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November 26, 1997, Vol 278, No. 20 >
ARTICLE | November 26, 1997

Routine Antimicrobial Treatment of Acute Otitis Media: Title and subTitle BreakIs it Necessary? FREE

Larry Culpepper, MD, MPH; Jack Froom, MD
[+] Author Affiliations

Reprints: Larry Culpepper, MD, MPH, Department of Family Medicine, Boston University School of Medicine, One Boston Medical Center Place, Boston, MA 02118.

Controversies section editor: Phil B. Fontanarosa, MD, Senior Editor.


JAMA. 1997;278(20):1643-1645. doi:10.1001/jama.1997.03550200019007
Text Size: A A A
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Article
References

EVIDENCE THAT routine antimicrobial treatment improves the course and outcomes after acute otitis media is weak. Given the lack of evidence for benefit and the potential for adverse effects, including altering normal respiratory flora and development of resistant organisms, routine treatment using 10 days of antimicrobials for all cases of acute otitis media is not warranted.

See also p 1640.

There have been 7 randomized, blinded, placebo-controlled trials of acute otitis media over the past 30 years. Neither short- nor long-term differences were demonstrated in 3,1-3 and minor differences noted in the other 4 studies were limited to short-term benefits of antimicrobials.4-7 In a study by Howie and Ploussard,4 all case patients receiving placebo were asymptomatic at early follow-up (2 to 7 days) but had more positive tympanocentesis cultures than those receiving antimicrobials. Mygind et al5 found decreased pain in the penicillin group compared with the

REFERENCES

1 +
Halsted C, Lepow ML, Balassanian N, Emmerich J, Wolinsky E.  Otitis media: clinical observations, microbiology, and evaluation of therapy . AJDC . 1968;;115:542-551.
2 +
van Buchem FL, Dunk JHM, van't Hof MA.  Therapy of acute otitis media: myringotomy, antibiotics, or neither: a doubleblind study in children . Lancet . 1981;;2:883-887.
3 +
Appelman CLM, Claessen JQPJ, Touw-Otten FWMM, Hordijk GJ, DeMelker RA.  Coamoxiclav in recurrent acute otitis media: placebo-controlled study . BMJ . 1991;;303:1450-1452.
4 +
Howie VM, Ploussard JH.  Effectiveness of erythromycin estolate, triple sulfonamide, ampicillin, erythromycin estolate—triple sulfonamide, and placebo in 280 patients with acute otitis media under 2 and one-half years of age . Clin Pediatr . 1972;;11:205-214.
5 +
Mygind N, Meistrup-Larsen KI, Thomsen J, Thomsen VF, Josefsson K, Sorensen H.  Penicillin in acute otitis media: a double-blind, placebo-controlled trial . Clin Otolaryngol . 1981;;6:5-13.
6 +
Kaleida PH, Casselbrant ML, Rockette HE, et al.  Amoxicillin or myringotomy or both for acute otitis media: results of a randomized clinical trial . Pediatrics . 1991;;87:466-474.
7 +
Burke P, Bain J, Robinson D, Dunleavey J.  Acute red ear in children: controlled trial of nonantibiotic treatment in general practice . BMJ . 1991;;303:558-562.
8 +
Rosenfeld RM, Vertrees JE, Carr J, et al.  Clinical efficacy of antimicrobial drugs for acute otitis media: meta-analysis of 5400 children from thirty three randomized trials . J Pediatr . 1994;;124:355-367.
9 +
Laxdal OE, Merida J, Trefor Jones RH.  Treatment of acute otitis media: a controlled study of 142 children . Can Med Assoc J . 1970;;102:263-268.
10 +
Claessen JQPJ, Appleman CLM, Touw-Otten FWMM, de Melker RA, Hordijk GJ.  A review of clinical trials regarding treatment of acute otitis media . Clin Otolaryngol . 1992;;17:251-257.
11 +
Meistrup-Larsen KI, Sorensen H, Johnsen NJ, Thomsen J, Mygind N, Sederberg-Olsen J.  Two versus seven days penicillin treatment for acute otitis media . Acta Otolaryngol . 1983;;96:99-104.
12 +
Chaput de Saintonge DM, Levine DF, Savage IT, Gurgess GWS.  Trial of three-day and ten-day course of amoxycillin in otitis media . BMJ . 1982;;284:1078-1081.
13 +
Hendrickse WA, Kusmiesz H, Shelton S, Nelson JD.  Five vs ten days of therapy for acute otitis media . Pediatr Infect Dis J . 1988;;7:17-23.
14 +
Bain J, Murphy E, Ross F.  Acute otitis media: clinical course among children who received a short course of high dose antibiotic . BMJ . 1985;;291:1243-1246.
15 +
Froom J, Culpepper L, Grob P, et al.  Diagnosis and antibiotic treatment of acute otitis media: report from International Primary Care Network . BMJ . 1990;;300:582-586.
16 +
van Buchem FL, Peeters MF, van't Hof MA.  Acute otitis media: a new treatment strategy . BMJ . 1985;;290:1033-1037.
17 +
Kilpi T, Anttila M, Kallio MJ, Peltola H.  Severity of childhood bacterial meningitis: duration of illness before diagnosis . Lancet . 1991;;338:406-409.
18 +
Eavey RD, Gao YZ, Schuknecht HF, Gonzalez-Pineda M.  Otologic features of bacterial meningitis of childhood . Pediatrics . 1985;;106:402-407.
19 +
Koshland DE.  The microbial wars . Science . 1992;;257:1021.
20 +
Neu HC.  The crisis in antibiotic resistance . Science . 1992;;257:1036-1038.
21 +
Gold HS, Moellering RC.  Antimicrobial-drug resistance . N Engl J Med . 1996;;335:1445-1453.
22 +
Barnett ED, Klein JO.  The problem of resistant bacteria for the management of acute otitis media . Pediatr Clin North Am . 1995;;42:509-517.
23 +
Cohen ML.  Epidemiology of drug resistance: implications for a post-antimicriobial era . Science . 1992;;257:1050-1055.
24 +
Center for Disease Control and Prevention. Addressing Emerging Infectious Disease Threats . Atlanta, Ga: US Dept of Health and Human Services, Public Health Service; 1994;.
25 +
McCaig LF, Hughes JM.  Trends in antimicrobial drug prescribing among office-based physicians in the United States . JAMA . 1995;;273:214-219.
26 +
Touw-Otten FW, Johansen KS.  Diagnosis, antibiotic treatment and outcome of acute tonsillitis: report of a WHO regional office for Europe study in 17 European countries . Fam Pract . 1992;;9:255-264.
27 +
Harrison CJ, Marks MI, Welch DF.  Microbiology of recently treated acute otitis media compared with previously untreated acute otitis media . Pediatr Infect Dis J . 1985;;4:641-646.
28 +
Faden H, Bernstein J, Stanievich J, Brodsky L, Ogra PL.  Effect of prior antibiotic treatment on middle ear disease in children . Ann Otol Rhinol Laryngol . 1992;;101:87-91.
29 +
Faden H, Doern G, Wolf J, Blocker M.  Antimicrobial susceptibility of nasopharyngeal isolates of potential pathogens recovered from infants before antibiotic therapy: implications for the management of otitis media . Pediatr Infect Dis J . 1994;;13:609-612.
30 +
Henderson KW, Gilligan PH, Wait K, Goff DA.  Nasopharyngeal carriage of antibiotic-resistant pneumococci by children in group day care . J Infect Dis . 1988;;157:256-263.
31 +
Klein JO.  Otitis media . Clin Infect Dis . 1994;;19:823-833.
32 +
Reichler MR, Allphin AA, Breiman RF, et al.  The spread of multiply resistant Streptococcus pneumoniae at a day care center in Ohio . J Infect Dis . 1992;;166:1346-1353.
33 +
Sloas MM, Barrett FF, Chesney PJ, et al.  Cephalosporin treatment failure in penicillin and cephalosporin-resistant Streptococcus pneumoniae meningitis . Pediatr Infect Dis J . 1992;;11:662-666.
34 +
Bluestone CD, Klein JO. Otitis Media in Infants and Children . Philadelphia, Pa: WB Saunders Co; 1988;:45-48.
35 +
Sugita R, Kawamura S, Ichikawa G, DeGuchi K.  Bacteriology of acute otitis media in Japan and chemotherapy, with reference to Hemophilus influenzae . Int J Pediatr Otolaryngol . 1983;;6:135-144.
36 +
Trujillo H, Callejas R, Mejia GI, Castrillon L.  Bacteriology of middle ear fluid specimens obtained by tympanocentesis from 111 Columbian children with acute otitis media . Pediatr Infect Dis J . 1989;;8:361-363.
37 +
van Dishoeck HAE, Derkes ACW, Voorhorst R.  Bacteriology and treatment of acute otitis media in children . Acta Otolaryngol . 1959;;50:250-261.
38 +
Appelbaum PC.  Worldwide development of antibiotic resistance in pneumococci . Eur J Clin Microb Infect Dis . 1987;;6:367-377.
39 +
de Neeling AJ, Hemmes JH, van Klingeren B. Resistentie Tegen Antibiotica bij Routine Isolaten van Bacteriën in Zeven Streeklaboratoria [English abstract]. Bilthoven, the Netherlands: Rijksinstituut Voor Volksgezondheid en Milieuhygiene; 1993;.
40 +
Van Klingeren B, Michelen MF, Wagenvoort JHT.  Beheersing van het resistentievraagstuk door het voeren van een antbioticum beleid . Ned Tijdschr Geneeskd . 1992;;136:860-864.
41 +
Stephenson J.  Icelandic researchers are showing the way to bring down rates of antibiotic-resistant bacteria . JAMA . 1996;;275:175-176.
42 +
Froom J, Culpepper L, Grob P, et al.  Effect of patient characteristics and disease manifestations on the outcome of acute otitis media at two months . Arch Fam Med . 1993;;2:841-846.

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Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Halsted C, Lepow ML, Balassanian N, Emmerich J, Wolinsky E.  Otitis media: clinical observations, microbiology, and evaluation of therapy . AJDC . 1968;;115:542-551.
2 +
van Buchem FL, Dunk JHM, van't Hof MA.  Therapy of acute otitis media: myringotomy, antibiotics, or neither: a doubleblind study in children . Lancet . 1981;;2:883-887.
3 +
Appelman CLM, Claessen JQPJ, Touw-Otten FWMM, Hordijk GJ, DeMelker RA.  Coamoxiclav in recurrent acute otitis media: placebo-controlled study . BMJ . 1991;;303:1450-1452.
4 +
Howie VM, Ploussard JH.  Effectiveness of erythromycin estolate, triple sulfonamide, ampicillin, erythromycin estolate—triple sulfonamide, and placebo in 280 patients with acute otitis media under 2 and one-half years of age . Clin Pediatr . 1972;;11:205-214.
5 +
Mygind N, Meistrup-Larsen KI, Thomsen J, Thomsen VF, Josefsson K, Sorensen H.  Penicillin in acute otitis media: a double-blind, placebo-controlled trial . Clin Otolaryngol . 1981;;6:5-13.
6 +
Kaleida PH, Casselbrant ML, Rockette HE, et al.  Amoxicillin or myringotomy or both for acute otitis media: results of a randomized clinical trial . Pediatrics . 1991;;87:466-474.
7 +
Burke P, Bain J, Robinson D, Dunleavey J.  Acute red ear in children: controlled trial of nonantibiotic treatment in general practice . BMJ . 1991;;303:558-562.
8 +
Rosenfeld RM, Vertrees JE, Carr J, et al.  Clinical efficacy of antimicrobial drugs for acute otitis media: meta-analysis of 5400 children from thirty three randomized trials . J Pediatr . 1994;;124:355-367.
9 +
Laxdal OE, Merida J, Trefor Jones RH.  Treatment of acute otitis media: a controlled study of 142 children . Can Med Assoc J . 1970;;102:263-268.
10 +
Claessen JQPJ, Appleman CLM, Touw-Otten FWMM, de Melker RA, Hordijk GJ.  A review of clinical trials regarding treatment of acute otitis media . Clin Otolaryngol . 1992;;17:251-257.
11 +
Meistrup-Larsen KI, Sorensen H, Johnsen NJ, Thomsen J, Mygind N, Sederberg-Olsen J.  Two versus seven days penicillin treatment for acute otitis media . Acta Otolaryngol . 1983;;96:99-104.
12 +
Chaput de Saintonge DM, Levine DF, Savage IT, Gurgess GWS.  Trial of three-day and ten-day course of amoxycillin in otitis media . BMJ . 1982;;284:1078-1081.
13 +
Hendrickse WA, Kusmiesz H, Shelton S, Nelson JD.  Five vs ten days of therapy for acute otitis media . Pediatr Infect Dis J . 1988;;7:17-23.
14 +
Bain J, Murphy E, Ross F.  Acute otitis media: clinical course among children who received a short course of high dose antibiotic . BMJ . 1985;;291:1243-1246.
15 +
Froom J, Culpepper L, Grob P, et al.  Diagnosis and antibiotic treatment of acute otitis media: report from International Primary Care Network . BMJ . 1990;;300:582-586.
16 +
van Buchem FL, Peeters MF, van't Hof MA.  Acute otitis media: a new treatment strategy . BMJ . 1985;;290:1033-1037.
17 +
Kilpi T, Anttila M, Kallio MJ, Peltola H.  Severity of childhood bacterial meningitis: duration of illness before diagnosis . Lancet . 1991;;338:406-409.
18 +
Eavey RD, Gao YZ, Schuknecht HF, Gonzalez-Pineda M.  Otologic features of bacterial meningitis of childhood . Pediatrics . 1985;;106:402-407.
19 +
Koshland DE.  The microbial wars . Science . 1992;;257:1021.
20 +
Neu HC.  The crisis in antibiotic resistance . Science . 1992;;257:1036-1038.
21 +
Gold HS, Moellering RC.  Antimicrobial-drug resistance . N Engl J Med . 1996;;335:1445-1453.
22 +
Barnett ED, Klein JO.  The problem of resistant bacteria for the management of acute otitis media . Pediatr Clin North Am . 1995;;42:509-517.
23 +
Cohen ML.  Epidemiology of drug resistance: implications for a post-antimicriobial era . Science . 1992;;257:1050-1055.
24 +
Center for Disease Control and Prevention. Addressing Emerging Infectious Disease Threats . Atlanta, Ga: US Dept of Health and Human Services, Public Health Service; 1994;.
25 +
McCaig LF, Hughes JM.  Trends in antimicrobial drug prescribing among office-based physicians in the United States . JAMA . 1995;;273:214-219.
26 +
Touw-Otten FW, Johansen KS.  Diagnosis, antibiotic treatment and outcome of acute tonsillitis: report of a WHO regional office for Europe study in 17 European countries . Fam Pract . 1992;;9:255-264.
27 +
Harrison CJ, Marks MI, Welch DF.  Microbiology of recently treated acute otitis media compared with previously untreated acute otitis media . Pediatr Infect Dis J . 1985;;4:641-646.
28 +
Faden H, Bernstein J, Stanievich J, Brodsky L, Ogra PL.  Effect of prior antibiotic treatment on middle ear disease in children . Ann Otol Rhinol Laryngol . 1992;;101:87-91.
29 +
Faden H, Doern G, Wolf J, Blocker M.  Antimicrobial susceptibility of nasopharyngeal isolates of potential pathogens recovered from infants before antibiotic therapy: implications for the management of otitis media . Pediatr Infect Dis J . 1994;;13:609-612.
30 +
Henderson KW, Gilligan PH, Wait K, Goff DA.  Nasopharyngeal carriage of antibiotic-resistant pneumococci by children in group day care . J Infect Dis . 1988;;157:256-263.
31 +
Klein JO.  Otitis media . Clin Infect Dis . 1994;;19:823-833.
32 +
Reichler MR, Allphin AA, Breiman RF, et al.  The spread of multiply resistant Streptococcus pneumoniae at a day care center in Ohio . J Infect Dis . 1992;;166:1346-1353.
33 +
Sloas MM, Barrett FF, Chesney PJ, et al.  Cephalosporin treatment failure in penicillin and cephalosporin-resistant Streptococcus pneumoniae meningitis . Pediatr Infect Dis J . 1992;;11:662-666.
34 +
Bluestone CD, Klein JO. Otitis Media in Infants and Children . Philadelphia, Pa: WB Saunders Co; 1988;:45-48.
35 +
Sugita R, Kawamura S, Ichikawa G, DeGuchi K.  Bacteriology of acute otitis media in Japan and chemotherapy, with reference to Hemophilus influenzae . Int J Pediatr Otolaryngol . 1983;;6:135-144.
36 +
Trujillo H, Callejas R, Mejia GI, Castrillon L.  Bacteriology of middle ear fluid specimens obtained by tympanocentesis from 111 Columbian children with acute otitis media . Pediatr Infect Dis J . 1989;;8:361-363.
37 +
van Dishoeck HAE, Derkes ACW, Voorhorst R.  Bacteriology and treatment of acute otitis media in children . Acta Otolaryngol . 1959;;50:250-261.
38 +
Appelbaum PC.  Worldwide development of antibiotic resistance in pneumococci . Eur J Clin Microb Infect Dis . 1987;;6:367-377.
39 +
de Neeling AJ, Hemmes JH, van Klingeren B. Resistentie Tegen Antibiotica bij Routine Isolaten van Bacteriën in Zeven Streeklaboratoria [English abstract]. Bilthoven, the Netherlands: Rijksinstituut Voor Volksgezondheid en Milieuhygiene; 1993;.
40 +
Van Klingeren B, Michelen MF, Wagenvoort JHT.  Beheersing van het resistentievraagstuk door het voeren van een antbioticum beleid . Ned Tijdschr Geneeskd . 1992;;136:860-864.
41 +
Stephenson J.  Icelandic researchers are showing the way to bring down rates of antibiotic-resistant bacteria . JAMA . 1996;;275:175-176.
42 +
Froom J, Culpepper L, Grob P, et al.  Effect of patient characteristics and disease manifestations on the outcome of acute otitis media at two months . Arch Fam Med . 1993;;2:841-846.

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