Duration of Treatment for Mastoiditis
Antibiotic Duration
For uncomplicated acute mastoiditis, intravenous antibiotics should be administered for 7-10 days, followed by transition to oral antibiotics based on clinical improvement and culture results. 1
Initial Intravenous Therapy
- Start IV broad-spectrum antibiotics immediately upon diagnosis, targeting common pathogens including Streptococcus pneumoniae, Streptococcus pyogenes, and Staphylococcus aureus. 1, 2
- High-dose IV amoxicillin-clavulanate (80-90 mg/kg/day of the amoxicillin component, maximum 4000 mg/day) is the preferred first-line agent for pediatric patients with serious infection. 1
- For adults, cloxacillin/flucloxacillin 2g IV every 6 hours is recommended. 3
- Continue IV antibiotics for a minimum of 7-10 days before considering transition to oral therapy. 1, 3
Transition to Oral Therapy
- Once clinical improvement is noted, transition to oral antibiotics may be considered, with the specific agent guided by culture results when available. 1
- For patients who fail initial therapy, consider clindamycin with or without coverage for Haemophilus influenzae and Moraxella catarrhalis, guided by culture results. 1
Total Treatment Duration Considerations
The total duration of antibiotic therapy depends on several factors:
- Uncomplicated mastoiditis: After 7-10 days of IV antibiotics, continue oral antibiotics for an additional period to complete treatment, though specific total duration is not rigidly defined in guidelines. 1, 3
- Complicated mastoiditis with intracranial involvement: Requires prolonged therapy, with broader coverage including vancomycin plus piperacillin-tazobactam, a carbapenem, ceftriaxone plus metronidazole, or a fluoroquinolone plus metronidazole. 1
- Post-surgical cases: Continue IV antibiotics for 7-10 days postoperatively, then transition to oral antibiotics based on culture results. 3
Surgical Management Timeline
- Reassess at 48-72 hours: If no improvement after 48 hours of IV antibiotics, or if clinical deterioration occurs at any point, obtain CT imaging and consider surgical intervention (mastoidectomy). 1, 2, 4
- Conservative management (antibiotics alone or with myringotomy) achieves success in 68-78% of uncomplicated cases, while 22% require mastoidectomy. 1, 5
Follow-Up and Monitoring
- Regular follow-up is essential to ensure complete resolution and monitor for complications or recurrence. 1
- Persistent middle ear effusion is common after resolution of acute symptoms and should be monitored. 1
- Perform hearing assessment if effusion persists for ≥3 months. 1
Important Caveats
- Prior antibiotic treatment does not prevent mastoiditis development, with 33-81% of patients having received antibiotics before diagnosis. 1, 3
- Hospital stay averages 4.3 days for conservative management of uncomplicated cases versus 7.8 days for surgical cases. 4
- For complicated cases with intracranial involvement, mean hospital stay is 12.8 days with surgery versus 18 days with conservative management alone. 4