TREATMENT OF OTITIS MEDIA: AN UPDATE, REVISIONS AND RECONSIDERATION OF ESTABLISHED GUIDELINES

What has brought about the latest recommendations in terms of modifying the treatment for otitis media?

The increasing worldwide prevalence of infection due to muiltiple-drug-resitant organisms has become the biggest threat to mankind and the most formidable challenge facing the medical profession as we enter the 21st Century. The use of antibiotics, particularly for otitis media remain an important contributor to the development of Streptococcus Pneumoniae drug resistance. A modified approach to the use of antibiotics for otitis media must be considered in this light.

What is different about S. Pneumoniae resistance?

Unlike resistance to amoxicillin by certain strains of Haemophilus Influenzae and most strains of Moraxella catarrhalis- which is mediated via beta-lactamases (and can therefore be largely obviated by using a drug which is resistant to beta-lactamase activity), resistance to the penicillins by various strains of S. pneumoniae is mediated by an entirely different mechanism: alteration in penicillin binding proteins. This type of resistance is therefore not affected by measures aimed at blocking or resisting beta-lactamase activity.

Why is S. Pneumoniae resistance so important in otitis media?

S. Pneumoniae is the most common organism causing otitis media in children.

Are any children at greater risk for developing pneumococcal resistance?

The prevalence of resistant pneumococcal strains is higher in children who have recently been treated with beta-lactam drugs and those who attend day care centers. Both the development of resistant strains and their rapid spread have likely been fostered and facilitated by selective pressures resulting from extensive use of antibiotics.

What strategies should now be considered in treating otitis media?

1. The duration of antibiotic treatment should be individualized according to each patient.

2. Antibiotic treatment for serous otitis media (otitis media with effusion, OME) is not necessary and should be eliminated except for specific indications (See below).

3. Antibiotic prophylaxis for the prevention of recurrent acute otitis media should be reconsidered.

For how long should acute otitis media (AOM) be treated?

AOM is defined as a middle ear effusion, usually purulent, occurring in a child with recent ear pain, marked redness of the ear drum and bulging of the tympanic membrane. An empirical course of 10 days of antibiotic is usually prescribed but in certain situations a 5 day course may be sufficient e.g. the older child with a mild episode, occurring in the summer months and who has little or no previous history of otitis media.

How should serous otitis media (OME) be treated?

OME may occur either from following an episode of AOM or as a result of eustachian tube obstruction following an upper respiratory tract infection. Most episodes of OME resolve spontaneously in 1 to 3 months and require no antibiotic treatment. Antibiotics should be used if:

(1) acute ear pain develops in association with the effusion.

(2) the serous effusion changes to a purulent effusion.

(3) the effusion persists for more than 3 months with an associated conductive hearing loss of greater than 30 decibels. Antibiotics should be given in this situation before resorting to tube placement.

What recommendations are advised for managing recurrent AOM?

(More than 3 episodes in 6 months or 4 episodes within 1 year).

Although there is evidence to show that continuous antibiotic prophylaxis provides variable protection against the development of recurrent AOM, its risks particularly with regard to the development of pneumococcal resistance likely outweigh its benefits. Current revised recommendations therefore include:

(1) the use of intermittent prophylactic antibiotics beginning at the first sign of an upper respiratory tract infection (URI) and discontinued after the URI has resolved.

(2) the placement of tubes

(3) for older children with recurrent AOM who have undergone one or more tube placements, adenoidectomy may be efficacious in reducing the risk of subsequent occurrences of AOM.

What does the future hold in store for the management of otitis media?

Research is currently in the works for the development of a vaccine against the common organisms which cause otitis media. Meanwhile the influenza vaccine may provide limited protection against AOM in some children, particularly in day care centers. The use of polyvalent pneumococcal vaccine in children older than 2 years of age may protect against pneumococcal specific episodes, without reducing the overall occurrence of AOM.

Parental input?

Physicians should discuss the relative benefits and risks of the various treatment options with the child’s parents, so that they can participate as knowledgeably as possible in the decision making process. Some parents will express a clear desire for surgical intervention and tube placement and some will alternately avoid such treatment at all costs.