Pediatric Infectious Disease Express Report

Based on the CME-symposium "New Data, New Guidelines-Management of Otitis and Sinusitis in Children" presented November 1, 2003 during the American Academy of Pediatrics 2003 National Conference and Exhibition, November 1-5, 2003 New Orleans, Louisiana

Publication date: 2003-12-24

New Data, New Guidelines for the Management of Pediatric Otitis Media and Sinusitis

This report was reviewed for medical and scientific accuracy by University of Medicine and Dentistry of New Jersey.

Expert Commentary

Ron Dagan, MD, Director, Pediatric Infectious Disease Unit, Soroka University Medical Center; Professor of Pediatrics and Infectious Diseases, Ben-Gurion University of the Negev, Beer-Sheva, Israel

New guidelines on treating acute otitis media will soon be issued from the American Academy of Pediatrics/American Academy of Family Physicians that will reaffirm the safety and efficacy of high-dose amoxicillin and high-dose amoxicillin/clavulanate (Augmentin ES) in the management of infections caused by penicillin-susceptible, penicillin-intermediately-resistant, and penicillin-resistant bacteria. In a recent comparative study of acute otitis media, high-dose amoxicillin/clavulanate demonstrated superior bacteriologic efficacy in 90 to 96% of pathogens, and produced significantly more favorable clinical success rates at 12 to 14 days (end-of-therapy) than azithromycin (Zithromax).¹ Amoxicillin and amoxicillin/clavulanate, therefore, remain the mainstays of our armamentarium, including initial and recurrent infections alike, though their judicious use is only part of the proper management of acute otitis media.

Increasing bacterial resistance to antibiotic therapies is a growing global problem that threatens the utility of existing therapies and compromises patient care. The highest frequency of bacterial resistance is observed in children, especially those with acute otitis media and acute bacterial rhinosinusitis, and is generally attributed to extensive use of antibiotics and selective pressure on bacterial strains of nasopharyngeal flora. Current dogma holds that a reduction in antibiotic use will lead to a reduction in the incidence of bacterial resistance, but this approach is insufficient. The factors behind the appropriate selection of initial antibiotic therapy must also be considered. Accurate diagnosis is also critical, not only for optimal clinical outcomes but in order to reserve antibiotics for children who really need them.

This Pediatric Infectious Disease Express Report will review these important issues that were presented during a two-hour interactive CME-symposium on the management of otitis and sinusitis conducted during the American Academy of Pediatrics 2003 National Conference and Exhibition.

Introduction

According to Faculty Chair Colin D. Marchant, MD, Associate Professor of Pediatrics, Boston University School of Medicine and Tufts University School of Medicine, Director, Center for Pediatric Vaccine Research, Boston University, Boston, Massachusetts, acute otitis media and acute bacterial rhinosinusitis have similar anatomic and pathophysiologic features, are often preceded or accompanied by a viral upper respiratory infection, and have a common bacterial etiology, principally Streptococcus pneumoniae (S. pneumoniae), Haemophilus influenzae (H. influenzae), and Moraxella catarrhalis (M. catarrhalis).² Both acute otitis media and acute bacterial rhinosinusitis improve faster when treated with antibiotics than in untreated children. Upper respiratory infections without acute otitis media or acute bacterial rhinosinusitis, however, do not warrant antibiotics and their indiscriminate use result in the selection of antibiotic-resistant bacteria, side effects and unnecessary costs for the patient.

Accurate Diagnosis is Essential

The effective and responsible management of acute otitis media and acute bacterial rhinosinusitis hinges largely on proper diagnosis, which can be difficult in young children, advised Michael D. Poole, MD, PhD, Professor and Chair of Otolaryngology-Head and Neck Surgery, University of Texas Health Science Center, Houston, Texas.³ Otitis media with effusion is characterized by middle ear fluid without significant signs of inflammation. Acute otitis media, on the other hand, prese