Otitis media: Antibiotics for Ear Infection
Updated according to 2013 AAP Clinical Practice Guidelines for The Diagnosis and Management of Acute Otitis Media.
What is Otitis media?
Otitis media is an inflammation of the middle ear. This inflammation often begins when the infection that causes respiratory illness spreads to the middle ear.
Acute otitis media is a short-term ear infection with sudden onset of signs and symptoms of middle-ear effusion and inflammation.
Chronic otitis media is when ear infections keep coming back or one infection lasts for a very long time. It often has less severe symptoms so the infection may be unnoticed and untreated for a long time, which means it can cause more damage than an acute infection.
Otitis media with effusion (OME) is fluid in the middle ear without signs or symptoms of infection. Unlike children with an acute ear infection, children with OME do not act sick. Otitis media with effusion usually goes away on its own over weeks or months.
Otitis media causes
Cells in the middle ear make a fluid that normally drains out through the eustachian tube and into the throat. But if the eustachian tube (the passage that connects the back of the nose to the middle ear) becomes swollen, the fluid can become trapped in the middle ear, forming a breeding ground for bacteria that can cause the area to become inflamed and infected. Children are at greater risk of ear infection than adults because of the small size and horizontal position of their eustachian tube.
Bacteria and viruses can cause middle ear infection. Bacteria such as Streptococcus pneumoniae (pneumococcus), nontypable Hemophilus influenzae and Moraxella catarrhalis account for about 85% of cases of acute otitis media. Viruses account for the remaining 15%.
Otitis media symptoms
The most common symptoms of Acute otitis media are:
Chronic otitis media often has fewer and milder symptoms. However, the illness goes on for a long time or keeps coming back. There is also more likely to be pus or fluid coming out of the ear.
Otitis media is often difficult to detect because most young children do not yet have sufficient speech and language skills to tell someone what is bothering them. Common signs to look for are:
Antibiotics for Otitis media
Not all forms of otitis need to be treated with antibiotics. It is important to distinguish Acute otitis media, which may benefit modestly from antibiotics, from Otitis media with effusion, which does not. In otitis media with effusion (OME) antibiotics may help if the fluid is still present after a few months and is causing hearing problems in both ears.
Many children do not benefit from antibiotics because their illness is not caused by bacterial infection or the infection is cleared by the immune system.
The decision to prescribe antibiotics depends on the child's age, the certainty of the diagnosis and the severity of symptoms.
The use of prophylactic antibiotics to prevent recurrent otitis media is controversial. Current AAP Practice Guidelines don't recommend prophylactic antibiotics to reduce the frequency of episodes of AOM.
Decongestants and antihistamines are not effective in the treatment of acute otitis media, and they may cause complications.
Currently, there are 19 antimicrobial agents approved by the U.S. FDA for the treatment of ear infection. The preferred antibiotic must be active against Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis.
When to give antibiotics
Children with ear infection with high temperature and vomiting are more likely to benefit from immediate treatment with antibiotics. Children who don't have high fever and vomiting are unlikely to have complications and unlikely to benefit from immediate antibiotics4.
There are situations when antibiotics should be given promptly:
About 80% of children with ear infection get better without antibiotics. And children whose ear infections are not treated immediately with drugs are not likely to develop a serious illness. Therefore it is better to wait and give antibiotics only if they are needed.
Parents may be advised to wait 48 to 72 hours to see whether the ear infection clears on its own1.
If after 48 hours your child is not improved and needs antibiotics, you may have to wait at least another 48 hours for antibacterial medication to take effect.
Amoxicillin: a first-line choice
Amoxicillin is the mainstay of treatment for ear infections. 2013 updated American Academy of Pediatrics Treatment Guidelines support the selection of amoxicillin as a first-line therapy.
Amoxicillin is the best antibiotic for ear infection because of high effectiveness, safety, favorable taste, and reasonable cost. Amoxicillin is active against all bacterial pathogens causing acute otitis media. It is effective even in populations with certain highly resistant bacteria.
The length of treatment is 10 days for younger children and people with severe illness, and 5- to 7-day course is recommended for children older than 6 years.
Indications for using another (second-line) antibiotic include 6:
Amoxicillin-clavulanate is the treatment of choice for children with severe symptoms. If the child with the ear infection has a fever over 102.2 F (39°C) or is severely ill, then the best starting antibiotic is Amoxicillin/Clavulanate, according to the American Academy of Pediatrics (AAP)/American Academy of Family Physicians (AAFP) guidelines6.
Also, when initial amoxicillin treatment fails, all guidelines recommend high-dose amoxicillin/clavulanate as a preferred second-line choice6.
The addition of clavulanate to amoxicillin provides the additional activity against beta-lactamase-producing bacteria.
Amoxicillin/clavulanate frequently causes gastrointestinal side effects, such as diarrhea. It may be quite problematic in very sick children, who often refuse to eat or drink enough milk to protect their gastrointestinal tracts from the distress of medication on an empty stomach.
Amoxicillin/clavulanate suspension tastes worse than other antibiotics.
TMP-SMX (Bactrim) is bactericidal against all the middle ear pathogens H. influenzae, S. pneumoniae, staphylococci and streptococci. Acute ear infections and chronic active otitis media7 respond well to treatment with trimethoprim-sulfamethoxazole. Moreover, it is safe for children.
According to the new Guidelines 6 TMP/SMX is considered an inferior option because of the high rate of pneumococcal resistance.
TMP-SMX (Bactrim) dosage:
Cefuroxime is considered a second-line choice for the treatment of ear infection, when amoxicillin or amoxicillin/clavulanate are ineffective or cannot be used.
Cefuroxime can be prescribed in penicillin-allergic children (Type I reaction), as this antibiotic possesses differing chemical side chains.
Results of controlled clinical studies5 in children 3 months to 12 years of age with AOM show that a 10-day course of cefuroxime is as effective or more effective than a 10-day course of cefaclor, amoxicillin, or amoxicillin/clavulanate potassium. Cefuroxime axetil treatment provides cure or improvement rate of 70-86% in children with ear infection8.
Research shows, that short-term 5-day course of Cefuroxime is also effective8. However, some doctors caution that short-term antibiotic regimens (i.e., 5 days or less) may not be appropriate for the treatment of ear infections in children younger than 2 years of age or for persons with underlying disease, recurrent or persistent otitis media, or perforated tympanic membranes and spontaneous purulent drainage.
Cefpodoxime proxetil (Vantin)
Cefpodoxime is one of the recommended agents for second line choice. Cefpodoxime is effective against both pneumococci and beta-lactamase producing organisms.
The most frequent side effects are gastrointestinal and dermatological.
Cefpodoxime can be prescribed in penicillin- or amoxicillin-allergic children (Type I reaction), as this antibiotic possesses differing chemical side chains.
Cefpodoxime proxetil (Vantin) dosage:
Cefdinir is a possible second line choice. The advantages of cefdinir (Omnicef) include pleasant taste, once- or twice- per day dosing, and a 5-day course for acute ear infection treatment.
Cefdinir also can be prescribed in penicillin- or amoxicillin-allergic children (Type I reaction).
Cefdinir (Omnicef) dosage:
Ceftriaxone (Rocephin) is typically reserved as an antibiotic of last resort, due to the increased expense, inconvenience, onerousness, and rare risk for anaphylaxis.
Ceftriaxone is injected intramuscularly. It may be a right choice for children who have vomiting or other conditions that hamper oral administration.
Ceftriaxone provides excellent antibacterial activity against the major Otitis media pathogens: S. pneumoniae, H. influenzae, and M. catarrhalis.
Azithromycin or clarithromycin are not perfect options for otitis media, however they are preferred for patients with severe penicillin allergy. Azithromycin and clarithromycin concentrate intracellularly, not in the middle ear fluid, and are bacteriostatic, not bactericidal.
Although azithromycin is a very convenient antibiotic, it does not provide as good antibacterial activity against relevant pathogens. Its activity toward lactamase producing strains of Hemophilus influenzae and Moraxella catarrhalis is low. The current pediatric guidelines endorse azithromycin (and clarithromycin) for the treatment of AOM only when the patient has an anaphylactic allergy to penicillin.
Topical fluoroquinolones -- ofloxacin otic and ciprofloxacin/dexamethasone otic (Ciprodex) -- are effective in patients with tympanostomy tubes and or who suffer acute otorrhea 9.
Published: July, 2010