Controversy about appropriate antibiotics, length of treatment and whether to treat acute otitis media continues. In addition, when antibiotic therapy has been chosen as the most appropriate course and a primary treatment failure occurs, the choice for repeat treatment may not be clear. Hueston and colleagues reviewed the antibiotics being used in these cases and evaluated reports to see which medications were most likely to be effective and result in fewer treatment failures.

The medical records of children younger than 12 years with otitis media were reviewed. The patients who returned within 45 days of the initial diagnosis for otitis media and received a new prescription for an antibiotic were classified as primary treatment failures. Those with primary treatment failure were reviewed to determine which of these children subsequently had a 90-day period without otitis media, followed by a new diagnosis of otitis media. The antibiotic used in the final episode of otitis media was recorded, as was the medication chosen for the first episode. First-line drugs were amoxicillin, ampicillin, penicillin and trimetho-prim-sulfamethoxazole. All other drugs were considered second-line medications.

A total of 7,807 children were diagnosed with otitis media. Of these, 1,416 patients (18 percent) were classified as having a primary treatment failure. Subsequently, 343 patients were seen for recurrent otitis media occurring at least 90 days after the primary treatment failure. A first-line medication was prescribed in 69 percent of these cases. Second-line antibiotics were more likely to be used if the recurrence occurred soon after the treatment failure. Rates of failure were similar for first-and second-line antibiotics (13 percent vs. 19 percent, respectively).

The authors conclude that there is no benefit to choosing a second-line antibiotic (a broad-spectrum antibiotic) when otitis media recurs following a treatment failure. When a child presents with a recurrence of otitis media after a presumed treatment failure, amoxicillin, ampicillin or trimethoprim-sulfa-methoxazole are reasonable treatment choices that will be less costly, just as effective and less likely to cause resistant strains of micro-organisms than would use of broad-spectrum agents.