What is the recommended treatment for suppurative ear disease?

Treatment of Suppurative Ear Disease

For acute suppurative otitis media (AOM), amoxicillin-clavulanate is the first-line antibiotic treatment, reducing clinical failure rates from 42-46% (placebo) to 17-22%, with a number needed to treat of 3-4 when using stringent diagnostic criteria. 1

Initial Antibiotic Selection for Acute Suppurative Otitis Media

Amoxicillin-clavulanate should be prescribed as first-line therapy for children with confirmed AOM, targeting the primary bacterial pathogens: Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. 1, 2, 3

• The standard dosing is 90 mg/kg/day of amoxicillin component divided twice daily for 10 days in children under 2 years or those with severe disease. 1, 3
• Clinical failure rates with amoxicillin-clavulanate are 17.2% for unilateral AOM and 21.7% for bilateral AOM, compared to 42.7% and 46.3% respectively with placebo. 1
• Diarrhea occurs in approximately 53% of patients on amoxicillin-clavulanate versus 36% on placebo, but this side effect profile is acceptable given the substantial clinical benefit. 1

When Observation Without Antibiotics Is Appropriate

Observation for 48-72 hours is acceptable only in select children: those aged 6-23 months with unilateral, non-severe AOM, or children ≥24 months with unilateral or bilateral non-severe disease, provided close follow-up is ensured. 1

• Approximately one-third of observed children ultimately require rescue antibiotics. 1
• This approach can reduce antibiotic use by 65% in eligible children without increasing suppurative complications like mastoiditis. 1
• Never withhold antibiotics universally, as this risks return of preantibiotic-era complications. 1

Management of Treatment Failure

If symptoms persist or worsen after 48-72 hours of amoxicillin-clavulanate, escalate to intramuscular ceftriaxone 50 mg/kg daily. 1

• A 3-day course of ceftriaxone is superior to a single dose for treatment-refractory AOM. 1
• Do not use trimethoprim-sulfamethoxazole or erythromycin-sulfisoxazole due to substantial pneumococcal resistance. 1

For Multiple Treatment Failures

Perform tympanocentesis with culture and susceptibility testing when multiple antibiotic regimens have failed. 1

• If tympanocentesis is unavailable, consider clindamycin (with or without cefdinir/cefixime/cefuroxime to cover H. influenzae and M. catarrhalis). 1
• For suspected multidrug-resistant S. pneumoniae serotype 19A, consult infectious disease and otolaryngology specialists before using levofloxacin or linezolid, as these are not FDA-approved for AOM in children. 1

Chronic Suppurative Otitis Media (CSOM)

Topical fluoroquinolone antibiotics are the first-line treatment for CSOM, not systemic antibiotics. 1, 4, 5

• Systemic antibiotics alone show very uncertain benefit for CSOM resolution (RR 8.47,95% CI 1.88-38.21). 4
• When topical antibiotics are already being used, adding oral antibiotics provides little or no additional benefit (RR 1.05,95% CI 0.94-1.17). 4
• Avoid ototoxic preparations (aminoglycosides) in patients with tympanic membrane perforation, as they cause permanent sensorineural hearing loss. 2

Surgical Management for CSOM

Tympanoplasty is the definitive curative treatment for CSOM, not conservative antimicrobial therapy. 6, 7

• Cartilage reconstruction provides superior structural outcomes compared to temporalis muscle fascia, with better graft integration rates (92.4% vs 84.3%). 1
• Consider surgery earlier in patients with treatment-refractory disease to debride biofilms and minimize antibiotic resistance development. 5
• Basic fibroblast growth factor (b-FGF) with gelatin sponge achieves 98.1% closure rates versus 10% with saline control. 2

Acute Otitis Externa (AOE) with Suppuration

Topical antimicrobials are the primary treatment; systemic antibiotics should not be prescribed unless there is extension beyond the ear canal or specific host factors (diabetes, immunocompromised state, non-intact tympanic membrane). 1

• Provide analgesics based on pain severity: acetaminophen or NSAIDs for mild-moderate pain; combination products with oxycodone or hydrocodone for moderate-severe pain. 1, 2
• Keep the ear dry and avoid irrigation in patients with suspected or confirmed tympanic membrane perforation. 2

Critical Pitfalls to Avoid

• Never use ototoxic ear drops (aminoglycosides) when the tympanic membrane is perforated or uncertain. 2
• Do not prescribe systemic antibiotics for otitis media with effusion (OME), as they provide no benefit and only increase adverse effects. 8
• Avoid ear irrigation in patients with tympanic membrane perforation, as this introduces infection risk. 2
• Do not use antihistamines or decongestants for OME management (RR 0.99,95% CI 0.92-1.05 for benefit). 8