Otitis Media ============ þ Do antibiotics help otitis media? - probably not [Del Mar C, Glasziou P, Hayem M. Are antibiotics indicated as initial treatment for children wiht acute otitis media? A meta-analysis. BMJ 1997;314:1526-9.] [Marchant CD, Carlin SA, Johnson CE, Shurin PA. Measuring the comparative efficacy of antibacterial agents for acut eotitis media: the "Polyanna phenomenon." J Pediatr 1992;120(1):72-7.] þ Drugs for Otitis Media - In adults, amoxicillin is best first line drug. - Study found that aspirates from adult otitis grew mostly amoxicillin-sensitive bugs: H. flu. (26%; 28% of the H. flu. had beta-lactamase; nontypable, won't be affected by HIB vaccinations.) Pneumococcus (26%) Moraxella catarrhalis (9%; had beta-lactamase) (70-90% resistant in another study) - Paper also argues against treating with antibiotics that don't hit H. flu (e.g., penicillin, erythro, cephalexin, TCN). [Celin, SE; Bluestone, CD, et al. Bacteriology of acute otitis media in adults. JAMA 1991;266(16):2249-2252.] - Though much of otitis (15%) is H. Flu or Moraxella Catarrhalis resistant to Amoxicillin, 70% will resolve spontaneously, so Amoxicillin is still a good drug. - 20-40% of European strep is resistant to Bactrim - Ceftin (cefuroxime) has good gram + coverage (like an oral ceftriaxone) - "We too recently recieved an 'alert' from our ID folks concerning penicillin resistant pneumoccocci. Two cases of resistant (pneumoccocal) meningitis have recently been identified at our institution. Many of these organisms are not only resistant to penicllin but to multiple other antibiotics as well (5). [Reichler MR, Rakovsky J, Sobotova A, Slacikova M, Hlavacova B, Hill B, Krajcikova L, Tarina P, Facklam RR, Breiman RF. Multiple antimicrobial resistance of pneumococci in children with otitis media, bacteremia, and meningitis in Slovakia. J Infect Dis 1995;171(6):1491-6.] Abstract: - Although a recent review (6) [Barnett ED, Klein JO. The problem of resistant bacteria for the management of acute otitis media. Pediatr Clin North Am 1995;42(3):509-17.] Abstract: advanced the proposition these organisms are uncommon enough (so far) that, at least for OM, amoxicillin is still considered to be the drug of choice. - "Based upon the recommendation (Antimicrobial Agents and Chemotherapy Oct. 1995) we have been advised to use ceftrioxone (100 mg/kg/d) or cefotaxime (200 mg/kg/d) (either drug) WITH vancomycin (60 mg/kg/d). (In adults the dosage is ceftrioxone 2 gr q 12 or cefotaxime 2 gr q 4 WITH vancomycin 30 mg/kg/d). These organisms are uniformly sensitive to vancomycin (8). [McCracken GH Jr. Emergence of resistant Streptococcus pneumoniae: a problem in pediatrics. Pediatr Infect Dis J 1995; 14(5):424-8.] Abstract: - "As far as OM is concerned several studies have documented the effectiveness of single dose (usually ceftrioxone) therapy (1,4) [Chamberlain JM, Boenning DA, Waisman Y, Ochsenschlager DW, Klein BL. Single-dose ceftriaxone versus 10 days of cefaclor for otitis media. Clin Pediatr 1994;33(11):642-6.] Abstract: [Green SM, Rothrock SG. Single-dose intramuscular ceftriaxone for acute otitis media in children [see comments]. Pediatrics 1993;91(1):23-30.] Abstract: - "Amoxicillin in a single dose of 100 mg/kg is apparantly not effective (3). [Puczynski MS, Stankiewicz JA, O'Keefe JP. Single dose amoxicillin treatment of acute otitis media. Laryngoscope 1987;97(1):16-8.] Abstract: Single dose ceftrioxone is also effective for preventing complications in children with fever and possible occult bacteremia (2). [Fleisher GR, Rosenberg N, Vinci R, Steinberg J, Powell K, Christy C, Boenning DA, Overturf G, Jaffe D, Platt R. Intramuscular versus oral antibiotic therapy for the prevention of meningitis and other bacterial sequelae in young, febrile children at risk for occult bacteremia [see comments]. J Pediatr (1994 Apr) 124(4):504-12.] Abstract: - "I'm not familiar with the no-dose treatment (references please) but infants with OM are probably excluded from this option (7). [Shapiro AM, Bluestone CD. Otitis media reassessed. Up-to-date answers to some basic questions. Postgrad Med 1995;97(5):73-6, 79-82. Abstract: - "I have been concerned about the potential for developing drug resistance particularly given our practice of freely prescibing antibiotics in the pediatric population. I am aware of at least one physician who simply prescibes antibiotics for any child under the age of two with fever even if no focal infection is identified and in the absence of laboratory findings consistant with a high risk of occult bacteremia. Just last week I saw an child who had been evaluated earlier that day in our fast track (by one of our ED physicians) who had been given a diagnosis of acute OM and discharged home on amoxicillin. His TMs were completely normal. Either the single dose oral antibiotic was remarkably effective or I examined the wrong patient. --H. Louzon MD I just reviewed yesterday the "Practice Guidelines for the Management of Infants and Children 0 to 36 Months of Age with Fever without Source" out of July 1993's Pediatrics. (an AHCPR-funded consensus paper from pediatrics, ID, and EM.) Typical stuff, but in it I was struck by a reference which I think indirectly addresses your 'prevention' question: "Recently, there have been two multicenter randomized, controlled trials comparing oral antibiotic therapy with ceftriaxone given intramuscularly for outpatient therapy of occult bacteremia...a meta-analysis that included these two recent studies demonstrated parenteral antibiotics to be significantly more effective than either no or oral antibiotic therapy in reducing the risk of subsequent bacterial meningitis. (footnote reference: Baraff LJ, Lee SI. Fever without source: management of children 3 to 36 months of age. Pediatr Infect Dis J. 1992;11:146-151) The mean probabilities of subsequent bacterial meningitis in a child with occult bacteremia were for no antibiotics, 9.8%; oral antibiotics, 8.2%; and parenteral antibiotics, 0.3%." þ Complications/Special Cases: - pseudomonas: - tympanocentesis: extreme pain, toxic, newborn, got OM on antibiotics, immunopsuppresed