Print Topic

Page 1

Otitis Media
PATHOGENS

Johns Hopkins Antibiotic (A B X ) Guide

Diagnosis

Heent

Daniel J. Lee, M.D.; Ophir Handzel , M.D., LL.B.

S . pneumoniae Haemophilus influenzae

CLINICAL
O n s e t o f s x is usually acute , typical s x : otalgia , aural fullness, decreased hearing +/-fever. E x a m (otoscopy): erythema, T M bulging, o r fluid /p u s behind T M , reduced T M mobility o n insufflation (T M color, bulging a n d mobility). W e b e r test: 512 Hz tuning fork - lateralizes to involved e a r . T a k e note if facial n. function is a b n o r m a l. Main indications oral a b x s : pain , T M erythema, fever. Presence o f middle e a r fluid a l o n e - n o t strict indication for a b x. Abx-steroid e a r drops for purulent otorrhea. Cultures n o t routine (a n d n o t obtainable ) until s p o n t a n e o u s T M rupture o r myringotomy performed - cultures m a y b e helpful in chronic draining infection resistant to multiple therapies. I m a g i n g : fine-cut t e m p o r a l b o n e C T indicated for chronic infection, concern for middle e a r m a s s , retraction p o c k e t, cholesteatoma , o r if febrile +/- mastoid erythema, otalgia a n d O M. Obtain hearing test, if a question o f n o n -conductive hearing loss arises. Complications : c o m m o n --conductive hearing loss, mastoiditis , T M perforation; rare --labyrinthitis /vertigo, facial p a l s y, meningitis , Gradenigo s syndrome (abducens p a l s y/retroorbital pain /O M).

DIAGNOSIS
M o s t cases d i a g n o s e d clinically b a s e d u p o n s y m p t o m s a n d e x a m findings above .

TREATMENT
Uncomplicated acute otitis media (non-immunocompromised adults )
Amoxicillin 500m g P O three times a d a y x 7-10 d . C e f u r o x i m e (Ceftin ) 500m g P O twice daily x 7-14d . Ceftriaxone 1 gm IM (Rocephin ) every other d a y x 3 d o s e s. C e f p o d o x i m e 200m g P O twice daily x 7-10d . Alt (beta-lactam allergy o r fails initial rx ): cefdinir 300m g P O twice daily/600m g P O once daily, clindamycin 300m g P O three times a d a y/four times a d a y,+ levofloxacin (Levaquin ) 500m g P O every d a y, moxifloxacin (Avelox) 400m g P O every d a y --all x 7-10d . Amoxicillin / clavulanate u s e a s primary therapy for i m m u n o c o m p r o m i s e d o r diabetic patient.

Uncomplicated acute otitis media (immunocompromised adults ) or recurrent/chronic otitis media

Amoxicillin /clavulanate (Augmentin ) 875m g P O twice daily (o r 500m g P O three times a d a y) x 10-14 d . Amoxicillin / clavulanate u s e a s primary therapy for i m m u n o c o m p r o m i s e d o r diabetic patient. C e f p o d o x i m e 200m g P O twice daily x 7-10d . Alt : cefdinir 300m g P O twice daily /600m g P O once daily x 7-10d o r clindamycin 300m g three times a d a y x 7 -10 d (p e n allergy). Referral to specialist to r/o chronic otomastoiditis o r cholesteatoma in setting o f chronic O M.

Adjunctive therapy for otitis media

Address risk factors for eustachian tube dysfunction: s m o k i n g /allergies/sinusitis /GERD. Nasal decongestants : p s e u d o e p h e d r i n e 120m g + topical vasoconstrictors - oxymetazoline n a s a l sprays 2 puffs three times a d a y x 3-4 days only (m a y u s e O T C preparations such a s Afrin , Neosynephrine , Dristan). Although they m a y provide relief from congestive s y m p t o m s, decongestants a l o n e d o n o t improve the healing o f A O M n o r help prevent complications. For patients with suspected R T allergy consider the u s e o f antihistamines such a s loratadine (Claritin ) 10m g P O every d a y o r f e x o f e n a d i n e (Allegra ) 60 m g P O twice daily. Analgesia : NSAIDs - ibuprofen (Motrin ) 400m g P O three times a d a y x 5d , celecoxib (C e l e b r e x ) 200m g P O once daily x 5 d . Acetaminophen (Tylenol) can also b e u s e d . Local analgesics (e .g ., Auralgan) m a y provide a n additional benefit when T M intact. For persistent infection , intractable pain , o r complications listed above , referral to specialist e s s e n t i a l. M o s t adults tolerate myringotomy +/- t y m p a n o s t o m y tube p l a c e m e n t in clinic setting. Severe vertigo/facial p a l s y/mastoid abscess/meningitis requires t y m p a n o s t o m y a n d ventilation tube p l a c e m e n t , hospital a d m i s s i o n , t e m p o r a l b o n e C T , cultures / LP , intravenous antibiotics , possible surgical drainage.

FOLLOW UP
Local a n d systemic s y m p t o m s should improve o r resolve in 24-72h . C o n s i d e r pathogenic role o f drug resistant H. influenza o r S . pneumoniae, o r u n u s u a l p a t h o g e n s in n o n -responders . Chronic effusion following antibiotic therapy w/o otalgia d o e s n o t warrant a b x s . Patient with muffled hearing a n d fluid (clear o r a m b e r) b u t n o otalgia m a n a g e d with decongestants /n a s a l steroids/referral.

OTHER INFORMATION
Guidelines b a s e d o n authors opinion a n d Current T h e r a p y in Otolaryngology-H e a d a n d Neck Surgery (6th Edition, 1998, Gates, G., Editor). Much o f the evidence available in the literature concerns the pediatric a g e

http://www.hopkinsguides.com/hopkins/ub/pview/Johns_Hopkins_ABX_Guide/540408/all/Otitis%20Media

06-Jul-11 10:50:18 PM

Print Topic
group; m a y n o t b e directly applicable to adults . In contrast to the pediatric population, observation is n o t a r e c o m m e n d e d treatment choice for adults with A O M, a s course m a y n o t b e a s benign in n o n -pediatric populations. Anti-pneumococcal vaccinations m a y change the profile o f pathogenic bacteria b y increasing prevalence o f less c o m m o n p a t h o g e n s (e .g ., S. aureus [MRSA]) a n d strains o f pneumococcus n o t included in the vaccines . Topical steroid / antibiotic e a r drops n o t helpful in acute O M unless tympanic perforation present with otorrhea. Otorrhea a n d tenderness o f pinna is otitis externa, n o t O M , which can b e m a n a g e d with topicals a l o n e ; oral a b x n o t u s e f u l unless patient diabetic , i m m u n o c o m p r o m i s e d. "Muffled hearing" should n o t b e treated w/ antibiotics / decongestants unless obvious otitis media present & tuning forks testing is compatible with conductive hearing loss , a s it m a y represent s u d d e n neural hearing loss rather than A O M; neural hearing loss is considered a n otologic emergency requiring high d o s e steroids a n d referral to a n otologist.

Page 2

Pathogen Specific Therapy

Pathogen S. pneumoniae 1 s t Line A g e n t Amoxicillin Amoxicillin -Clavulanate Cefuroxime 2 n d Line A g e n t Cefpodoxime Cefdinir Azithromycin Clarithromycin Doxycycline Erythromycin Ceftriaxone Levofloxacin Moxifloxacin Cefpodoxime Cefdinir T M P -SMX Doxycycline Telithromycin Clarithromycin Levofloxacin Moxifloxacin Ceftriaxone T M P -SMX Azithromycin Clarithromycin Levofloxacin Moxifloxacin Clindamycin

H. influenzae

Amoxicillin -Clavulanate Cefuroxime Azithromycin

Moraxella catarrhalis

Amoxicillin -Clavulanate Cefuroxime Cefpodoxime Cefdinir

Strep pyogenes

Amoxicillin Amoxicillin -Clavulanate Cefdinir Amoxicillin -Clavulanate Cefdinir

S. aureus (MSSA )

Clindamycin

Basis for recommendation

Pichichero ME, Brixner DI: A review o f r e c o m m e n d e d antibiotic therapies with impact o n outcomes in acute otitis media a n d acute bacterial sinusitis . Am J Manag Care 12:S292, 2006 [PMID:16910756]
Comment : This is a n i c e meta- analysis reviewing recent studies on antibiotic therapy for acute otitis media. Amoxicillin and amoxicillin /clavulanate are considered first line therapies for A O M , followed by 2 nd and 3 rd generation cephalosporins s u c h as cefdinir, cefpodoxime, ceftriaxone, and cefuroxime . Cefdinir in several studies has been shown to be an effective agent in patients with A O M and penicillin allergies . Rating: Basis for recommendation

American A c a d e m y o f Pediatrics Subcommittee o n M a n a g e m e n t o f Acute Otitis Media: Diagnosis a n d m a n a g e m e n t o f acute otitis media . Pediatrics 113:1451, 2004 [PMID:15121972]
Comment : P r a c t i c e guidelines for the diagnosis and treatment of pediatric acute otitis media from the subcommittee on the management of A O M , American A c a d e m y of Pediatrics. T h e guidelines include a comprehensive description of the symptoms and signs of A O M , applicable to a large extent to the adult population but m o s t recommendations within are directed toward pediatric populations . Rating: Basis for recommendation

References
1. Benninger MS: Acute bacterial rhinosinusitis a n d otitis media : changes in pathogenicity following widespread u s e o f pneumococcal conjugate vaccine. Otolaryngol Head Neck Surg 138:274, 2008 [PMID:18312870]
Comment: Adults are influenced by childhood vaccination by herd immunity . P n e u m o c o c c a l conjugate vaccination has reduced the overall incidence of pneumococcal A O M , however nonvaccine serotypes , some with reduced A B sensitivity and increased virulence may be on the r i s e in some communities .

2. Jang C H, Park SY : Emergence o f ciprofloxacin -resistant p s e u d o m o n a s in chronic suppurative otitis media . Clin Otolaryngol Allied Sci 29 :321, 2004 [PMID:15270816]
Comment: This is a retrospective review of 8 8 adult patients with chronic suppurative O M who were unresponsive to ciprofloxacin topical therapy . Cipro- resistant Pseudomonas was isolated in all c a s e s . T h e s e resistant organisms were sensitive to imipenem, amikacin, piperacillin /tazobactam and ceftazidime. T h e incidence of cipro- resistant C S O M is increasing and careful guided therapy is necessary to manage t h e s e patients . Rating: Important

3. Pichichero ME, C a s e y JR : Otitis media . Expert Opin Pharmacother 3:1073, 2002

[PMID:12150687]

http://www.hopkinsguides.com/hopkins/ub/pview/Johns_Hopkins_ABX_Guide/540408/all/Otitis%20Media

06-Jul-11 10:50:18 PM

Print Topic
Comment: T h e authors , who have published extensively on O M , provide a comprehensive meta- analysis of clinical trials to evaluate the bacteriology of acute O M and the efficacy of antimicrobials . Antibiotic therapy for acute O M improves symptoms and middle- ear effusion resolution compared with the natural c o u r s e of O M . T h e authors conclude that selection and dosing of antimicrobials should account for drug- resistant S. pneumoniae and beta- l a c t a m a s e producing Gram- negative organisms . Tympanocentesis is warranted for complicated c a s e s .

Page 3

4. S h e a h a n P , Donnelly M, Kane R : Clinical features o f newly presenting cases o f chronic otitis media . J Laryngol Otol 115:962, 2001 [PMID:11779324]
Comment: This prospective study from Ireland examined the 5 8 consecutive patients presenting with recurrent or chronic O M . T h e mean age was 3 4 years . 7 8 % presented with hearing l o s s ; 6 4 % with otorrhea. 7 4 % of t h e s e patients had an attic defect or cholesteatoma. T h e high incidence of cholesteatomas or retracted tympanic membranes reaffirms the importance to refer recurrent c a s e s of O M to an otologist for surgical evaluation to minimize the risks of worsening hearing l o s s and ossicular chain erosion, adhesive O M , sepsis, or meningitis .

5. Y u n g MW , Arasaratnam R : Adult-o n s e t otitis media with effusion: results following ventilation tube insertion. J Laryngol Otol 115:874, 2001 [PMID:11779300]
Comment: This prospective study examined the outcomes of adults who underwent ventilation tube insertion for serous O M . A high incidence of recurrence occurred following tube extrusion. Endoscopic examination revealed inflammation of the lateral nasal wall and eustachian tube orifice, and skin- p r i c k testing was positive in greater than half of t h e s e patients. T h e authors conclude that underlying r i s k factors s u c h as atopy and chronic inflammation of the nasopharynx need to be treated to d e c r e a s e the r i s k of recurrent d i s e a s e.

6. C u l p e p p e r L e t a l: Acute otitis media in adults : a report from the International Primary Care Network . J Am Board Fam Pract 6:333, 1993 J u l -Aug [PMID:8352035]
Comment: This prospective study compiled data from 3 2 2 4 patients presenting with acute O M . 5 0 0 patients were older than 1 5 years . This was the first large study comparing pediatric and adult O M outcomes . Adults and children younger than 1 2 months had significantly lower rates of recovery at two months compared with older infants and children. Similar bacterial spectra were seen in both groups . Female s e x , history of O M , prophylactic antibiotics, decreased hearing, otorrhea, and serous O M were associated with poor outcome in adults . T y p e /duration of abx u s e did not affect outcomes in adults .

7. Celin SE e t a l: Bacteriology o f acute otitis media in adults . JAMA 266:2249, 1991 Oct 23-30

[PMID:1920724]

Comment: This prospective clinical study examined the bacteriology of middle ear fluid obtained by myringotomy in 3 4 adults presenting with O M . Common organisms were H. influenzae and S . pneumoniae (2 6 % and 2 1 % ) followed by M. catarrhalis . Based on their antibiotic sensitivity, the authors concluded that amoxicillin is an appropriate first- line therapy for acute O M . O t h e r antibiotics with minimal activity against H. influenzae s u c h as the tetracyclines , erythromycin, cephalexin, and penicillin are not as effective. Rating: Important

http://www.hopkinsguides.com/hopkins/ub/pview/Johns_Hopkins_ABX_Guide/540408/all/Otitis%20Media

06-Jul-11 10:50:18 PM