Pediatric Infection: Otitis Media Therapy and Drug Resistance Part 2: Current Concepts and New Directions

Eugene Leibovitz, MD, Ron Dagan, MD, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel

Infect Med. 2001;18(5) 

In This Article

Management Recommendations

Clinicians involved in the treatment of children should be aware of the major increase in the proportion of resistant organisms that cause AOM and of the direct relationship between this increase and antibiotic use. It is well known that in some Western European countries, the treatment policy for AOM is to withhold antimicrobial drugs in patients with AOM, using antibiotics only after a 1- to 3-day observation period during which the patient remains ill.[73] However, no evidence-based data exist to support the withholding of antibiotic therapy in children younger than 2 years with AOM, patients with complicated AOM, or children attending day-care centers. Therefore, the policy of observation alone may be recommended only in children older than 2 years who are mildly symptomatic.[43]

Table 2 summarizes recommendations for first- and second-line therapy for AOM. The Drug-resistant Streptococcus pneumoniae Therapeutic Working Group of the CDC has recently published new guidelines for the antibiotic treatment of AOM in the present era of pneumococcal resistance.[43] According to these guidelines, amoxicillin (40 to 50 mg/kg/d or the higher dosage of 70 to 90 mg/kg/d) represents the first-line treatment of choice for AOM. High-dose amoxicillin or amoxicillin/clavulanate or cefuroxime axetil is recommended as first-line treatment of AOM in those patients who have received antimicrobial therapy during the month preceding the AOM episode.

In cases of clinical failure after 3 full days of therapy, we recommend the performance of a diagnostic (and in many situations therapeutic) tympanocentesis, particularly in areas with a high prevalence of antibiotic-resistant S pneumoniae.

The 3 second-line antibiotic drugs recommended for clinical failures are:

  • Amoxicillin/clavulanate (the 45 mg/kg/d amoxicillin dosage or in the future a 90 mg/kg/d dosage) for 10 days.

  • Cefuroxime axetil (30 mg/kg/d) for 10 days.

  • Intramuscular ceftriaxone (50 mg/kg/d) for 3 days.

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