Acute otitis media: making sense of recent guidelines on antimicrobial treatment; several new recommendations could influence treatment choices

Journal of Family Practice, April, 2005 by Michael E. Pichichero, Janet R. Casey

All guidelines recommend oral amoxicillin as first-line therapy in AOM. The AAP/AAFP guideline recommends increasing the dosage used for empiric treatment from 40-45 mg/kg/d to 80-90 mg/kg/d for all children, because the prevalence of penicillin-resistant S pneumoniae has continued to rise and has reached a level in 2004 where standard-dose amoxicillin is no longer considered adequate (see Acute otitis media's etiologic profile today).

Differences among the guidelines

After the CDC (2) and Clinical Advisory Committee; guidelines were published, the Agency for Healthcare Research and Quality (AHRQ) report (13) was released; it suggested most episodes of AOM resolve without the use of antimicrobials.

Therefore, the AAP/AAFP guideline (4) included a watchful waiting option in its clinical algorithm.

Disagreement over watchful waiting. The CDC guideline did not comment on spontaneous resolution and watchful waiting as an option, and the Clinical Advisory Committee (3) did not agree with the often quoted 70% to 80% spontaneous resolution. The Clinical Advisory Committee and Wald (14) expressed concerns that the included studies used poor enrollment criteria and likely misclassified some benign upper respiratory infections and OME as AOM. Wald resigned from the AAP/AAFP writing group in a dispute on this issue. She and the Clinical Advisory Committee favored effective antibiotic therapy because it more rapidly resolves the clinical signs and symptoms of AOM, (13) and because children who receive only symptomatic treatment have consistently higher failure rates than those treated with antimicrobials. (13)

How compliance factors influence treatment outcomes. The CDC guidelines (2) did not give weight to the taste of the medication, frequency of dosing, duration of therapy, or adverse side effects (rash, spitting, vomiting, and diarrhea). The Clinical Advisory Committee guideline (3) and the AAP/AAFP guideline (4) viewed these compliance factors as important in selecting an appropriate antimicrobial for children. (3,12,15)

Two new antibiotics were licensed following publication of the CDC and Clinical Advisory Committee Guidelines--amoxicillin/clavulanate extra-strength, and the third-generation cephalosporin, cefdinir. Cefdinir was endorsed by the Clinical Advisory Committee and the AAP/AAFP guideline, given the drug's efficacy and compliance-enhancing features--ie, pleasant taste, once- or twice-per-day dosing, and a 5-day course for AOM treatment.

Which drugs get priority. In the event initial amoxicillin treatment fails, all guidelines recommend high-dose amoxicillin/clavulanate as a preferred second-line agent.

In addition, the CDC and Clinical Advisory Committee guidelines cite one or several of the cephalosporins as preferred second-line agents, including ceftriaxone, cefdinir, cefpodoxime, cefprozil, or cefuroxime.

The AAP/AAFP guideline endorsed cefdinir, cefpodoxime, cefuroxime, and ceftriaxone as alternatives to amoxicillin and amoxicillin/clavulanate for patients with "non-type I allergy." The addition of cefdinir was based on satisfactory efficacy and high-compliance potential. Designation of the preferred cephalosporins as "alternatives" was not explained.