Otite media acuta

Changing circumstances often call for reconsideration of established procedures. Such a circumstance is the increasing prevalence worldwide of infection due to multiple-drug-resistant Streptococcus pneumoniae.

In most parts of the world the increase in resistance has involved beta-lactam drugs, mainly the various penicillins, but in Italy the increase in penicillin resistance has been limited and resistance has increased mainly in regard to macrolides. In my view the increasing prevalence of antibiotic resistance on the part of S. pneumoniae calls for certain modifications of common, current practice in managing otitis media: individualizing to a greater extent the duration of antimicrobial treatment for episodes of acute otitis media (AOM); substantially curtailing antimicrobial treatment for secretory otitis media (otitis media with effusion; OME); and largely backing away from antimicrobial prophylaxis to prevent AOM recurrences.

The prevalence of beta-lactam resistant pneumococcal strains is directly related to previous treatment with beta-lactam drugs, and also to day-care attendance. Resistance to macrolides appears to be related mainly to widespread use of the newer macrolide drugs in particular. Both the development of resistant strains and their rapid spread have likely been fostered and facilitated by selective pressure resulting from extensive use of antimicrobial drugs, the most common target of which, in children, undoubtedly is otitis media. Currently, the only antimicrobial to which resistance by S. pneumoniae has not been reported is vancomycin. The possibility remains that multiply resistant pneumocci will eventually develop resistance to vancomycin also, leaving us with no effective means of treating serious infections caused by these organisms.

Given this background, I believe that we must curtail antimicrobial treatment where we can do so without subjecting individual patients to undue risk. Rational management strategies first require that otitis media be classified clinically as either AOM or OME, a distinction that, to some extent, is necessarily arbitrary.

AOM 

Individual episodes of AOM have customarily been treated with an antimicrobial drug(s) for 10 days. Shorter courses of treatment are sufficient for many cases, but evidence suggests that shorter courses are not sufficient for infants and younger children. Reasonably, one should individualize the duration of treatment, based on the child's age, the season of the year, the severity of the episode, the child's previous history of otitis media, and the child's response to current treatment. Although some authors have recommended withholding antimicrobial treatment entirely in some or all cases of AOM unless symptoms persist or worsen, this policy seems injudicious currently, not only because symptomatic improvement and resolution of infection occur more promptly and more consistently with antimicrobial treatment than without, but also because the striking secular decline in the occurrence of mastoiditis and other suppurative complications of otitis media over the past half-century appears attributable mainly to the widespread routine treatment of AOM with antimicrobials. Nonetheless, the policy of routinely withholding treatment initially will deserve further consideration if the problem of resistant pneumococci continues to escalate.

OME

In a number of studies of OME antimicrobial treatment has afforded higher rates of short-term resolution of effusion, but not of longer-term resolution. These findings have prompted many physicians to prescribe antimicrobial treatment more or less routinely both for new episodes of OME and for OME persisting for variable periods after initial antimicrobial treatment for AOM. Further, when OME has persisted despite antimicrobial treatment, some physicians have continued to prescribe, in succession, courses of alternative antimicrobial drugs. Prudence dictates that these practices be sharply curtailed. I would currently reserve antimicrobial treatment in children with OME for (1) those with a very unfavorable past history of otitis media, or (2) those with an associated chronic (duration >2 weeks) upper respiratory tract infection that is not improving, or (3) those in whom persistence of effusion is prompting consideration of tympanostomy-tube placement. If antimicrobial treatment is undertaken, its duration should be kept limited.

Recurrent AOM

Antimicrobial prophylaxis provides variable protection against the development of recurrent episodes of AOM. For that reason physicians have often recommended prophylaxis for children who have developed frequent episodes. However, because of the probable contribution of antimicrobial usage to pneumococcal resistance, the risks of sustained antimicrobial prophylaxis now likely outweigh the benefits. Particularly does this seem to be the case for children in day care, who are at increased risk of colonization with multiple-drug-resistant S. pneumoniae. In children severely affected with AOM recurrences, alternatives to prophylaxis consist of either antimicrobial treatment of recurrent episodes as they develop, or tube placement. Tube placement may seem attractive because it is reasonably effective in the short term and also dramatic and definitive, but tube placement also is associated with both short- and long-term risks. Overall, continued reliance on episodic antimicrobial treatment seems the best course to follow if the problem is not seen as extreme or overwhelming, because this course appears to pose the fewest long-term risks, and because AOM recurrences tend to become less frequent and less severe as children grow older.