Acute otitis media: management and surveillance in an era of pneumococcal resistance.
Pediatr Infect Dis J 1999 Jan;18(1):1-9 [33 references]
Not applicable: Guideline was not adapted from
In response to the rapid dissemination of drug-resistant Streptococcus
pneumoniae (DRSP) and the evidence that such dissemination may have a
substantial impact on the management of otitis media, the DRSP therapeutic
working group makes the following recommendations:
- Amoxicillin should be the first-line antibiotic for
acute otitis media.
- In view of the increasing prevalence of DRSP, the
safety of amoxicillin at higher than standard dosages, and evidence that
higher dosages of amoxicillin can achieve effective middle ear fluid
concentrations; the initial dose of amoxicillin should be increased from 40
to 45 mg/kg/day to 80 to 90 mg/kg/day.
- Patients at very low risk for infection with DRSP
(e.g., patients older than 2 years with no antimicrobial exposure in the
preceding 3 months and no day-care attendance) would be appropriate
candidates for amoxicillin given in the standard dosage of 40 to 45
- In cases of clinically defined treatment failure,
consideration should be given to identification of the etiologic agent by
tympanocentesis for susceptibility testing to guide alternate antibiotic
- For clinically defined treatment failures after 3
days of therapy, an alternative agent should be selected after considering
the likelihood of infection with resistant strains and should be effective
with against DRSP and beta-lactamase-producing pathogens. Three agents that
best meet these criteria include oral amoxicillin-clavulanate, oral
cefuroxime axetil, and intramuscular ceftriaxone. Many of the 13 other Food
and Drug Administration-approved otitis media drugs lack good evidence for
efficacy against DRSP.
- Currently available data on local patterns of
pneumococcal resistance from microbiology laboratories, health departments,
or published surveys are often poorly representative of the outpatient
population with AOM. In general such data should rarely be used to guide
treatment decisions for AOM.
- Recommendations to improve surveillance include
establishing criteria for setting susceptibility breakpoints for clinically
appropriate antimicrobials to ensure relevance for treating AOM, testing
middle ear fluid or nasal swab isolates in addition to sterile site isolates
and testing of drugs that are useful in treating AOM.
- Future electronic laboratory surveillance may be both comprehensive and
timely. Such surveillance may eventually allow clinicians to incorporate
local susceptibility information into clinical decision
Centers for Disease Control and Prevention (CDC) - Federal Government Agency [U.S.]
Drug-Resistant Streptococcus Pneumoniae Therapeutic
The Drug-Resistant Streptococcus Pneumoniae Therapeutic Working Group
was convened by the Centers for Disease Control and Prevention (CDC) to respond
to changes in antimicrobial susceptibility and included among its members
practicing pediatricians, family physicians and internists, academicians, and
public health practitioners
Authors: Scott F. Dowell, MD, MPH; Jay C. Butler, MD; G. Scott Giebink,
MD; Michael R. Jacobs, MD; Daniel Jernigan, MD; Daniel M. Musher, MD; Alexander
Rakowsky, MD; Benjamin Schwartz, MD, and the Drug-Resistant Streptococcus
This is the current release of the guideline.
An update is not in progress at this time.
Electronic Copies: Not available at this time.
Print copies: Available from the Centers for Disease Control and Prevention,
MMWR, Atlanta, GA 30333. Additional copies can be purchased from the
Superintendent of Documents, U.S. Government Printing Office, Washington, DC
20402-9325; (202) 783-3238.
This summary was completed by ECRI on March 20, 1999. The information was verified by the guideline developer on April 30, 1999.
No copyright restrictions apply.
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