SELECTED ARTICLES FROM THE RECENT LITERATURE 2003

12/23/03

Treatment of acute otitis media

Summary
The therapeutic approach to acute otitis media (AOM) in childhood has been debated in recent years. Although most clinicians prescribe antibiotic (ABx) treatment for AOM, the efficacy of this approach has been brought into question by the results of a number of recent controlled studies. This situation was reviewed by Pappas and Owen of the Univ. of Virginia in Charlottesville, VA. They pointed out several lines of evidence questioning the major therapeutic benefit of empiric ABx treatment in all cases of AOM: 1) A meta analysis of controlled trials showed that ABx treatment increased the frequency of resolution of AOM at 7 days post-treatment by only 13%; 2) ABx treatment at the onset of symptoms reduces the overall duration of symptoms by just one day; 3) Amoxicillin treatment appears to be as effective as use of newer ABx even though resistance to amoxicillin is quite common in bacterial isolates from AOM; 4) a delay onset of ABx treatment (where ABx are initiated only if symptoms persist/worsen after 48-72 hours) has been successfully applied in the Netherlands and in some sites elsewhere. In such studies, the manifestation of AOM started resolving with just supportive therapy by 48 hours in the majority of cases; initiation of antibiotic treatment was found necessary at 48-72 hours in only 24-30% of the children.

Therefore, some experts recommend that ABx be with held for the first 48-72 hours of symptoms attributed to AOM. ABx treatment should be started at this juncture only is there is fever persisting past this point, increasing local ear symptoms, excessive irritability or other mental status changes.

Some preventive approaches may reduce the incidence of AOM in young children: 1) Influenza immunization - now recommended for all children ages 6-23 months; 2) pneumococcal immunization - although the preventive efficacy of the current pneumococcal vaccine has likely decreased because of an increasing frequency of AOM caused by pneumococcal strains not present in the current vaccine.

Reference
Pediatr 2003;55:407-14

Editor's Comments
Concerns about the common practice of ABx treatment at the first signs of AOM have been raised because of: 1) the lack of convincing overall efficacy of ABx treatment as compared to placebo. It appears that a large percentage of AOM cases resolve spontaneously with or without ABx treatment in the first 48-72 hours; 2) the rising incidence of ABx resistant bacterial strains in childhood thought to be due to the rather promiscuous use of potent ABx (Pediatr Drugs 2001;3:639-47).

However, it takes a courageous clinician to withhold ABx treatment for a toxic looking irritable infant with a high fever. This is especially true in older clinicians who remember when acute mastoiditis and meningitis occurred commonly as complications of AOM. However, recent studies have pointed out that prompt ABx treatment of AOM does not always prevent as mastoiditis; indeed, in a number of cases of acute mastoiditis, the AOM was not clinically manifest in advance (Int J Pediatr Otolaryngol 2001;57:1-9; Arch Otolaryngol 2002;128:660-3).Ot remains to be seen whether the incidence of long-term middle ear complications will be greater in those children in whom the AOM was allowed to resolve spontaneously as compared to the frequency of such complications in those children treated with ABx at the first signs of AOM.

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