From the Guidelines
Mastoiditis can often be treated on an outpatient basis for mild to moderate cases with a course of high-dose intravenous antibiotics, typically administered through a peripherally inserted central catheter (PICC) line at home, as supported by recent trends in nonsurgical management 1.
Treatment Approach
The primary treatment approach for mastoiditis in an outpatient setting involves:
- High-dose intravenous antibiotics, which may include ceftriaxone and vancomycin, to provide broad-spectrum coverage against common causative organisms, including Streptococcus pneumoniae, Haemophilus influenzae, and Staphylococcus aureus.
- Pain management with acetaminophen or ibuprofen as needed to ensure patient comfort.
- Regular follow-up with an ENT specialist to monitor progress and adjust treatment as necessary.
Antibiotic Regimen
A recommended antibiotic regimen could be:
- Ceftriaxone 2g IV once daily for 2-4 weeks
- Plus Vancomycin 15-20 mg/kg IV every 12 hours for 2-4 weeks This combination is based on the need for broad-spectrum coverage and the potential for resistance among common pathogens, as indicated by the variety of guidelines and treatment approaches discussed in the evidence 1.
Additional Considerations
- Patient Education: Patients should be educated on signs of worsening infection, such as increased pain, fever, or neurological symptoms, which would necessitate immediate medical attention.
- Follow-Up: Regular follow-up with an ENT specialist is crucial to monitor progress and ensure that the infection is fully eradicated.
- Imaging: A CT scan after treatment completion may be necessary to ensure resolution of the infection and to assess for any potential complications.
Rationale
The extended antibiotic course is necessary to fully eradicate the infection from the mastoid air cells, which have poor blood supply, as highlighted by the evidence suggesting that antibiotics administered for AOM treatment do not eliminate the risk of developing mastoiditis 1. Home IV therapy allows for effective treatment while avoiding prolonged hospitalization, improving patient comfort and reducing healthcare costs. This approach aligns with recent trends towards nonsurgical management of mastoiditis, where possible, to minimize morbidity and improve quality of life 1.
From the Research
Treatment Overview
The treatment for mastoiditis in an outpatient setting typically involves parenteral antibiotic therapy, with or without surgical intervention.
- Outpatient parenteral antibiotic therapy has been shown to be effective in treating acute mastoiditis with periosteitis in children, with a clinical cure rate of 96.8% 2.
- Daily intravenous ceftriaxone has been used as a treatment option, with a cure rate of 93% in one study 3.
Surgical Intervention
Surgical intervention, such as myringotomy and tube insertion, may be necessary in some cases.
- In one study, 4 out of 27 children treated as outpatients underwent myringotomy and tube insertion 3.
- Mastoidectomy may be performed if the infection fails to be controlled after 48 hours of intravenous antibiotic therapy 4.
Patient Selection and Monitoring
Careful patient selection and close monitoring are essential for successful outpatient treatment of mastoiditis.
- Patients with complications, such as fever, high leukocyte count, or high C-Reactive Protein value, should be monitored closely 5.
- Children under 24 months, with high leukocyte count or with high C-Reactive Protein value, should be monitored closely since complications tend to be more frequent 5.
Antibiotic Therapy
The use of broad-spectrum antibiotics should be minimized, and middle ear cultures should be obtained to guide antibiotic therapy.