Update on Otitis Media Treatment

ABSTRACT & COMMENTARY

Synopsis: An expert group convened by the Centers for Disease Control and Prevention addressed key questions related to treatment of otitis media in the current circumstances of increasing drug-resistant Streptococcus pneumoniae.

Source: Dowell SF, et al. Acute otitis media: Management and surveillance in an era of pneumococcal resistance—A report from the drug-resistant Streptococcus pneumoniae Therapeutic Working Group. Pediatr Infect Dis J 1999;18:1-9.

Published and unpublished data summarized from the scientific literature and from the experience of more than 30 experts provided consensus opinion on the following questions: 1) Which is the best initial agent for treatment of acute otitis media (AOM)? Amoxicillin should remain the first-line antimicrobial agent for treating AOM, at doses of 80-90 mg/kg/d; 2) What are suitable alternatives if amoxicillin fails? For patients with clinically defined treatment failure after three days of therapy, alternative agents include oral amoxicillin-clavulanate, cefuroxime axetil, and intramuscular ceftriaxone; 3) Should empirical treatment of AOM vary by geographic region? Local surveillance data of pneumococcal resistance that are relevant for the clinical management of AOM are not available from most areas in the United States.

Comment by Hal B. Jenson, MD, FAAP

The management of otitis media has entered a new era with the increasing prevalence of drug-resistant Streptococcus pneumoniae. This organism causes 40-50% of all cases of AOM, with reduced susceptibility to penicillin in 8-35% (2-4% highly resistant) of isolates and reduced susceptibility to third-generation cephalosporins in 10% of isolates (about 4% highly resistant); the reduced antibiotic susceptibilities occur independently. The recommendations of this group provide a framework for appropriate management of AOM in 1999.

There is no single oral antimicrobial that eradicates all AOM pathogens. Amoxicillin at higher doses of 80-90 mg/kg/day which achieves the higher middle ear fluid concentrations necessary to treat resistant S. pneumoniae, is effective as a first choice. There are surprisingly (at least to me) few adverse events even at these higher doses, and amoxicillin is inexpensive compared to many of the alternatives. There are compelling data for cefuroxime axetil (Ceftin) and amoxicillin-clavulanate (Augmentin) orally, and ceftriaxone (Rocephin) intramuscularly, as second-line drugs for treatment failure, which is defined as ear pain, fever, or bulging tympanic membrane or otorrhea after three days of therapy. (Persisting middle ear fluid is found in 70% of children at 10 days and, in the absence of specific evidence of ongoing infection, does not represent treatment failure.) However, many of the 13 other drugs approved by the Food and Drug Administration lack good evidence for efficacy against drug-resistant S. pneumoniae. There are promising but insufficient data at this time to recommend cefpodoxime (Vantin) and cefprozil (Cefzil), but many of the traditional second-line drugs should now be considered ineffective for AOM. These include trimethoprim-sulfamethoxazole and erythromycin-sulfisoxazole, which have traditionally been used for AOM, and the newer macrolides, clarithromycin and azithromycin, which initially showed promise. Some of these other drugs may be useful for selected cases based on susceptibility testing of middle ear fluid isolates obtained by tympanocentesis.

The increasing frequency of drug-resistant pneumococci further increases the urgency of the release of a conjugated pneumococcal vaccine that may be effective in preventing the 40% of infantile otitis media that are now caused by S. pneumoniae, especially drug-resistant strains.