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

TABLE 1
Consistency of guidelines for acute otitis media

All recommend as first-line              Amoxicillin, mostly at
                                         80-90 mg/kg/d

All recommend as second-line             Amoxicillin/clavulanate,
                                         mostly "ES" 80-90 mg/kg/d

Some recommend as second-line            Cefdinir 14 mg/kg/d
                                         Cefprozil 30 mg/kg/d
                                         Cefuroxime axetil 30 mg/kg/d
                                         Cefpodoxime 10 mg/kg/d
                                         Ceftriaxone 50 mg/kg/d

Not recommended by any guideline         Azithromycin
Unless pathogen known to be sensitive;   Clarithromycin
patient had severe allergic reaction     Trimethoprim/sulfamethoxazole
to penicillin or amoxicillin; or         Erythromycin/sulfisoxazole
combined with another antibiotic         Cefaclor
that is effective against                Loracarbef
additional organisms                     Cefixime
                                         Ceftibuten
                                         Clindamycin

TABLE 2
AOM treatment recommendations by the CDC DRSP Working Group

                                                      CLINICALLY
ANTIBIOTICS                       CLINICALLY          DEFINED TREATMENT
IN PRIOR                          DEFINED TREATMENT   FAILURE ON
MONTH?        DAY 0               FAILURE ON DAY 3    DAY 10-28

No            High-dose           High-dose           Same as day 3
              amoxicillin; or     amoxicillin/
              usual-dose          clavulanate; or
              amoxicillin         cefuroxime
                                  axetil; or IM
                                  ceftriaxone

Yes           High-dose           IM ceftriaxone;     High-dose
              amoxicillin; or     or clindamycin;     amoxicillin/
              high-dose           tympanocentesis     clavulanate; or
              amoxicillin/                            cefuroxime
              clavulanate; or                         axetil; or IM
              cefuroxime axetil                       ceftriaxone;
                                                      tympanocentesis

High-dose amoxicillin = 80-100 mg/kg/d. High-dose amoxicillin
clavulanate = 80-100 mg/kg/d for the amoxicillin component (requires
newer formulation, or combination with amoxicillin). Ceftriaxone
injections recommended for 3 days. Clindamycin is not effective
against H influenzae or M catarrhalis.

TABLE 3
AAP/AAFP criteria for treatment decisions in children with
acute otitis media

AGE             CERTAIN DIAGNOSIS           UNCERTAIN DIAGNOSIS

Under           Antibacterial therapy       Antibacterial therapy
6 months

6 months to     Antibacterial therapy       Antibacterial therapy if
2 years                                       severe illness.
                                            Observation option * if
                                              non-severe illness.

2 years or      Antibacterial therapy       Observation option *
older             if severe illness.
                Observation option *
                  if non-severe illness

Modified from the New York State Department of Health and the
New York Region Otitis Project Committee (20,21)

* Observation is an appropriate option only when follow-up can be
assured and antibacterial agents started if symptoms persist or worsen.

Non-severe illness is mild otalgia and fever <39[degrees]C in the past
24 hours. Severe illness is moderate to severe otalgia or fever
[less than or equal to]39[degrees]C. A certain diagnosis of AOM meets
all 3 criteria: 1) rapid onset, 2) signs of middle-ear effusion, and
3) signs and symptoms of middle-ear inflammation.

Table 4

AAP/AAFP therapy options for AOM
in varying clinical circumstances

At diagnosis when observation is not an option
Recommended: Amoxicillin 80-90 mg/kg/d
Alternative for penicillin allergy: Non-type I: cefdinir, cefuroxime,
cefpodoxime; Type I: azithromycin, clarithromycin

Clinically defined failure of observation option after 48 to 72 hours
Recommended: Amoxicillin 80-90 mg/kg/day
Alternative for penicillin allergy: Non-type I: cefdinir, cefuroxime,
cefpodoxime; Type I: azithromycin, clarithromycin

Clinically defined failure of initial antibiotic treatment
after 48 to 72 hours
Recommended: Amoxicillin/clavulanate (90 mg/kg/d of amoxicillin
component, with 6.4 mg/kg/d of clavulanate)
Alternative for penicillin allergy: Non-Type I: ceftriaxone--3 days;
Type I: clindamycin

At diagnosis when observation is not an option
Recommended: Amoxicillin/clavulanate (90 mg/kg/d of amoxicillin
with 6.4 mg/kg/d of clavulanate
Alternative for penicillin allergy: Ceftriaxone--1 or 3 days

Clinically defined failure of observation option after 48 to 72 hours
Recommended: Amoxicillin/clavulanate (90 mg/kg/d of amoxicillin
with 6.4 mg/kg/d of clavulanate)
Alternative for penicillin allergy: Ceftriaxone 1 or 3 days

Clinically defined failure of initial antibiotic treatment
after 48 to 72 hours
Recommended: Ceftriaxone 3 days
Alternative for penicillin allergy: Tympanocentesis, clindamycin

Table 5

Comparative taste ratings
for antibiotic suspensions

Compliance-enhancing, strongly

Amoxicillin
Cefaclor (Ceclor)
Cefdinir (Omnicef)
Cefixime (Suprax)
Loracarbef (Lorabid)

Compliance enhancing, moderately

Cefprozil (Cefzil)
Ceftibuten (Cedax)

Equivocal compliance enhancement

Azithromycin (Zithromax)

Not compliance-enhancing

Amoxicillin-clavulanate (Augmentin)
Erythromycin-sulfisoxazole (Pediazole)
TMP-SMZ (Bactrim or Septra)

Discourages compliance

Cefpodoxime (Vantin)
Cefuroxime (Ceftin)
Clarithromycin (Biaxin)

Sources: Steele et al 2001; (33) Ruff et al 1991; (34) Demers
et al 1994. (35)