Otitis Media
Pediatrics 2013; 131:e964-99.
- It is critical to distinguish between:
i) acute otitis media (AOM)
ii) myringitis
iii) otitis media with effusion (OME)
AOM:
- AOM is very common in young children. AOM presents with fever, irritability, and otalgia, with a bulging, inflamed tympanic membrane or new onset of otorrhea not due to acute otitis externa. (The redness and light reflex of a tympanic membrane are nonspecific and often misleading signs.) Acute inflammation with decreased mobility on pneumatoscopic exam confirms diagnosis of AOM. AOM does not always require antibiotics, providing good follow-up is provided.
- Adequate analgesia is essential and should be used for as long as needed whether antibiotic therapy is prescribed or not.
- Routine follow-up post-therapy is not necessary for asymptomatic patients. Three month follow-up post-AOM recommended to rule out persistent OME (occurs in 10-25% of children) and potential risk for hearing loss.
OME:
- OME is defined as fluid in the middle ear without signs or symptoms of acute infection of the eardrum.
- OME is common. Up to 40% of children will have an effusion for 1 month post AOM. Antibiotic therapy is not required.
- Prophylactic antibiotics not recommended for recurrent AOM.
- Prevention:
Handwashing
Breastfeeding for at least 6 months
Avoidance of environmental tobacco smoke
Avoidance of feeding in a supine, flat position
Decrease pacifier use in children ≥ 6 months old
Pneumococcal conjugate vaccine
Annual influenza vaccine
- Decongestants/antihistamines are not routinely recommended in the treatment of AOM (may be of benefit if allergic etiology).
- Adequate coverage of S. pneumoniae in AOM is essential. Amoxicillin provides the best coverage of all oral agents used for AOM.
- Use of pneumococcal vaccines has shifted etiology of AOM such that H. influenzae and M. catarrhalis are more prevalent. Hence, if failure of therapy with amoxicillin, coverage of these organisms is recommended.
Antibiotic Therapy
Amoxicillin
- Drug of choice in AOM as retains the best activity of all oral ß-lactam agents against S. pneumoniae, even majority of penicillin-resistant strains.
- No activity against β-lactamase (+) H. influenzae, M. catarrhalis
Amoxicillin-clavulanate
- Drug of choice for failure of high-dose amoxicillin, and used in combination with amoxicillin for high risk patients and those who have failed low dose amoxicillin.
- Activity against S. aureus, β-lactamase (+) H. influenzae and M. catarrhalis.
- 7:1 formulations (Clavulin-200 or Clavulin-400) allow for bid dosing, lower volume, and less diarrhea compared to 4:1 formulations (Clavulin-125F or Clavulin-250F).
Doxycycline
- Alternative agent for AOM in β-lactam allergic patients > 8 years of age.
- Increasing resistance of S. pneumoniae.
- Reasonable activity against S. aureus, and Group A Streptococcus.
- Good activity against H. influenzae and M. catarrhalis.
Cephalexin
- Not recommended in AOM
- No activity against Pen I/R S. pneumoniae.
- No activity against Haemophilus/Moraxella spp.
Cefaclor
- Not recommended in AOM.
- No activity against Pen I/R S. pneumoniae.
- Poor activity against Haemophilus influenzae, M. catarrhalis.
Cefuroxime axetil/Cefprozil
- Not routinely recommended in AOM, but may be used in penicillin allergic patients (clindamycin + cefixime provides better coverage of AOM pathogens).
- Poor activity against Pen I/R S. pneumoniae and M. catarrhalis.
- Increasing resistance of H. influenzae due to non-β-lactamase mechanism.
Cefixime
- Option in AOM but only in combination with clindamycin.
- No activity against Pen I/R S. pneumoniae.
- Excellent activity against Haemophilus spp/M. catarrhalis.
Ceftriaxone
- May be an option in high risk patients with penicillin allergy, or neonates.
NB: Ceftriaxone 50mg/kg IM/IV daily x 3 days recommended (single dose not as effective in eradicating penicillin resistant S. pneumoniae).
Clindamycin
- Option in AOM but only in combination with cefixime.
- Reasonable activity against S. pneumoniae.
- No activity against Haemophilus/Moraxella spp.
TMP/SMX
- Not recommended in AOM but may be considered for β-lactam allergic patients if local S. pneumoniae TMP/SMX resistance < 20%.
- Significant TMP/SMX resistance in S. pneumoniae and H. influenzae.
Macrolides: Azithromycin, Clarithromycin, Erythromycin
- Not recommended in AOM.
- Poor activity against Haemophilus influenzae.
- Significant macrolide resistance in S. pneumoniae and Group A Strep.
Levofloxacin
- Not approved for use in children nor recommended in AOM but may be only option in high risk patients with cephalosporin or severe penicillin allergy or patients who have failed amoxicillin plus amoxicillin-clavulanate regimen.
- Good activity against most AOM pathogens. S. aureus coverage not optimal.