New evolving strategies for the management of acute otitis media

Abstract

In these times of increasing antibiotic resistance among community-acquired bacterial organisms, efforts are urgently needed to limit the widespread overuse of antibiotics (1). Furthermore, the dramatic emergence of multiple drug-resistant Streptococcus pneumoniae (DRSP) has forced the management of otitis media to enter a new era. Acute otitis media (AOM) remains the primary reason for prescribing antibiotics to children, despite meta-analyses confirming that antibiotics may not be necessary for the treatment of uncomplicated AOM. There is good evidence that AOM resolves in 95% of recipients treated with antibiotics and in 80% of placebo recipients, meaning that seven children need to be treated in order to cure one child with antibiotics (2). It is time for physicians to be more selective in determining which children require immediate treatment with antibiotics and which children may benefit from short course treatment, delayed treatment or treatment without antibiotics. The criteria used to identify children at low risk for serious sequelae who are most likely to benefit from the new strategies are identified in Table 1. These low risk children may be suitable candidates for observation and analgesic therapy alone, provided good follow-up is available. When antibiotics are used for AOM, the duration of treatment is controversial. There is evidence to support short course treatment (five to seven days) (3) for uncomplicated low risk AOM (Table 1). TABLE 1: Children with acute otitis media (AOM) considered at low risk for serious sequelae and children at potential risk for drug-resistant Streptococcus pneumoniae (DRSP) infection The selection and dose of antibiotics for the treatment of AOM has also been modified significantly because of the rapid emergence and dissemination of DRSP. Amoxicillin (40 mg/kg/day administered three times daily) remains the drug of choice for the treatment of uncomplicated AOM in children of all ages. Failure to respond to amoxicillin within two to three days at standard doses may be due to the presence of DRSP or a beta-lactamase-producing strain of Haemophilus influenzae or Moraxella catarrhalis. A higher dose of amoxicillin (80 to 90 mg/kg/day administered three times daily or twice daily) may be used for children who have failed to respond to amoxicillin at standard doses or for those at risk for DRSP (4) (Table 1). High dose amoxicillin produces middle ear fluid concentrations greater than 3 μg/mL for at least 3 h after the dose is given, which is sufficient to eliminate most penicillin nonsusceptible strains (5). Children who fail to respond to amoxicillin may also benefit from the use of amoxicillin/clavulanate at the standard dose or at a high dose (up to 90 mg kg/day of amoxicillin and up to 10 mg/kg/day clavulanate) administered twice daily (this requires the new 7:1 formulation that produces less diarrhea than the standard 4:1 ratio). Amoxicillin/clavulanate is the best choice for a second-line agent because it has both anti-beta-lactamase and anti-DRSP activity with excellent middle ear penetration (4,5). While there are several other Canadian approved antibiotics for AOM that are used as second-line agents, many lack the evidence for efficacy necessary in the DRSP era. Physicians who take care of children must be made aware of the current and evolving evidence-based choices for treating childhood otitis media. The choice of antibiotic should take into account the local or regional prevalence of DRSP.