Evaluating the need, timing and best choice of antibiotic therapy for acute otitis media and tonsillopharyngitis infections in children

Deciding whether an antibiotic is necessary, when to begin therapy and sele cting an optimal drug is an everyday challenge in clinical practice, rn vit ro susceptibility testing which determines the minimum concentration necess ary for a particular antibiotic to inhibit or kill most strains of a bacter ial species and pharmacodynamic modeling are useful but have limitations. T he need for antibiotic therapy for acute otitis media (AOM) has been recent ly questioned. However, explanations for uniformly positive results with ma ny antibiotic and placebo comparative trials include overdiagnosis of AOM a t study entry, inclusion of patients with mild or uncomplicated AOM and bro ad criteria for the definition of clinical success. Recurrent and persisten t AOM does not have as favorable a natural history as uncomplicated AOM; ch ildren below 2 years of age benefit most from antibiotic therapy. Selecting the best choice among the many antibiotics that can be used to treat AOM h as become more complex over the last decade due to escalating antibiotic re sistance among the pathogens that cause this infection. Broader spectrum an tibiotics such as cefdinir, the newly introduced third generation cephalosp orin, have their most prominent use in the treatment of persistent and recu rrent AOM. In the early 1950s and 1960s penicillin clearly was the best available agen t for the treatment of group A streptococcal (GAS) infections. In the 1970s the situation began to change as cephalosporin antibiotics became availabl e. Superior eradication rates with cephalosporins such as cefdinir have now been well-documented. The leading hypothesis to explain the widening gap i n efficacy between penicillin and cephalosporins relates to two major conce pts: the presence of copathogens and differential alteration of the normal microbial ecology in the throat as a consequence of the selected therapy. T here are positive and negative consequences to early initiation of antibiot ic therapy for GAS tonsillopharyngitis, Penicillin has persisting good effi cacy in patients older than the age of 12 years and in those who have been ill for >2 days. Shortening therapy for GAS tonsillopharyngitis offers a th erapeutic advantage. Cefpodoxime proxetil and cefdinir have a B-day indicat ion for the treatment of GAS tonsillopharyngitis. Antibiotics with lower side effect profile, infrequent dosing, good palatab ility in suspension formulation and efficacy with short duration of treatme nt may lead to better outcomes because noncompliance often results in faile d therapy, persistence of infection and morbidity.