Chapter 128. Pneumococcal Infections (Part 7) doc

Pneumococcal Infections Part 7 Antibiotic Regimens Otitis Media Table 128-4 Current treatment recommendations for otitis media are based on the following points: 1 Acute otitis media

Chapter 128 Pneumococcal Infections

(Part 7)

Antibiotic Regimens

Otitis Media

(Table 128-4) Current treatment recommendations for otitis media are

based on the following points: (1) Acute otitis media is the most common

diagnosis leading to an antibiotic prescription in the United States (2) The

diagnosis is often based on inadequate evidence for true middle-ear infection (3)

In proven cases, S pneumoniae and H influenzae are the most likely causes (4)

Because penetration into a closed space may be reduced, high serum levels of an

effective antibiotic are required to treat otitis caused by intermediately or fully

resistant pneumococci (5) S pneumoniae is more likely than Haemophilus and

much more likely than Moraxella to cause progression to serious complications

without specific therapy (6) Antibiotics that are effective against pneumococci

and yet resist β-lactamases tend to be very expensive compared with amoxicillin

Table 128-4 Regimens for the Treatment of Pneumococcal Otitis Media

or Sinusitisa

Otitis: 3–5

days after clinical

response, not to

exceed 7 days

total (see text)

First-line Amoxicillin, 1 g

q8hb

Sinusitis:

7–10 days after

clinical response,

not to exceed 2

weeks total

If this

regimen fails, try a

second-line regimen

Second-line

Amoxicillin, 1 g

q8h, plus clavulanic acid,

125 mg q8hc

Same as

above

If this

regimen fails, try the

third-line regimen

or

Fluoroquinoloned

or

Telithromycin,

800 mg/d

Otitis: 3–5

days

Third-line

Ceftriaxone, 1 g

qd

Sinusitis:

Longer

If this

regimen fails,

consider

complications

Consult an

otolaryngologist

and/or infectious

disease specialist

Except as noted, doses are for adults Treatment for otitis media or

sinusitis is empirical, since aspiration of the involved area to establish an etiologic

diagnosis is rarely undertaken, except under the conditions of a research protocol

b

Dose for infants and toddlers: 80–90 mg/kg per day in 2 or 3 divided

doses

c

Give half as amoxicillin alone (500 mg) and half as amoxicillin (500

mg)/clavulanic acid (125 mg)

d

Moxifloxacin, 400 mg/d; or levofloxacin, 500 mg/d

As a result of these considerations, the American Academies of Pediatrics

and Family Practice recommend that clinicians apply due diligence in diagnosing

otitis In children 6 months to 2 years of age with nonsevere illness and an

uncertain diagnosis and in children >2 years of age with nonsevere illness (even if

the diagnosis seems certain), symptom-based therapy and observation may be used

instead of antimicrobial therapy When parents of children with otitis are given a

prescription for an antibiotic but are instructed not to fill it unless the disease

progresses, no antibiotic is given in many cases, yet rates of patient satisfaction are

high If otitis media is clearly diagnosed, high-dose amoxicillin is recommended

(Table 128-4) If this regimen fails, highly penicillin-resistant pneumococci or

β-lactamase-producing Haemophilus or Moraxella may be responsible; amoxicillin

may be given at the same total dosage but with one-half of the dose in the form of

amoxicillin/clavulanic acid If this regimen fails, three doses of ceftriaxone at

daily intervals are likely to be curative A quinolone or ketolide may also be tried

in adults Patients must be monitored closely for a response An otolaryngology

consultation is recommended if all these treatments fail Despite the detection (by

molecular analysis) of pneumococcal DNA in middle-ear fluid, chronic serous

otitis ("glue ear") is probably not due to active infection and does not require

antibiotic therapy Treatment for otitis is recommended for a total of 10 days in

children <2 years of age but for only 5 days in children ≥2 years old who do not

have complicated infections A recent study reported identical rates of clinical and

bacteriologic cure with a 10-day course of amoxicillin and a single dose of

azithromycin (30 mg/kg)