Otitis media - Antibiotics for Ear Infection

• What is Otitis media (ear infection)?
• Causes
• Symptoms
• Antibiotics for Otitis media
• When to give antibiotics
• "Wait-and-see" approach

Quick facts:

• Next to the common cold, ear infections are the most commonly diagnosed childhood illness in the United States.
• About 75% of children experience at least one episode of ear infection by age of 3 years.
• Although otitis media is primarily a disease of infants and young children, it can also affect adults.

Otitis media is an inflammation of the middle ear. This inflammation often begins when infections that cause sore throats, colds, or other respiratory illnesses spread to the middle ear. These can be viral or bacterial infections.

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.

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 account for about 85% of cases of acute otitis media. Viruses account for the remaining 15%.

The most common symptoms of Acute otitis media are:

• severe ear ache, due to the pressure of the mucus on the eardrum
• fever
• flu-like symptoms in children, such as vomiting and lethargy
• hearing difficulties

Chronic otitis media often has fewer symptoms or milder ones. However, they go on for a long time or keep 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:

• unusual irritability
• difficulty sleeping
• tugging or pulling at one or both ears
• fever
• fluid draining from the ear
• not respond to soft sounds
• turn up the television or radio
• talk louder
• appear to be inattentive at school

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 with acute otitis media do not benefit from antibiotics because their illness is not caused by bacterial infection or the infection is cleared by the immune system without the use of a drug.

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.

Decongestants and antihistamines are not effective in the treatment of acute otitis media, and they may cause complications.

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 without waiting:

• Child is very sick with severe pain.
• Child has a high fever (more than 102°F or 38.89°C).
• Child is dehydrated.
• Child has serious chronic conditions, such as heart disease or cystic fibrosis, that could put him or her at risk for complications from an ear infection.
• Child younger than 2 years of age, because the risk of complications is higher for very young children.

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.

"Wait-and-see" approach helps to lower the total number of antibiotics used by patients and prevent growing resistance.

Amoxicillin is the mainstay of treatment for ear infection. When antibiotics are necessary, the drug used for initial treatment is usually amoxicillin.

Reasons for using amoxicillin include high effectiveness, safety, favorable taste, good tolerability and reasonable cost. Amoxicillin is active against all bacterial pathogens causing acute otitis media.

Evidence in the literature supports the selection of amoxicillin as first-line therapy for acute otitis media. It is inexpensive and effective, even in populations with certain highly resistant bacteria.

The disadvantage is frequent dosing regimen - it should be taken 3 times daily.

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.

Amoxicillin dosage:

• Children:
  For mild or moderate ear infections, the usual dose is 25 mg per 2.2 pounds of body weight, divided into two daily doses and taken every 12 hours; or 20 mg per 2.2 pounds of body weight, divided into three daily doses and taken every 8 hours.
  For severe infections, the dose is 45 mg per 2.2 pounds of body weight, divided into two daily doses and taken every 12 hours; or 40 mg per 2.2 pounds of body weight, divided into three daily doses and taken every 8 hours.
  Children weighing 88 pounds and over should follow the recommended adult dose schedule.
  
• Adults: For mild or moderate infections, the usual dose is 250 mg every 8 hours, or 500 mg every 12 hours.
  For severe infections, the dose is 500 mg every 8 hours, or 875 mg every 12 hours.

Indications for using another medication (second line antibiotics) include:

• failure to respond to initial treatment (resistant or persistent acute otitis media)
• history of lack of response to initial treatment drug (failure of medication on at least two occasions in the current respiratory season)
• hypersensitivity to initial treatment medications
• presence of resistant organism determined by culture
• coexisting illness requiring a different medication.

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 agent6.

The addition of clavulanate to amoxicillin provides the combination product with 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.

It's palatability is worse compared with other antibiotics, especially compared with a number of cephalosporins.

Dosage:

• Children:
  Children weighing 88 pounds or more are usually prescribed the adult dosage.
  Children less than 3 months take 30 mg per 2.2 pounds of body weight per day, divided into 2 doses and taken every 12 hours.
  Older than 3 months: the usual dose of the 200- or 400-milligram suspension is 45 mg per 2.2 pounds per day, in 2 doses, every 12 hours, and of the 125- or 250-milligram suspension, 40 mg per 2.2 pounds per day, in 3 doses, every 8 hours
• Adults:
  The usual adult dose is one 500 mg tablet every 12 hours or one 250 mg tablet every 8 hours.
  For more severe condition the dose should be one 875 mg tablet every 12 hours or one 500 mg tablet every 8 hours.

Cefuroxime, a second generation cephalosporin antibiotic, 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- or amoxicillin-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. According to the research the overall improvement rate to a 10-day cefuroxime in children with ear infection ranges from 62-94%.

Research shows, that short-term 5-day course of Cefuroxime is also effective. 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.

Cefuroxime dosage:

• Children:
  Oral suspension may be given to children ranging in age from 3 months to 12 years.
  Your doctor will determine the dosage based on child's weight and the type of infection. Ceftin oral suspension is given twice a day for 10 days. The maximum daily dose ranges from 500 to 1000 mg. For children who are able to swallow tablets whole, the usual dosage for ear infection is 250 mg 2 times a day for 10 days.
• Adults:
  The usual dose for adults and children 13 years and older is 250 mg, 2 times a day for up to 10 days. For more severe infections 500 mg, 2 times per day.

The third-generation cephalosporin cefpodoxime is one of the recommended agents for second line choice.

Cefpodoxime has similar side effects to amoxicillin, cefaclor, cefixime, and regular-strength amoxicillin/clavulanate. Gastrointestinal and dermatological side effects are the most frequent.

Cefpodoxime is effective against both pneumococci and beta-lactamase producing organisms.

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:

• Children:
  Children 2 months through 12 years of age: 5 mg/kg every 12 hours for 5 days. Maximum 200 mg every 12 hours for children 2 months to 12 years of age.
• Adults:
  100 to 400 mg every 12 hours.

Cefdinir, a new cephalosporin with a broad spectrum of antimicrobial activity, 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:

• Children:
  7 mg per 2.2 pounds every 12 hours for 5 to 10 days or 14 mg per 2.2 pounds once a day for 10 days.
• Adults:
  300 mg every 12 hours for 5 to 10 days or 600 mg once a day for 10 days.

Ceftriaxone (Rocephin) is an injectable cephalosporin. Ceftriaxone 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: Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis.

Azithromycin or clarithromycin are not perfect options for otitis media, however were preferred for patients with severe penicillin allergy. Azithromycin and clarithromycin concentrate intracellularly, not in 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.

Azithromycin has an appealing once-daily regimen for either 1, 3, or 5 days, which is attractive not only to physicians but also to parents who would benefit from the decreased burden of multiple doses. In a taste test, children prefer the taste of azithromycin over amoxicillin/clavulanate, erythromycin, ethylsuccinate/sulfisoxazole, and clarithromycin.

Azithromycin dosage:

• Children:
  For children aged 6 months and up, treatment may be given three ways. One option is a single dose of 30 mg per 2.2 pounds of body weight. Another option is a dose of 10 mg per 2.2 pounds given each day for 3 days. Azithromycin can also be given over a period of 5 days, starting with a dose of 10 mg per 2.2 pounds on the first day and continuing with daily doses of 5 mg per 2.2 pounds for the next 4 days.

Clarithromycin dosage:

• Children:
  Clarithromycin is not recommended for children under 6 months of age. The dose for children older than 6 months depends on how much the child weighs. Clarithromycin is usually given twice a day for 10 days.
• Adults:
  The usual dose varies from 250 to 500 mg every 12 hours for 7 to 14 days.

• 1. Otitis Media (Ear Infection) National Institute on Deafness and Other Communication Disorders.
• 2. Spiro DM, Tay KY, Arnold DH, Dziura JD, Baker MD, Shapiro ED. Wait-and-See Treatment of Acute Otitis Media. JAMA. Sep 2006;296:1235-1241.
• 3. Otitis Media on eMedicine
• 4. Little P, Gould C, Moore M, Warner G, Dunleavey J, Williamson I. Predictors of poor outcome and benefits from antibiotics in children with acute otitis media: pragmatic randomised trial. BMJ. 2002 Jul 6;325(7354):22
• 5. Pichichero M, Aronovitz GH, Gooch WM, McLinn SE, Maddern B, Johnson C, Darden PM. Comparison of cefuroxime, cefaclor, and amoxicillin-clavulanate potassium suspensions in acute otitis media in infants and children. South Med J. 1990 Oct;83(10):1174-7.
• 6. American Academy of Pediatrics Subcommittee on Management of Acute Otitis Media. Diagnosis and management of acute otitis media. Pediatrics. 2004;113(5):1451-1465.