Diagnosis and pharmacological management of acute otitis media

Pediatric Nursing, Sept-Oct, 1998 by Nancy H. Montville, Mary A. White

Abbreviations: SP= Streptococcus pneumoniae HI= Haemophilus infiuenzae MC= Moraxella catarrhalis

Sources: Physician's Desk Reference (1998); Mason (1996); Pichichero (1994); Eden, Fireman, & Stool (1996); Goldfarb (1995); Schentag, (1995).

Controversy Over Antibiotic Use

Much of the discussion above concerns the use of new antibiotics to combat antibiotic-resistant bacteria. In The Antibiotic Paradox (1992), Dr. Stuart Levy points out that it is precisely the success of antibiotic therapy that has created tremendous selective pressure in favor of bacteria that are antibioticresistant. Thus, overuse of antibiotics containing beta-lactamase inhibitors will help generate bacteria that are resistant by some other mechanism. The recommendation that practitioners start with first line antibiotics is critically important to stemming the tide of antibiotic-resistant pathogens. Similarly, discontinuing treatment prior to completion of the full course allows bacteria resistant to that antibiotic to become dominant.

Clinicians have become increasingly aware of the problems associated with the indiscriminate use of antibiotic therapy in everyday primary care practice. The American Society of Microbiology found that AOM is the most common reason for prescribing antibiotics in the United States. The organization attributes much of the antimicrobial resistance of H. influenzae and S. pneumoniae to the treatment of AOM (American Society for Microbiology, ! 995). Most pediatric primary care providers in this country continue to prescribe antibiotics for symptomatic cases of AOM. Overuse of antibiotics must be avoided, and practitioners should avoid diagnosis of AOM by telephone, or over diagnosis and treatment due to coercion by anxious, concerned parents Pichichero, 1994).

It is also important to remember that 70 to 90% of AOM may resolve spontaneously with no antibiotic treatment (Rosenfeld et al., 1994). Routine use of antibiotics has become more controversial in recent years. In the United Kingdom and many European and Scandinavian countries, uncomplicated AOM is treated with analgesics and supportive care. These countries report a high rate of spontaneous resolution and few complications.

A meta-analysis of antibiotic use in AOM concluded that antibiotics shorten the length of the acute illness. There was also increased symptomatic relief in studies that compared the use of antibiotics and a placebo for treatment of AOM. The analysis concluded that even though a small percentage of children benefited from antibiotic use, it was impossible to predict ahead of time which children they would be. The researchers endorsed a qualified approval for the use of antibiotics (Rosenfeld et al., 1994). Experts in the field of pediatrics and infectious disease have urged that greater caution be used in prescribing antibiotics for this common childhood illness.

Parent Education

Parents need information about the prevention and treatment of otitis media. All new mothers should be encouraged to breast feed their infants because of the immunologic benefits. Parents who choose to bottle feed must be aware of proper positioning during feeds. Positioning the child upright during feeds is best because lying the child flat can permit the entrance of liquid into the eustachian tube. Other preventive measures include avoidance of cigarette smoke and other children and adults who are sick (Eden et al., 1996).