Probably 60% of infections are mixed viral/bacterial! Pneumococcus, Haemophilus (non capsulated), Moraxella catarrhalis. Group A Strep is characterized by older age, higher local aggressiveness (ie tympanic perforation and mastoiditis) but lower rates of fever and respiratory symptoms. Associated with dummy use, adenoids/tonsillitis.
60% of placebo treated children were pain free within 24 hours of presentation (Cochrane 2004, PMID 14973951). Antibiotics do not increase this proportion. At 2-7 days after presentation, anitibiotics reduce by a third the number of children who still have pain (only 14% of the original number), giving a NNT of 15. Too few cases of complications eg mastoiditis to be able to comment on whether antibiotics are useful for preventing such complications.
Maximize analgesia. Codeine if necessary. No role for decongestants/antihistamines (Cochrane).
BNFc suggests delaying antibiotics until 72 hours. Goes along with SIGN guideline 66 on AOM, which does not recommend routine antibiotics (but if used, Amoxicillin or co-amox for 5 days recommended). SIGN warns that evidence is poor in infants or in severe disease. Delaying antibiotics certainly reduces prescriptions, but in some studies reduced satisfaction and increased duration of symptoms. Better off just avoiding? Cochrane 2007 Delayed antibiotics in URTI, PMID 17636757
BNFc does suggest antibiotics if:
BNFc also suggests that perforation of the tympanic membrane usually heals spontaneously without treatment; but treat if there is no improvement (eg pain or discharge persists).
Lancet 2006 pmid 17055944 meta-analysis supports the idea of treating under 2s with bilateral signs (NNT=4), but unlike the BNFc supports treating otorrhoea (NNT=3)!
Exponential increase in drug resistance and multiresistance. Given how effective placebo is, an effective drug has to do considerably better! Amoxicillin no longer useful, cefaclor and TMP-SMX not good for borderline resistant pneumococci, azithromycin does not achieve MIC for Hib/Pneumo in ear (although cure rates may not be all that bad...). Co-amox in double dose ie 90 mg/kg/d in 2 divided doses is effective, but increasing resistance.
Treatment leads to higher numbers of resistant species in nasopharynx, esp dually resistant bugs. Azithromycin persists in body for several weeks so is excellent for inducing resistance. Despite overall trend towards reducing antibiotic usage in AOM, most reduction in amoxicillin, with increased prescribing of quinolones and azithromycin. So don't treat at all unless added features (unless under a year).Ron Dagan, Beersheva
AAP guidelines - middle-ear effusion (MEE) must be present to make the diagnosis (confirm by pneumatic otoscopy! Recommend treating children uncer 6 months, otherwise only if moderate to severe ear pain or temperature 39degC. (Arch 2004)
Gradenigo syndrome – intratemporal extension of AOM, causing VI nerve palsy (via apex of petrous temporal bone).
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