Pharmacologic Therapy

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Antimicrobial Therapy

When antimicrobial therapy is needed, many factors influence initial drug selection. Clinicians must consider drug factors such as antimicrobial spectrum, likelihood of clinical response, middle ear fluid penetration, incidence of side effects, drug interactions, and cost, as well as patient factors, including risk factors for bacterial resistance, allergies, ease of dosing regimen, medication palatability, and presence of other medical conditions. Studies in uncomplicated AOM have not revealed significant differences between antibiotics in clinical response rates but most were confounded by spontaneous resolution in children likely to have had viral illnesses. Bacteriologic response varies among antibiotics and does not always correlate well with clinical response but is considered important when selecting an agent.4,5

Guidelines from the American Academy of Pediatrics and the American Academy of Family Physicians are available for children between 2 months and 12 years of age with uncomplicated AOM (Fig. 72-2) and are based on published trials and expert opinion.4 Amoxicillin remains the drug of choice in most patients because of its proven effectiveness in AOM, high middle ear concentrations, excellent safety profile, low cost, good-tasting suspension, and relatively narrow spectrum of activity (Table 72-2). High-dose amoxicillin (80-90 mg/kg/day) is preferred over conventional doses because higher middle ear fluid concentrations can overcome pneumococcal penicillin resistance without substantially increasing adverse effects.15 In cases of severe illness or when coverage for fi-lactamase-producing organisms is desired, high-dose amoxicillin-clavulanate is the preferred agent. Pneumococcal resistance to trimethoprim-sulfamethoxazole and macrolides is problematic and strikingly common in PRSP, making these agents less desirable for most patients.6,11 Patients with penicillin allergies require alternative firstline therapy (see Fig. 72-2). Children who have received an antimicrobial in the previous month are more likely to harbor resistant organisms and should also receive alternative therapy.6 A single dose of intramuscular ceftriaxone is effective for children who cannot tolerate oral medications, but a 3-day course may be preferred because of increasing pneumococcal resistance and failure of single doses.1 Ototopic antibiotics are an alternative to systemic agents

for AOM in patients with otorrhea or tympanostomy tubes.

FIGURE 72-1. Treatment algorithm for initial antimicrobials or observation in children with suspected or certain uncomplicated AOM. (From Ref. 4.)

Penicillin allergy?

FIGURE 72-2. Treatment algorithm for uncomplicated AOM in children 2 months to 12 years of age. (From Refs. 4, 6.)

If there is a lack of improvement or worsening with initial therapy during the first 48 to 72 hours, antibiotic selection must be reassessed and other contributing diseases must be excluded.4'6 Tympanocentesis can help to guide therapy in difficult cases.

Duration of therapy, like drug selection, depends on patient age and disease severity. Standard 10-day oral therapy is more effective than shorter courses for uncomplicated AOM in children younger than 2 years of age and those with recurrent infections, as well as in older patients with severe illness. ' Exceptions to the 10-day regimen are for azithromycin and ceftriaxone. In older children with mild or moderate illness, antibiotic therapy is needed only for 5 to 7 days.

Adjunctive Therapy

Pain is a central feature of AOM but is often overlooked in its management. Acetaminophen and ibuprofen are commonly used nonprescription agents for mild to moderate pain. Ibuprofen has a longer duration of effect than acetaminophen but is not used routinely in children younger than 6 months of age because of increased toxicity concerns. Alternating ibuprofen with acetaminophen is not recommended because of a lack of safety and efficacy data on combination therapy and the potential for dosing confusion and error. Topical anesthetic drops such as benzocaine (in Auralgan) provide pain relief within 30 minutes of administration and may be preferred over systemic analgesics when fever is absent. Myringotomy provides immediate relief but is performed rarely. Other medications such as decongestants, antihistamines, and cor-ticosteroids have no role in the treatment of AOM and can, in some cases, prolong effusion duration.4,19 Data are lacking on the safety and efficacy of complementary and alternative treatments.

Prevention

Immunizations may prevent AOM in certain patients, such as those with recurrent infections. Influenza vaccine is more effective in preventing AOM in children older than 2 years of age than in younger patients possibly from impaired immune responses and immature host defense in infants and toddlers.20 Pneumococcal conjugate vaccine is protective against infection by vaccine serotypes only with a limited overall benefit for AOM.21 Antibiotic prophylaxis is no longer recommended for otitis-prone children because of increasing resistance. Avoidance or minimization of risk factors associated with otitis media, such as tobacco smoke and bottle feeding, is advised, but the effects of these interventions remain unproven.

Table 72-2 Antibiotics" for the Treatment of AOM

Drug

Uiuil DaicindSchedult Common Advene EffitU RelillviCoil' Comment!

Arriata ill

Amour rim-ckfulanJtL'

Wmftiiine iWHil

GfiMM

Cetpodowme fyowfiH Oflnaxone

Achromycin

Cl.siiihtomycin f rjrThnamytln-i-UllivJtilAlk1

jje*

eO-ft) mg/kqrtJa/in Í tkfcei fedutetifc "ixi iwi«driy>

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