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Don't routinely give antibiotics for otitis media. (Dutch Physicians Are In Lead).

NEW YORK -- Following the lead of the Dutch in the management of acute otitis media could help reduce pneumococcal resistance rates in this country, which now range from 16% to 40%.

Resistance rates of Streptococcus pneumoniae in the Netherlands are less than 1%, at least in part because Dutch physicians do not routinely administer antibiotics to children with acute otitis media unless symptoms persist beyond 48 hours. "Certainly the Dutch are doing something right," Dr. S. Michael Marcy said at a meeting sponsored by the American Academy of Pediatrics.

Initial watchful waiting with analgesic treatment is one of the evolving principles of treatment under discussion by a subcommittee of the AAP's committee on quality improvement, said Dr. Marcy, who is a member of both committees.

"But these are principles, not yet recommendations," he stressed.

A review of the literature identified nine studies that evaluated the utility of antibiotic treatment, compared with placebo in acute otitis media, looking at efficacy at 24 hours, at 2-3 days, at 4-7 days, and at 4-6 weeks. "In these studies, at the end of 24 hours patients were just as likely to be symptomatic with antibiotics as without," said Dr. Marcy, clinical professor of pediatrics at the University of Southern California and the University of California, both in Los Angeles. "The data do not support a dramatic response with antibiotics compared to placebo," he said.

A second, much more certain principle that has been established is that treatment of pain and discomfort is paramount in the management of acute otitis media, Options include topical benzocaine or analgesia with acetaminophen, a nonsteroidal anti-inflammatory agent, or codeine plus promethazine with or without additional acetaminopheri. "I use a lot of this," Dr. Marcy said, noting that he favors the sedative plus analgesic effects, but cautions against this approach when the child has concomitant asthma or a wet cough.

And accurate diagnosis, holds a central place in the new principles. "Everybody agrees on this," he said of the subcommittee on otitis media management, which includes pediatricians and representatives of family medicine and otolaryngology.

Acute otitis media, the group says, will be defined as "the presence of middle ear effusion with the rapid onset (less than 48 hours) of one or more signs or symptoms of inflammation of the middle ear, such as otalgia, pulling of the ear, or irritability in an infant or toddler, otorrhea, and fever."

A very useful clinical sign of acute otitis media in infants is waking during the night crying, Dr. Marcy said. In addition, he cautioned against reliance on tympanic membrane color to diagnose acute otitis media. Position and mobility also must be taken into account, Bulging of the eardrum and distinctly impaired mobility frequently characterize the condition, he said.

RELATED ARTICLE: Options When Antibiotics Are Best

When symptoms of acute otitis media persist and antibiotics are indicated, amoxicillin is the preferred agent, Dr. Marcy said.

When a history of anaphylaxis or severe [beta]-lactam allergy exists, options include azithromycin, clarithromycin, trimethoprim / sulfamethoxazole, and erythromycin/ sulfisoxazole.

The recommended dosage is 40-90 mg/kg per day in two divided doses for 5-10 days depending on age: 10 days for children younger than 2 years old; 7 (lays for those 2-4 years old; 5 days For those older than 4 years old. At-risk children, such as those in day care or under age 3, should get the higher dose. Alternatives in case of non--type I or uncertain allergy to [beta]-lactams include cefdinir, cefuroxime, or cefpoxime.

Children who are vomiting or refuse medication can get a single intramuscular close of ceftriaxone, 50 mg/kg, he said. This is also an option if caretaker compliance is uncertain.
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Comment:Don't routinely give antibiotics for otitis media. (Dutch Physicians Are In Lead).
Author:Walsh, Nancy
Publication:Family Practice News
Article Type:Brief Article
Geographic Code:4EUNE
Date:Oct 15, 2001
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