Antibiotic Choices For Treating Acute Otitis Media
Standard Antibiotics for Acute Otitis Media (AOM)
While many different antibiotics may be used to effectively treat otitis media, the physician needs to balance effectiveness, safety, and convenience, as well as try to minimize the emergence of resistance. To this end the CDC has made very clear recommendations about first and second line treatments
First Line of Therapy
Of note, about 15% of the bacteria that cause ear infections are now believed to be resistant to the first-choice antibiotics. This means that only about half of children will respond to a given antibiotic.
The most widely prescribed antibiotic for acute otitis media is amoxicillin (Amoxil, Polymox, Trimox, Wymox, or any generic formulation). This oral penicillin is both inexpensive and highly effective against the S. pneumoniae bacteria. Unfortunately, bacterial resistance to amoxicillin has increased significantly. A 2000 study, in fact, reported that 24% of S. pneumonia strains in the US were resistant to penicillin. And resistant infections reached 32% in children under five. Amoxicillin is also not as effective against H. influenzae . In areas where bacterial-resistance to antibiotics is high, some physicians recommend high-dose amoxicillin.
Ofloxacin (Floxin), an antibiotic available in ear drops is now recommended as first-line therapy for children with AOM who also have perforated ear drums or implanted tympanostomy tubes. Ofloxacin is known as a fluoroquinolone (also simply called quinolone) and is proving to be very effective and safe for these children. (It should be noted that drops are effective only in these cases.) Another quinolone, ciprofloxacin, is also available in eardrop form outside the US.
If treatment fails after 72 hours, for recurrent or persistent acute otitis media, or if the patient has had other antibiotics within the past month then the following are recommended:
Amoxicillin/clavulanate combination (Augmentin). This agent is known as an augmented penicillin, which works against a wide spectrum of bacteria.
Certain second- or third-generation oral cephalosporin antibiotics may also be good second-line options. Of these Cefuroxime (Ceftin) and cefpodoxime (Vantin) has the best record to date among the cephalosporins for coverage against bacteria that infect the upper respiratory tract. (Their safety and effectiveness in infants under six months old are not proven.)
Ceftriaxone (Rocephin), an injectable cephalosporin, is also an option. Administering it in a single injection may be sufficient for some children, although a 2001 study reported that a three-day regimen was more effective for children with non-responsive otitis media.
Antibiotics for Other Circumstances
More powerful and expensive antibiotics are available for other circumstances, including the following:
For children who are allergic to penicillin, cephalosporins, of both. (These antibiotics belong to a class beta lactam antibiotics. A person who is allergic to penicillin has a 5% to 14% chance of being allergic to a cephalosporin.)
For children who do not respond to these agents other options are available For children with persistent or recurrent episodes of acute otitis media.
These antibiotics are usually very expensive, however, and are not commonly used. They include the following:
Trimethoprim-sulfamethoxazole (Bactrim, Cotrim, Septra) or a combination of erythromycin and sulfisoxazole (Eryzole, Pediazole) are useful for people allergic to penicillin. It should not be used in patients whose infections occurred after dental work or in patients allergic to sulfa drugs. Allergic reactions can be very serious. Bacterial resistance to these agents has increased dramatically, however, and failure rates are high in certain regions. An oral solution (Primsol) uses trimethoprim alone. It poses less risk for an allergic reaction than the combination and yet is still effective.
Macrolides are other agents sometimes used as an alternative. They include erythromycin, azithromycin (Zithromax), clarithromycin (Biaxin), and roxithromycin (Rulid). These antibiotics are effective against S. pneumoniae and M catarrhalis , but there is increasing bacterial resistance to these agents. They are not effective against H. influenzae. Azithromycin only needs to be taken for five days. Shorter regimens are being investigated. In one study comparing Zithromax to Augmentin, the five day regimen of azithromycin (Zithromax) was less effective than Augmentin. In another study, however, a one dose regimen was as effective as Augmentin. More research is needed.
Side Effects of Antibiotics
The most common side effects of nearly all antibiotics are gastrointestinal problems, including cramps, nausea, vomiting, and diarrhea.
Allergic reactions can also occur with all antibiotics but are most common with medications derived from penicillin or sulfa. These reactions can range from mild skin rashes to rare but severe, even life-threatening anaphylactic shock.
Some drugs, including certain over-the-counter medications, interact with antibiotics; patients should report to the physician all medications they are taking.
Warnings on Antibiotic Over-Use and Resistant Bacteria
Over-prescription of Antibiotics for Colds and Flus
Each year in the United States, 160 million prescriptions are written for antibiotics, equal to about 25,000 tons of these drugs. About half are used for patients and half animal, fish, and other agricultural uses.
Virtually no antibiotics for colds are necessary, even with persistent cough and thick, green mucus, unless there is evidence of an accompanying infection. In one disturbing study, antibiotics were prescribed for nearly half of children who went to the doctor for a common cold. And experts estimate that, outside the hospital setting, only half of the antibiotics currently being prescribed for sore throat and 20% of prescriptions for persistent coughing are necessary.
Antibiotics may be required for upper respiratory tract infections only under certain situations, such as the following:
In patients, particularly small children or the elderly, who have medical conditions that put them at high risk for complications from such infections.
In strep throat (which is caused by the Streptococcal bacteria). (Strep throat makes up only about 12% of all sore throat cases.)
In some cases of an accompanying sinusitis, ear, or other bacterial infection.
Prescribing antibiotics to so many people who do not require antibiotics is raising great concern among health professionals because of emerging strains of bacteria that are no longer eliminated using many standard antibiotics. Although new powerful antibiotics continue to be designed, they are expensive and are also prone to resistance eventually.
The prevalence of such antibiotic-resistant bacteria has dramatically increased worldwide. A 2000 study reported that 24% of Streptococcus pneumoniae strains are resistant to penicillin in the US. In general, regions and institutions with the highest rate of resistance are those in which antibiotics are heavily prescribed. In America, for instance, Georgia and Tennessee have the highest resistance to penicillin.
As of yet, the average person is not endangered by this problem. Patients at greater risk for developing an infection resistant to common antibiotics are those with following conditions:
- Being very old or very young.
- Being exposed to patients with drug-resistant infection.
- Hospitalization in intensive care.
- Having had an invasive procedure.
- Having had a hospital stay.
- Having had prior and prolonged antibiotic therapy, particularly within the past four to six weeks.
- The presence of a wound.
- Having intravenous lines, catheters, or tubes down the throat.
- Being immunosuppressed.
There are some signs of hope:
The Centers for Disease Control and Prevention (CDC) is reporting a decline in antibiotic prescriptions since the early 1990s.
And, countries that have reduced their dependence on penicillin are reporting a parallel decline in bacteria resistant to the antibiotic.
Innovative approaches are being investigated. One involves creating antibiotics that have the capacity to either self-destruct or regenerate themselves.
Greater emphasis is being placed on development of vaccines and expanding immunization programs to prevent infections in the first place.
What Patients and Parents Can Do.
For colds and mild flu, use remedies to relieve symptoms. Realize that antibiotics will not shorten the course of a viral infection.
Don't pressure a physicians into prescribing an antibiotic if it is clearly inappropriate. The physician very often will give in. It is important for patients and parents to understand that although antibiotics may bring a sense of security, they provide no significant benefit for a person with viral infection, and overuse can contribute to the growing problem of resistant bacteria.
If an antibiotic is prescribed, take the full course.
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