What is the antibiotic of choice for severe mastoiditis?

From the Guidelines

The antibiotic of choice for severe mastoiditis is a combination of intravenous ceftriaxone (1-2g every 12-24 hours) plus vancomycin (15-20 mg/kg every 8-12 hours). This combination therapy is typically administered for 10-14 days, followed by oral antibiotics based on culture results and clinical response. Severe mastoiditis requires hospitalization for parenteral antibiotics and possible surgical intervention. The rationale for this regimen is to provide broad-spectrum coverage against the most common pathogens in mastoiditis, including Streptococcus pneumoniae, Streptococcus pyogenes, Staphylococcus aureus (including MRSA, which is covered by vancomycin), and anaerobes. In children, Haemophilus influenzae should also be considered. Surgical consultation is essential, as many cases of severe mastoiditis require mastoidectomy to drain purulent material and remove infected bone. Antibiotic therapy should be adjusted based on culture and sensitivity results once available. Patients should be monitored for clinical improvement, including reduction in pain, fever, and ear discharge, as well as improvement in hearing and resolution of any neurological symptoms.

Key considerations for antibiotic selection include:

• Coverage of common mastoiditis pathogens, such as Streptococcus pneumoniae and Staphylococcus aureus, including MRSA 1
• Broad-spectrum coverage to address potential polymicrobial infections
• Parenteral administration for severe cases, with potential transition to oral antibiotics based on clinical response and culture results
• Surgical consultation for possible mastoidectomy to address complications and promote recovery

The provided evidence does not directly address mastoiditis treatment; however, the principles of antibiotic selection and the importance of broad-spectrum coverage are relevant to the management of severe infections, as discussed in the guidelines for skin and soft tissue infections 1. The choice of ceftriaxone plus vancomycin is based on their effectiveness against common pathogens and their recommendation in various infectious disease guidelines, although the specific context of mastoiditis requires consideration of the unique pathogens involved and the potential need for surgical intervention.

From the Research

Antibiotic of Choice for Severe Mastoiditis

The choice of antibiotic for severe mastoiditis depends on various factors, including the causative organisms and their susceptibility to antibiotics.

• The most common causative organisms of acute mastoiditis include Streptococcus pneumoniae, Streptococcus pyogenes, Staphylococcus aureus, and Haemophilus influenzae 2.
• Ceftaroline, a broad-spectrum cephalosporin, has been shown to be effective against a wide range of Gram-positive and Gram-negative pathogens, including MRSA 3.
• Ceftriaxone, a third-generation cephalosporin, has also been used to treat MSSA infections, with a once-daily dosing regimen and a short infusion time 4.
• The choice of antibiotic should be guided by the results of bacterial cultures and susceptibility testing, as well as the severity of the infection and the patient's clinical condition.
• In some cases, antibiotic treatment may not be effective in preventing the development of acute mastoiditis, and early myringotomy may be necessary to decrease the incidence of complications 2.
• The distribution of causative organisms in acute mastoiditis differs from that in acute otitis media, and the growing resistance of bacteria to antibiotics makes it essential to obtain a sample for culture prior to antibiotic treatment 2.

Considerations for Antibiotic Selection

When selecting an antibiotic for severe mastoiditis, the following factors should be considered:

• The spectrum of activity of the antibiotic against the likely causative organisms
• The susceptibility of the organisms to the antibiotic
• The severity of the infection and the patient's clinical condition
• The potential for antibiotic resistance
• The need for surgical intervention, such as myringotomy or mastoidectomy
• The results of bacterial cultures and susceptibility testing 5, 6.