From the Guidelines
Acute otitis media complications can be severe and life-threatening, and prompt recognition and treatment are crucial to prevent morbidity and mortality, with the most recent and highest quality study suggesting that complications such as mastoiditis, meningitis, and brain abscesses require immediate antibiotic therapy and possible surgical intervention 1. The complications of acute otitis media can be divided into intratemporal and intracranial manifestations, including:
- Mastoiditis, which is the most common complication, presenting with postauricular pain, erythema, swelling, and outward protrusion of the auricle
- Intracranial complications, such as meningitis, brain abscess, subdural and epidural empyema, lateral sinus thrombosis, and otitic hydrocephalus Treatment of these complications involves:
- High-dose intravenous antibiotics, such as ceftriaxone and vancomycin, for 10-14 days
- Surgical intervention, such as mastoidectomy, if medical therapy fails
- Neurosurgical drainage alongside antibiotics for brain abscesses The risk factors for these complications include:
- Delayed antibiotic treatment
- Immunocompromised status
- Virulent pathogens Diagnosis and management of suspected complications require:
- Blood cultures
- Imaging, such as CT or MRI scans According to the most recent study, the treatment of acute mastoiditis has shifted towards nonsurgical management with intravenous antibiotics, either alone or combined with myringotomy and tympanostomy tube insertion and/or needle aspiration of the subperiosteal abscess 1.
From the FDA Drug Label
CLINICAL STUDIES SECTION Pediatric Patients ... Acute Otitis Media
For the 553 patients who were evaluated for clinical efficacy, the clinical success rate (i. e., cure plus improvement) at the Day 11 visit was 88% for azithromycin and 88% for the control agent.
The following presumptive bacterial/clinical cure outcomes (i.e., clinical success) were obtained from the evaluable group:
Presumed Bacteriologic Eradication
Day 11 Day 30
Azithromycin Azithromycin
S. pneumoniae 61/74 (82%) 40/56 (71%)
H. influenzae 43/54 (80%) 30/47 (64%)
M. catarrhalis 28/35 (80%) 19/26 (73%)
S pyogenes 11/11 (100%) 7/7
Overall 177/217 (82%) 97/137 (73%)
The FDA drug label does not answer the question about acute otitis media complications.
From the Research
Acute Otitis Media Complications
- Acute otitis media (AOM) is one of the most common infectious diseases affecting infants and children, and one of the leading causes of office visits and antibiotic prescriptions for this population 2.
- The incidence of AOM has increased during the past 25 years, probably due to an increased utilization of day care facilities in the United States 2.
- The predominant pathogens in AOM include S. pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 2, 3.
- The high prevalence of drug-resistant S. pneumoniae and beta-lactamase-producing organisms presents a clinical challenge for practitioners in the selection of empiric antimicrobial therapy 2, 3.
Treatment and Management
- Amoxicillin at conventional or high doses (80-90 mg/kg/day) remains an appropriate choice for first-line therapy for AOM 2, 3.
- For patients in whom amoxicillin is unsuccessful, second-line therapy should have demonstrated activity against penicillin-resistant S. pneumoniae as well as beta-lactamase-producing pathogens 2, 3.
- Appropriate options for second-line therapy include high-dose amoxicillin/clavulanate (90 mg/kg/day based on the amoxicillin component) and ceftriaxone 2, 3.
- Tympanocentesis is useful for identifying the causative pathogen, and it may be beneficial for patients who have failed multiple courses of antibiotics 2, 4.
Prevention of Recurrent AOM
- Azithromycin and amoxicillin have been compared in the prevention of recurrent AOM, with similar clinical responses (80.6% vs 89.5%, P=0.300) 5.
- A prophylaxis with azithromycin is as useful as amoxicillin to prevent recurrent AOM 5.
- Amoxicillin/clavulanate has superior bacteriologic and clinical efficacy compared with azithromycin in children with AOM, particularly in eradicating Haemophilus influenzae from middle ear fluid 4.