Acute otitis media: Making sense of recent guidelines on antimicrobial treatment

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).

TABLE 2
AOM treatment recommendations by the CDC DRSP Working Group

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).

Cefdinir, cefpodoxime, or cefuroxime were recommended for patients allergic to penicillin, unless the allergic reaction was severe, such as anaphylaxis (TABLE 4). Azithromycin or clarithromycin were preferred for patients with severe penicillin allergy.

In the event alternative antibiotic therapy failed, it was recommended that the patient receive 3 injections of ceftriaxone or undergo tympanocentesis to make a bacteriologic diagnosis.

Clindamycin was proposed as an option for presumed penicillin-resistant pneumococcal infection not responding to the previous regimens.

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

TABLE 4
AAP/AAFP therapy options for AOM in varying clinical circumstances