Otitis Media: Changing Causative Organisms, Changing Treatments

A comprehensive review of otitis media in North America addresses how shifts in the organisms that most commonly cause the condition affect preferred treatments.

Otitis media (OM) is a moving target. Primarily affecting young children, its causative agents change under the pressure of vaccination and emerging bacterial resistance to common antibiotics. Pharmacists who see many children in their practices need to stay current with emerging resistance patterns and treatment recommendations. Different prescribing practices in different countries mean that studies conducted in one country may not be applicable to other countries.

Michael E. Pichichero, MD, of the Center for Infectious Diseases and Immunology at the Rochester General Hospital Research Institute, has compiled a comprehensive review covering otitis media in North America. The review was published in the April 2013 issue of Pediatric Clinics of North America.

Dr. Pichichero’s analysis of OM-causing bacteria indicates that β-lactamase—producing Haemophilus influenzae and Moraxella catarrhalis have emerged as the leading causative organisms of acute otitis media. Streptococcus pneumonia follows in third place. He attributes these developments to antibiotic pressure and increased coverage with the pneumococcal conjugate vaccine.

Dr. Pichichero reports that, although current American Academy of Pediatrics guidelines designate amoxicillin as the preferred treatment for acute OM, recent elevated rates of amoxicillin-resistant H influenzae and M catarrhalis move high-dose amoxicillin-clavulanate into the preferred treatment realm. If an oral cephalosporin is necessary, he notes that cefdinir, cefuroxime, and cefpodoxime proxetil are preferred. In addition, he reminds clinicians that cefdinir is the most palatable of the cephalosporins to children.

Acute OM can become otitis media with effusion (OME), or chronic OME (defined as OME lasting longer than 3 months). In the past, pediatricians have addressed OME by prescribing a stronger antibiotic, but this is no longer recommended. Dr. Pichichero also notes that antibiotic prophylaxis is no longer recommended as a preventive strategy for acute OM recurrences. He presents an overview of pain management, which is recommended for all children who have OM, and points out that use of decongestants and antihistamines is not recommended in treatment of acute OM or OME.

In agreement with other experts, Dr. Pichichero advocates coverage with pneumococcal and influenza vaccines. He notes that use of the influenza vaccine can prevent at least 1 episode of acute OM each winter.

Ms. Wick is a visiting professor at the University of Connecticut School of Pharmacy and a freelance writer from Virginia.