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Otitis Media Treatment in the Era of Antibiotic Resistance



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Am Fam Physician. 2003 Mar 15;67(6):1343-1344.

Otitis media, the most common reason for prescribing antibiotics in children, figures prominently in the problem of antibiotic resistance. Hendley reviews the modern management of otitis media in children and provides his personal clinical recommendations for rational use of antibiotics.

Middle ear infections typically occur during a viral upper-respiratory infection. The eustachian tube becomes inflamed and dysfunctional, allowing fluid to accumulate in the middle ear. This fluid becomes a ripe medium for further infection. The usual infectious culprits, which occur in about equal proportions, include the viruses, and Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis.

Both middle ear inflammation and fluid accumulation are required for a diagnosis of acute otitis media. Retraction of the tympanic membrane signifies eustachian tube dysfunction and negative middle ear pressure but not bacterial infection. Bacterial otitis media produces a bulging tympanic membrane with purulent fluid behind it. The most common clinical presentation of acute otitis media is erythema of the eardrum without bulging, accompanied by other evidence of infection, such as fever, ear pain, and cold symptoms.

The usefulness of antibiotics in the treatment of ear infections has been widely investigated. A meta-analysis found that antibiotics improved resolution of otitis media at one week post-treatment by 13 percent (94 percent resolution for treatment versus 81 percent for placebo). Most analyses also have shown modest reductions in clinical symptoms after the first three to five days of antibiotic use compared with placebo.

Despite the well documented in vitro resistance to penicillin among the usual ear pathogens, no drug has been proved superior to amoxicillin for promoting resolution of bacterial ear infections. The author advocates a delayed antibiotic strategy to minimize unnecessary prescriptions for otitis media, such as is commonly practiced in the Netherlands (see accompanying table). In this approach, acetaminophen is used for fever and pain; antibiotics are withheld unless clinical symptoms fail to improve within two to three days from the onset of the ear infection. Clinical trials have shown that this tactic leads to use of an antibiotic prescription in only 31 percent of acute otitis media cases.

Recommendations for the Treatment of Otitis Media

Condition Treatment

Otitis media with bulging tympanic membrane

Immediate treatment with high-dose amoxicillin (80to 100 mg per kg of body weight per day orally) for 7 days*

Otitis media without bulging tympanic membrane

Delayed antibiotic-prescribing strategy†

Recurrent acute otitis media

Delayed antibiotic-prescribing strategy†

Immunization with influenza vaccine

Resistant bacterial otitis

High-dose amoxicillin–clavulanate potassium (80 to 100 mg of amoxicillin per kg of body weight per day orally) for 7 days, cefuroxime axetil (30 mg per kg twice a day orally) for 7 days, or ceftriaxone (50 mg per kg per day intramuscularly) for 3 days


*— In children who are allergic to penicillin, preferred alternatives include cefuroxime axetil or another second-generation cephalosporin (other than cefaclor, which may cause a serum-sickness–like reaction), azithromycin, or ceftriaxone (50 mg per kg of body weight once).

†— The delayed antibiotic-prescribing strategy is as follows: initiate treatment with full-dose acetaminophen; provide a prescription for amoxicillin to be used only if otalgia or fever persists or if there is no clinical improvement after 48 to 72 hours; advise the patient’s parents that antibiotics do not work very well against otitis media and have virtually no effect during the first 24 hours; explain the disadvantages of antibiotics to patient’s parents (they may have side effects such as diarrhea and rash); and select for resistant bacteria.

Adapted with permission from Hendley JO. Otitis media. N Engl J Med 2002;347:1171.

Recommendations for the Treatment of Otitis Media

View Table

Recommendations for the Treatment of Otitis Media

Condition Treatment

Otitis media with bulging tympanic membrane

Immediate treatment with high-dose amoxicillin (80to 100 mg per kg of body weight per day orally) for 7 days*

Otitis media without bulging tympanic membrane

Delayed antibiotic-prescribing strategy†

Recurrent acute otitis media

Delayed antibiotic-prescribing strategy†

Immunization with influenza vaccine

Resistant bacterial otitis

High-dose amoxicillin–clavulanate potassium (80 to 100 mg of amoxicillin per kg of body weight per day orally) for 7 days, cefuroxime axetil (30 mg per kg twice a day orally) for 7 days, or ceftriaxone (50 mg per kg per day intramuscularly) for 3 days


*— In children who are allergic to penicillin, preferred alternatives include cefuroxime axetil or another second-generation cephalosporin (other than cefaclor, which may cause a serum-sickness–like reaction), azithromycin, or ceftriaxone (50 mg per kg of body weight once).

†— The delayed antibiotic-prescribing strategy is as follows: initiate treatment with full-dose acetaminophen; provide a prescription for amoxicillin to be used only if otalgia or fever persists or if there is no clinical improvement after 48 to 72 hours; advise the patient’s parents that antibiotics do not work very well against otitis media and have virtually no effect during the first 24 hours; explain the disadvantages of antibiotics to patient’s parents (they may have side effects such as diarrhea and rash); and select for resistant bacteria.

Adapted with permission from Hendley JO. Otitis media. N Engl J Med 2002;347:1171.

Prevention rather than treatment of this common condition would be ideal, but the author notes that limited means are available to accomplish this. Influenza vaccination decreases episodes of acute otitis media only when influenza is epidemic. Pneumococcal vaccination produces a small decrease in rates of otitis media.

Hendley JO. Otitis media. N Engl J Med. October 10 2002;347:1169–74.


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