Treatment and prevention of otitis media

OBJECTIVE: To review and summarize recent advances in the treatment and pre vention of otitis media (OM). DATA SOURCES: A MEDLINE search (1996-March 2000) was performed to identify relevant primary and review articles. References from these articles were a lso reviewed if deemed important. STUDY SELECTION AND DATA EXTRACTION: English-language primary and review ar ticles focusing on the treatment and prevention of acute otitis media (AOM) were included. Studies focusing exclusively on OM with effusion or serous OM and chronic suppurative OM were excluded. Information regarding preventi on and drug therapy was reviewed, with an emphasis placed on advances made in the last two years. DATA SYNTHESIS: Recently, an expert panel of the Centers for Disease Contro l and Prevention recommended use of only three of 16 systemic antibiotics a pproved by the Food and Drug Administration for treatment of AOM: amoxicill in, cefuroxime axetil, and ceftriaxone. Controversy exists over the importa nce of key selection factors used by the expert panel in determining which antibiotics to recommend in a two-step treatment algorithm, that is, in vit ro data, pharmacodynamic profiles, and necessity for coverage of drug-resis tant Streptococcus pneumoniae at all steps of empiric treatment. Additional antibiotic and patient selection factors useful for individualizing therap y include clinical efficacy adverse effects, frequency and duration of admi nistration, taste, cost, comorbid infections, and ramifications should bact erial resistance develop to the chosen antibiotic. Presumed or past patient /caregiver adherence (especially when antibiotic failure has occurred) is a lso paramount in selecting antibiotic therapy. A three-step treatment algor ithm for refractory AOM that employs amoxicillin, trimethoprim/sulfamethoxa zole (TMP/SMX), or high-dose amoxicillin/clavulanate (depending on the prio r dose of and adherence to amoxicillin therapy), and ceftriaxone or tympano centesis at steps 1, 2, and 3, respectively, appears rational and cost-effe ctive. The recent upsurge in antimicrobial resistance is highlighted, and r ecommendations are presented for the treatment of AOM and prevention of rec urrent otitis media (AOM). CONCLUSIONS: Amoxicillin remains the antibiotic of choice for initial empir ic treatment of AOM, although the traditional dosage should be increased in patients at risk for drug-resistant S. pneumoniae. In cases refractory to high-dose amoxicillin, TMP/SMX should be prescribed if adherence to prior t herapy seemed good or complete, or high-dose amoxicillin/clavulanate if adh erence was incomplete or questionable. Ceftriaxone should be reserved as th ird-line treatment. The increasing prevalence of drug-resistant S. pneumoni ae emphasizes the importance of alternative medical approaches for the prev ention of OM, as well as judicious antibiotic use in established cases. Rem oval of modifiable risk factors should be first-line therapy for prevention of rAOM. We support the use of conjugate pneumococcal vaccine per guidelin es for prevention of rAOM from the Advisory Committee on Immunization Pract ice on the Centers for Disease Control and Prevention, with consideration g iven to influenza vaccine for cases of rAOM that historically worsen during the flu season. Sulfisoxazole prophylaxis should be reserved for children who are immunocompromised, have concurrent disease states exacerbated by AO M, or meet the criteria of rAOM despite conjugate pneumococcal and influenz a vaccination. Therapy should be intermittent, beginning at the first sign of an upper respiratory infection, and should continue for 10 days. The inv asive nature and risks of anesthesia relegate myringotomy, tympanostomy tub es, and adenoidectomy to last-line therapies for rAOM.