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 Sinusitis a Regimen Drug, Dose Duration Comments Otitis: 3– 5 days after clinical response, not to exceed 7 days total (see text) First-line Amoxicillin, 1 g q8h b Sinusitis: 7– 10 days after clinical respons e, 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 q8h c Same as above If this regimen fails, try the third-line regimen. or Fluoroquinolone d or Telithromycin, 800 mg/d Otitis: 3– 5 days Third- line Ceftriaxo ne, 1 g qd Sinusitis: Longer If this regimen fails, consider complications. Consult an otolaryngologist and/or infectious disease specialist. a Except as noted, doses are for adults. Treatment for otitis media or sinusitis is empiric al, 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 a lone (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). . Chapter 128. Pneumococcal Infections (Part 7) Antibiotic Regimens Otitis Media (Table 128- 4) Current treatment recommendations for otitis. resist β-lactamases tend to be very expensive compared with amoxicillin. Table 128- 4 Regimens for the Treatment of Pneumococcal Otitis Media or Sinusitis a Regimen Drug, Dose Duration Comments. 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