Should Acute Otitis Media Ever Be Treated with

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Abstract
The articles prior to January 2008 are part of the back file collection and are not available with a current paid subscription. To access the article, you may purchase it or purchase the complete back file collection here Dennis A Conrad, MD In a time of widespread availability of a number of broad-spectrum antimicrobial agents for the treatment of acute otitis media, one of the more contentious issues provoking discussion is not which antibiotic is best, but, instead, whether or not any antibiosis is needed at all to effect satisfactory clinical improvement. Prior to introduction of effective antibacterial therapy, otitis media often resulted in serious complications, including chronic suppurative otitis media, mastoiditis, brain abscess, epidural and subdural empyemia, and meningitis. In the preantibiotic era, mastoiditis was a complication of acute otitis media in approximately 20% of all cases, and intracranial extension of infection occurred in 2.5% of patients. Following the introduction of antibiotics, rates for these complications declined to 2.8% and 0.13%, respectively.1 The almost universal use of anti-infective therapy in this country to treat otitis media has undoubtedly played a part in the reduction of suppurative complications of otitis media. But because the incidence of infectious complications has also been reduced in countries where routine antibacterial treatment of acute otitis media is not as widely practiced, other nontreatment factors must have also contributed to this improvement in outcome. Despite the perceived benefit of the routine use of antibiotics to treat uncomplicated cases of acute otitis media to achieve prompt clinical resolution and prevent suppurative complications, the purported advantages of nondiscriminating therapy is being reconsidered, due largely to the emergence of penicillin resistance in previously susceptible Streptococcus pneumoniae.2 The initial detection of ampie illin-resistance in Haemophilus influenzas and Moraxella catarrhalis, mediated through the production of ß-lactamase hydrolytic enzymes, was transiently concerning but not overly problematic, due to the prompt development of β-lactamase-resistant antibacterial agents. However, the development of penicillin-resistance in S fmeumoniae is proving to be more worrisome, as the mechanism of resistance, alteration in penicillinbinding affinity by cell-wall receptors, has not yet been overcome by the development of broadly active oral antimicrobials. While awaiting an oral antibacterial effective against penicillin- resistant strains, one way the increasing prevalence of penicillin-resistant S pneumoniae may be muted in the meantime is by reducing the presence of ß-lactam antibiotics in the environment. As treatment of acute otitis media constitutes one of the most frequent uses of oral antimicrobials, any appreciable reduction Jn treatment will potentially reduce the environmental factors selecting the emergence of antibiotic resistance. Assuming decreased utilization of antibiotics will indeed diminish the prevalence of penicillin-resistant S pneumoniae, can we then safely forgo treatment of acute otitis media for this potential benefit without appreciably increasing the risks that nontreatment may hold for the patient? EFFECT OF NONTREATMENT VERSUS TREATMENT ON ACUTE OTITIS MEDIA The outcomes of treating and not treating acute otitis media have been reported in five medical articles that have compared the results of placebo (or nonantibiotic symptomatic therapy) against active anti-infective agents. The first study was designed to investigate the interrelationships among bacteria, viruses, mycoplasmas, and L-forms in otitis media; included was a comparative outcome of treatment with antibiotic therapy and placebo.3 Outcomes were measured by defervescence and decrease in symptoms at 24 to 72 hours following initiation of therapy and by lack of patient symptoms and normal appearance of the tympanic membrane at 14 to 18 days following initiation of therapy. Twenty of the 30 (66%) ampicillin recipients, 25 of the 32 (78%) penicillin-sulfisoxazole recipients, and 20 of the 27 (74%) placebo recipients showed improvement by 24 to 72 hours of treatment. Three (10%) of the ampicillin recipients, two (6%) of the penicillm-sulfisoxazole recipients, and six (22%) of the placebo recipients were removed from the study after 24 to 72 hours due either to recovery of Streptococcus pyogenes from ear… 10.3928/0090-4481-19980201-04