invasive pathogen), (3) patients in whom antimicrobial therapy has failed and who continue to experience local or systemic signs of sepsis, and (4) patients who have had a complication of AOM in conjunction with attempts to recover the etiological agent from other sites (eg, cerebrospinal fluid, blood).
- Additionally, tympanocentesis remains a valuable research tool in the evaluation of new antimicrobial agents for efficacy in AOM and for identification of host defense mechanisms or flaws in the middle ear immunochemistry.
- A tympanocentesis may be converted to a myringotomy and become therapeutic by enlarging the hole in the tympanic membrane, often by spreading the edges with microalligator forceps or suction tip. Instilling antibiotic drops and suctioning the middle ear are possible through the myringotomy. Typically, the patient experiences prompt relief of local symptoms. Culture results must be obtained before extension of the incision.
- The use of a carbon dioxide laser in myringotomy on children with AOM has been promoted widely and directly to the consumer by the manufacturers of these instruments; proponents claim to have ushered in a new treatment for AOM without the use of antimicrobials. While undoubtedly a boon to the otolaryngologist who is less technically adept, emerging studies demonstrate little or no change in efficacy over standard myringotomy.
- If the patient has a suppurative complication of the temporal bone and requisite prolonged drainage seems likely, the insertion of a tympanostomy tube may be needed. In most instances, general anesthesia or sedation is necessary in older children because topical anesthesia is relatively ineffective in acutely inflamed tympanic membranes. With increasing antimicrobial resistance, surgical intervention in the form of tympanostomy tube placement can be expected to increase in the coming years, after having fallen into disfavor in the past 2 decades when resistance was less of a factor. In the author's practice, children younger than 15 months and those who attend day care centers are most likely to require surgery.
Consultations
Consultation is seldom necessary, although some otolaryngologists might be more comfortable having the pediatrician provide all the primary care.
Medication
Antibiotics are the only medications with demonstrated efficacy in the management of AOM. Most antibiotics can be administered once or twice daily to improve compliance and to avoid the necessity of sending medication to school or day care centers. The following list excludes medications that have reduced activity against common pathogens or that have significant adverse effects without other redeeming features to warrant inclusion.
Antibiotics
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.
Amoxicillin (Amoxil, Trimox, Wymox)
DOC for management of AOM. Interferes with synthesis of cell wall mucopeptides during active multiplication, resulting in bactericidal activity against susceptible bacteria.
Adult
250-500 mg PO q8h
Pediatric
90 mg/kg/d PO q8-12h for all initial therapy for AOM
Reduces efficacy of oral contraceptives
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal impairment; may enhance risk of candidiasis
Amoxicillin/clavulanate (Augmentin)
Combination drug that includes a blocking agent (clavulanic acid).
Adult
250-500 mg amoxicillin with 62.5-125 mg clavulanate PO q8h
Pediatric
90 mg/kg/d PO of Amoxicillin component for recurrent AOM
Coadministration with warfarin or heparin increases risk of bleeding
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Give for a minimum of 10 d to eliminate organism and prevent sequelae (eg, endocarditis, rheumatic fever); following treatment, perform cultures to confirm eradication of streptococci
Erythromycin ethylsuccinate/sulfisoxazole (E.E.S. 400)
Doses supplied in 200 mg/5 mL (erythromycin) and 600 mg/5 mL (sulfisoxazole). Widely used for individuals who are penicillin-sensitive. Well absorbed from GI tract but best administered on full stomach to avoid GI upset.
Adult
Not used
Pediatric
50 mg/kg/d of erythromycin component divided PO q8-12h
Coadministration may increase toxicity of theophylline, digoxin, carbamazepine, and cyclosporine; may potentiate anticoagulant effects of warfarin; coadministration with lovastatin and simvastatin increases risk of rhabdomyolysis
Documented hypersensitivity; hepatic impairment
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in liver disease; estolate formulation may cause cholestatic jaundice; adverse GI effects are common (give doses pc); discontinue use if nausea, vomiting, malaise, abdominal colic, or fever occur
Trimethoprim/sulfamethoxazole (Bactrim, Bactrim DS, Septra, Septra DS)
Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid.
Adult
160 mg TMP with 800 mg SMZ PO bid
Pediatric
8 mg/kg TMP with 40 mg/kg SMZ PO divided q12h
May increase PT when used with warfarin (perform coagulation tests and adjust dose accordingly); coadministration with dapsone may increase blood levels of both drugs; coadministration of diuretics increases incidence of thrombocytopenia purpura in elderly persons; phenytoin levels may increase with coadministration; may potentiate effects of methotrexate in bone marrow depression; hypoglycemic response to sulfonylureas may increase with coadministration; may increase levels of zidovudine
Documented hypersensitivity; megaloblastic anemia due to folate deficiency
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Discontinue at first appearance of skin rash or sign of adverse reaction; obtain CBC counts frequently; discontinue therapy if significant hematologic changes occur; goiter, diuresis, and hypoglycemia may occur with sulfonamides; prolonged IV infusions or high doses may cause bone marrow depression (if signs occur, give 5-15 mg/d leucovorin); caution in folate deficiency (eg, chronic alcoholism, elderly persons, those receiving anticonvulsant therapy, those with malabsorption syndrome); hemolysis may occur in persons with G-6-PD deficiency; AIDS patients may not tolerate or respond to TMP-SMZ; caution in renal or hepatic impairment (perform urinalyses and renal function tests during therapy); give fluids to prevent crystalluria and stone formation
Cefixime (Suprax)
By binding to one or more of the penicillin-binding proteins, arrests bacterial cell wall synthesis and inhibits bacterial growth.
Adult
400 mg PO qd or divided bid
Pediatric
8 mg/kg PO qd or divided bid
Coadministration of aminoglycosides increase nephrotoxicity; probenecid may increase effects
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal impairment
Cefuroxime Axetil (Ceftin)
Second-generation cephalosporin that maintains gram-positive activity of first-generation cephalosporins; adds activity against Proteus mirabilis, H influenzae, E coli, Klebsiella pneumoniae, and M catarrhalis.
Condition of patient, severity of infection, and susceptibility of microorganism determine proper dose and route of administration.
Adult
250-500 mg PO q12h
Pediatric
15-30 mg/kg/d PO divided q12h
Disulfiramlike reactions may occur when alcohol is consumed within 72 h of administration; may increase hypoprothrombinemic effects of anticoagulants; may increase nephrotoxicity in patient receiving potent diuretics (eg, loop diuretics); coadministration with aminoglycosides increase nephrotoxic potential
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Administer half dose if creatinine clearance is 10-30 mL/min and one-quarter dose if <10 mL/min; fungal and microorganism overgrowth may occur with prolonged therapy
Cefprozil (Cefzil)
Binds to one or more of the penicillin-binding proteins, which, in turn, inhibits cell wall synthesis and results in bactericidal activity.
Adult
250-500 mg PO q12h
Pediatric
15-30 mg/kg/d PO divided q12h
Probenecid increases effect; coadministration with furosemide and aminoglycosides increases nephrotoxic effects
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dosage in renal impairment
Cefpodoxime (Vantin)
Indicated for management of infections caused by susceptible mixed aerobic-anaerobic microorganisms.
Adult
100-200 mg PO q12h
Pediatric
10 mg/kg/d PO divided q12h
Alcoholic beverages consumed <72 h after administration may produce disulfiramlike reactions; may increase hypoprothrombinemic effects of anticoagulants; coadministration with potent diuretics (eg, loop diuretics) and aminoglycosides may increase nephrotoxicity
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Reduce dosage by half if creatinine clearance is 10-30 mL/min and by three quarters if <10 mL/min; bacterial or fungal overgrowth of nonsusceptible organisms may occur with prolonged or repeated therapy
Cefdinir (Omnicef)
Third-generation cephalosporin indicated for treatment of uncomplicated skin infections.
Adult
600 mg PO qd or divided bid
Pediatric
14 mg/kg PO qd or divided bid
May increase hypoprothrombinemic effects of anticoagulants; coadministration with potent diuretics (eg, loop diuretics) and aminoglycosides may increase nephrotoxicity
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Reduce dosage by half if creatinine clearance is 10-30 mL/min and by one quarter <10 mL/min; bacterial or fungal overgrowth of nonsusceptible organisms may occur with prolonged or repeated therapy
Clindamycin (Cleocin HCl)
Lincosamide for treatment of serious skin and soft tissue staphylococcal infections. Also effective against aerobic and anaerobic streptococci (except enterococci). Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes, causing RNA-dependent protein synthesis to arrest.
Adult
600-1800 mg/d PO divided q6-8h
Pediatric
10-25 mg/kg/d PO divided q6-8h
Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects; antidiarrheals may delay absorption
Documented hypersensitivity, blood dyscrasias
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis by allowing overgrowth of Clostridium difficile
Clarithromycin (Biaxin)
Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes, causing RNA-dependent protein synthesis to arrest.
Adult
250-500 mg PO q12h
Pediatric
15 mg/kg/d PO divided q12h
Toxicity increases with coadministration of fluconazole and pimozide; effects decrease and adverse GI effects may increase with coadministration of rifabutin or rifampin; may increase toxicity of anticoagulants, cyclosporine, tacrolimus, digoxin, omeprazole, carbamazepine, ergot alkaloids, triazolam, and HMG CoA-reductase inhibitors
Plasma levels of certain benzodiazepines may increase, prolonging CNS depression; arrhythmias and increase in QTc intervals occur with disopyramide; coadministration with omeprazole may increase plasma levels of both agents
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Coadministration with ranitidine or bismuth citrate not recommended with CrCl <25 mL/min; give half dose or increase dosing interval if CrCl <30 mL/min; diarrhea may be sign of pseudomembranous colitis; superinfections may occur with prolonged or repeated antibiotic therapies
Azithromycin (Zithromax)
Broad-spectrum macrolide antibiotic. Absorption markedly reduced when taken with food.
Adult
500 mg on day 1; then 250 mg/d on days 2-5
Pediatric
10 mg/kg on day 1; then 5 mg/kg on days 2-5
May increase toxicity of theophylline, warfarin, and digoxin; effects are reduced with coadministration of aluminum and/or magnesium antacids; nephrotoxicity and neurotoxicity may occur when coadministered with cyclosporine
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Site reactions can occur with IV route; bacterial or fungal overgrowth may result with prolonged antibiotic use; may increase hepatic enzymes and cholestatic jaundice; caution in patients with impaired hepatic function, prolonged QT intervals, or pneumonia; caution in hospitalized, geriatric, or debilitated patients
Ceftriaxone (Rocephin)
Third-generation cephalosporin. Manufacturer has heavily promoted IM use of this drug to physicians and directly to the public for routine treatment of AOM. Subsequently, MDRSP resistance has emerged, making this less effective in many communities. Author believes this drug is best reserved for IV use for management of severe infections. Avoid widespread use for AOM.
Adult
1-2 g/d IM for 3 d
Pediatric
50 mg/kg/d IM for 3 d
Probenecid may increase levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal impairment; caution in breastfeeding and allergy to penicillin
More on Middle Ear, Acute Otitis Media, Medical Treatment |
| Overview: Middle Ear, Acute Otitis Media, Medical Treatment |
| Differential Diagnoses & Workup: Middle Ear, Acute Otitis Media, Medical Treatment |
 Treatment & Medication: Middle Ear, Acute Otitis Media, Medical Treatment |
| Follow-up: Middle Ear, Acute Otitis Media, Medical Treatment |
| Multimedia: Middle Ear, Acute Otitis Media, Medical Treatment |
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Further Reading
Clinical guidelines
Cincinnati Children's Hospital Medical Center. Evidence based clinical practice guideline for medical management of acute otitis media in children 2 months to 13 years of age. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2004 Oct. 16 p.
University of Michigan Health System (UMHS). Otitis media. Ann Arbor (MI): University of Michigan Health System (UMHS); 2007 July. 12 p.
Keywords
acute otitis media, AOM, OM, acute suppurative otitis media, acute otitis, otitis media with effusion, OME, chronic otitis media, COM, ear infection, ear ache, eustachian tube destruction, upper respiratory infection, URI, upper respiratory tract infection, URTI, bacterial ear infection, viral ear infection, Streptococcus pneumoniae, S pneumoniae, Haemophilus influenzae, H influenzae, Moraxella catarrhalis, M catarrhalis, Streptococcus pyogenes, S pyogenes, Staphylococcus aureus, S aureus, Streptococcus viridans, S viridans, Pseudomonas aeruginosa, P aeruginosa, staph infection, strep infection, otorrhea, ear bacteremia, middle ear effusion, otalgia, ear tugging, tympanocentesis, myringotomy
