How Should I Manage Otitis Media in Children With Suspected Penicillin-Resistant Pneumococci?

Marilyn W. Edmunds, PhD, NP

Disclosures

July 26, 2001

Question

Recently I have seen a lot more otitis media in children in day care who are not responding to standard-dose amoxicillin. What approaches are appropriate for suspected penicillin-resistant Staphylococcus pneumoniae?

Response from Marilyn W. Edmunds, PhD, NP

Acute otitis media (AOM) is one of the most common diagnoses in pediatrics, responsible for $3 billion in costs per year. Much of the research in this area has focused on monitoring resistance patterns and developing management protocols.

Although antibiotics have been the gold standard of management for years, many experts now recommend that children with AOM not be treated at all. A report released in June of 2001 concluded "almost two-thirds of children with uncomplicated AOM recover from pain and fever within 24 hours of diagnosis without treatment with antibiotics, and over 80% recover within 1-7 days. When treated with antibiotics, up to 93% of children will recover during the first week." This analysis was conducted by the RAND/Southern California Evidence-Based Practice Center and sponsored by the Agency for Healthcare Research and Quality (AHRQ). The entire report is available online.[1]

It seems prudent, then, to simply monitor children who present with symptoms such as fever and fussiness, and a "red," nonpurulent ear on exam. However, this still leaves the issue of how to treat those children who do require antibiotic therapy. This group includes children who present with a purulent ear or who have symptoms lasting beyond 48-72 hours.

Numerous expert panels have concluded that clinicians should continue to rely on amoxicillin as first-line therapy. However, because of the dramatic increase in multidrug-resistant Streptococcus pneumoniae, the most common etiologic agent in AOM, many children should be treated at doses higher than the traditional dose of 40 mg/kg per day. Intermediate and highly resistant pneumococcus prevalence ranges from 10% to 40% in some communities. Substantial cross-resistance exists between macrolides, trimethoprim-sulfamethoxazole (TMP-SMX), and penicillin. In fact, resistance to TMP-SMX has been shown to be as high as 80% in some communities.

Risk factors associated with infection with drug-resistant Streptococcus pneumonia (DRSP) include younger age, attendance at a day care center, higher socioeconomic status (ie, patients develop drug resistance from increased antibiotic usage), recent (within 3 months) antibiotic use, and recurrent AOM. The Centers for Disease Control recommends that children at high risk for DRSP be treated with amoxicillin at a dose of 80-90 mg/kg per day divided into 2 or 3 daily doses. For a complete discussion of management of AOM, the reader is referred to Otitis Media Therapy and Drug Resistance -- Part 1: Management Principles and Otitis Media Therapy and Drug Resistance -- Part 2: Current Concepts and New Directions.

Children who fail a course of amoxicillin and a second or third course of another agent and who have been treated with 2-3 courses of antibiotics without improvement should be referred to an otolaryngologist for tympanocentesis and culture in order to more definitively determine appropriate antibiotic choices. These children may also be candidates for myringotomy and tympanostomy tube placement. For a discussion of when to refer, the reader is referred to When Do You Refer a Child With Otitis Media to an Otolaryngologist?

It is prudent for nurse practitioners who care for children to continually educate themselves about resistance patterns in their own communities so that they can make the best choices in managing their young patients.

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