Antibiotic Treatment for Otomastoiditis
For otomastoiditis, cloxacillin/flucloxacillin should be administered intravenously at 50 mg/kg four times daily for 10 days as first-line treatment. 1
First-Line Treatment Options
The World Health Organization (WHO) Pocket Book of Hospital Care for Children provides clear guidance for treating otomastoiditis:
- First-line therapy: Cloxacillin/flucloxacillin IV at 50 mg/kg QDS (four times daily) for 10 days 1
- Second-line therapy: Ceftriaxone IV 1
Clinical Presentation and Diagnosis
Otomastoiditis typically presents with:
- Retroauricular swelling, erythema, and tenderness
- Displacement of the pinna
- Otomicroscopic evidence of acute otitis media
- Refractory otorrhea in many cases 2
Treatment Algorithm
Step 1: Initial Management
- Intravenous antibiotics: Begin with cloxacillin/flucloxacillin 50 mg/kg QDS 1
- Surgical intervention: Consider myringotomy for drainage, especially in cases not responding to initial antibiotic therapy within 48 hours 3
Step 2: Monitoring Response
- Assess clinical improvement within 48-72 hours
- If no improvement is seen, consider:
- Changing to second-line therapy (ceftriaxone)
- Surgical intervention
Step 3: Surgical Considerations
- Mastoidectomy should be performed in patients with:
- Acute coalescent mastoiditis
- Evidence of intracranial complications
- Failure to respond to medical management 3
Special Considerations
Outpatient Management
In select cases, outpatient management may be considered:
- Once-daily IM ceftriaxone has been used successfully in children with acute mastoiditis with periosteitis
- This approach requires daily evaluation by specialists and careful patient selection 2
Complications
Potential complications requiring more aggressive management include:
- Intracranial extension (brain abscess, meningitis)
- Sigmoid sinus thrombosis
- Facial nerve palsy
- Labyrinthitis 3
Microbiology
Common pathogens in otomastoiditis include:
- Streptococcus pneumoniae
- Streptococcus pyogenes
- Staphylococcus aureus 4
This is why anti-staphylococcal coverage with cloxacillin/flucloxacillin is recommended as first-line therapy.
Pitfalls to Avoid
Inadequate duration of therapy: The full 10-day course is essential for complete eradication of infection 1
Delayed surgical intervention: Failure to consider surgical drainage when antibiotics are not producing improvement within 48 hours can lead to complications 3
Overlooking resistant organisms: In cases of treatment failure, obtain cultures to guide antibiotic selection 4
Insufficient imaging: CT scanning should be performed when there is clinical suspicion of coalescent mastoiditis or intracranial complications 5
Premature discontinuation of IV antibiotics: Ensure complete resolution of acute inflammation before considering transition to oral therapy
In refractory cases, particularly those with unusual presentations or treatment failures, consider the possibility of nontuberculous mycobacterial infection, which requires specialized treatment approaches 6.