Acute otitis media: management and surveillance in an era of pneumococcal resistance - a report from the Drug-resistant Streptococcus pneumoniae Therapeutic Working Group

Objective. To provide consensus recommendations for the management of acute otitis media (AOM) and the surveillance of drug-resistant Streptococcus pn eumoniae (DRSP), Five questions were addressed: (1) Can amoxicillin remain the best initial antimicrobial agent for treating AOM in the current period of increasing prevalence of DRSP? (2) What are suitable alternative agents for use if amoxicillin fails? (3) Should empiric treatment of AOM vary by geographic region? (4) Where can clinicians learn about resistance patterns in their patient populations? (5) What modifications to laboratory surveil lance would improve the utility of the information for clinicians treating AOM? Participants. Experts in the management of otitis media and the DRSP Therap eutic Working Group, This group was convened by the CDC to respond to chang es in antimicrobial susceptibility among pneumococci and includes clinician s, academicians and public health practitioners. Evidence. Published and unpublished data summarized from the scientific lit erature and experience from the experts present. Consensus process. After group presentations and review of background mater ials, subgroup chairs prepared draft responses to the five questions, discu ssed the responses as a group and edited those responses until consensus wa s reached. Conclusions. Oral amoxicillin should remain the first line antimicrobial ag ent for treating AOM, In view of the increasing prevalence of DRSP, the saf ety of amoxicillin at higher than standard dosages and evidence that higher dosages of amoxicillin can achieve effective middle ear fluid concentratio ns, an increase in the dosage used for empiric treatment from 40 to 45 mg/k g/day to 80 to 90 mg/kg/day is recommended, For patients with clinically de fined treatment failure after 3 days of therapy, useful alternative agents include oral amoxicillin-clavulanate, cefuroxime axetil and intramuscular c eftriaxone. Many of the 13 other Food and Drug Administration-approved otit is media drugs lack good evidence for efficacy against DRSP, Currently loca l surveillance data for pneumococcal resistance that are relevant for the c linical management of AOM are not available from most areas in the United S tates. Recommendations to improve surveillance include establishing criteri a for setting susceptibility breakpoints for clinically appropriate antimic robials to ensure relevance for treating AOM, testing middle ear fluid or n asal swab isolates in addition to sterile site isolates and testing of drug s that are useful in treating AOM, The management of otitis media has enter ed a new era with the development of DRSP, These recommendations are intend ed to provide a framework for appropriate clinical and public health respon ses to this problem.