More on otitis media

For those of you who have been reading this weblog for a long time, you have probably noticed that one of my primary clinical interests is otitis media and it's closely related cousins: Sinusitis and bronchitis.  These conditions are the cause of the most frequent visits to physicians at children and adults in this country (aside from well-child care and prenatal visits).

These conditions may also represent the vast majority of antibiotic prescriptions that are written in this country and since all three of these conditions can usually be successfully treated without the use of antibiotics, appropriate diagnosis and deliberate management is important.

I say "deliberate management" because many patients care physicians medical students and residents think that when condition is not treated with an antibiotic, it isn't treated.  For example, in our electronic medical record, there is a template entry next to "upper respiratory infection" where the user has two choices: "Treat with antibiotic" and "no treatment."  

Of course, neither is appropriate care.  We need to give our patients to best tools that we can for the management of these perplexing problems. 

  • Good information. 
  • Good recommendations for symptomatic treatment including appropriate analgesics for otitis media and symptomatic relief for nasal congestion or persistent cough
  • Access to care if symptoms worsen or don't improve after a given period of time

Today I found a few articles related to otitis media that seem interesting albeit somewhat concerning:

Augmentin causes autism this seems like a rather poorly done study which I hope no one at USA Today decides to write a feature article on.

In this review of acute mastoiditis, over 200 cases were reviewed during a 10 year period.  It's interesting to note that the average age was 16 and more of the patient's who presented with mastoiditis were being treated with antibiotics and those who were not.  Of course, we can't draw any conclusions about this because of the timeframe of the study (for most of this period, Antibiotics were the treatment of choice for otitis media) and because there certainly can't be any causality established with a retrospective study like this.

This study is an unfortunate and rather detailed review of the microbiology observed in a number of cases of patient's with sinusitis or otitis media.  The problem with this study is that it is clearly focused on disease oriented evidence rather than patient oriented evidence.   There is in fact no clinical correlation mentioned, and the conclusion of the study: The amoxicillin clavulanic acid should be used for the treatment of these conditions – is inherently suspect.

Respiratory syncytial virus is a common cause of otitis media and young children.

Pneumococcal vaccine will likely help in reducing the emergence of resistant pneumococcus.

This one deserves a bit of reformatting so that we can interpret the abstract a little more easily.


  • Streptococcus pneumoniae
  • Haemophilus influenzae non-type b
  • Moraxella catarrhalis
  • Streptococcus pyogenes
  • Staphylococcus aureus

So far, this isn't news ..

"Resistance to the eight antimicrobial agents used was found in 37 instances in the AOM group as compared to 99 instances in the ROM group (P < 0.005). "

OK .. we still haven't learned anything new …

The difference between AOM and ROM was significant with Streptococcus pneumoniae resistance to amoxicillin (P < 0.005), to amoxicillin/clavulanate (P < 0.005), to trimethoprim/sulfamethoxazole (P < 0.01), to cefixime (P < 0.01) and to azithromycin (P < 0.01), and for H. influenzae resistance to amoxicillin (P < 0.025).

So the take-home message is clearly that treatment with antibiotics leads to the emergence of resistant organisms.  No kidding.