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

No guideline recommends trimethoprim/sulfamethoxazole (TMP/SMX) or azithromycin as a preferred second-line choice unless a severe reaction like anaphylaxis due to penicillin allergy is a confounding factor. Other antibiotics are recommended alone or in combination in some but not all guidelines (TABLE 1).

* Particulars of the CDC recommendations

In choosing preferred agents, the CDC gave primary consideration to pharmacokinetic/pharmacodynamic data and to clinical efficacy trials that used tympanocentesis results (especially double tympanocentesis) as evidence of diagnosis and bacteriologic outcome. Of the 16 FDA-approved drugs for the treatment of AOM, many lacked data on efficacy against multidrug-resistant S pneumoniae or [beta]-lactamase-producing H influenzae.

Following its review of the evidence base in 1997-1998, the CDC selected amoxicillin as the treatment of choice. The amoxicillin dose varied. If a child had been treated with an antibiotic in the preceding month, was aged <2 years, or had attended day care, the dose was increased from 40-45 mg/kg/d to 80-90 mg/kg/d.

High-dose amoxicillin/clavulanate, cefuroxime axetil, and intramuscular ceftriaxone (3 injections) were endorsed as the most appropriate alternative antimicrobials.

If resistant S pneumoniae was the isolate identified with tympanocentesis, clindamycin became another choice (TABLE 2).

* Recommendations from a clinical advisory committee

A clinical advisory committee made recommendations focused on the medical management of persistent and recurrent AOM. (5) Persistent AOM was defined as the persistence of the signs and symptoms of middle-ear infection following 1 or 2 courses of antimicrobials, whereas recurrent AOM was defined as 3 or more episodes of AOM in a 6-month time span or 4 or more episodes in a 12-month time span.

These guidelines coincide with the CDC guidelines in that amoxicillin/clavulanate (amoxicillin, 45-90 mg/kg/d; clavulanate, 6.4 mg/kg/d), cefuroxime axetil, and intramuscular ceftriaxone were endorsed as appropriate agents for persistent and recurrent AOM. Based on an analysis of clinical outcomes, cefpodoxime, cefprozil, and cefdinir were also recommended in this treatment algorithm (FIGURE 2). (16-19)

* AAP/AAFP guideline details The AAP/AAFP guideline recommended antimicrobials or observation for children with AOM, taking into consideration patient age and certainty of the diagnosis (TABLE 3).

In recommending the observation option, the committee cited rising bacterial resistance, injudicious antibiotic use, viruses as a common cause of AOM, a high spontaneous cure rate for AOM (80%-90%), and the lack of a substantial increase in complications when such a strategy is applied (as in the Netherlands).

Amoxicillin, 80-90 mg/kg/d, was selected by the AAP/AAFP as the empiric antibiotic preferred for AOM. High-dose amoxicillin/clavulanate or ceftriaxone were recommended if amoxicillin treatment fails, or as alternatives to amoxicillin in the presence of any 1 of 3 CDC guideline risk factors: (1) antibiotic treatment in the past month, (2) patient younger than 2 years of age, or (3) day care attendance (TABLE 4).