Acute Otitis Media To treat or not to treat Gary Kroukamp

Introduction Concern about antibiotic resistance Overuse of antibiotics, over diagnosis of AOM Most will improve spontaneously without antibiotics Normal part of childhood? 95% of kids by age 7 Part of viral URTI Netherlands vs Australia

Major controversies To treat or not to treat AOM with antibiotics To treat or not to treat MEE that persists after treatment of AOM with antibiotics To treat or not to treat OME with antibiotics Which management options are safe and effective for prevention of recurrent AOM

Microbiology Bacterial pathogens found in 70% of AOM and 30% of OME S. Pneumoniae – 40% H. Influenzae – 25% M. Catarrhalis – 12% Beta-haemolytic strep and Staph. Aureus Beta lactamase production in 25% of Haemophilus and all Moraxella Drug resistance in S.Pneumoniae is increasing

Against antibiotics Australia 98% vs. Netherlands 31% (vs Africa?) – no difference in complications European literature suggests non-antibiotic treatment has low complication rate and may be intercepted

Evidence for Antibiotics (vs Placebo) Sterilises the effusion – Howie et al 1972 Earlier resolution of symptoms – Rosenfeld et al (metanalysis 5400 children) 81% vs 95% resolution Shortens time of MEE – Kaleida et al, 2 weeks of antibiotics 47% vs 63% Decreases suppurative complications – mastoiditis and meningitis almost exclusively in placebo treated kids S. Pneumonia tends not to resolve spontaneously (20%)

Conclusion Treatment justified in SA If part of viral URTI may be watched if close follow-up is guaranteed Medico-legal implications of not treating?

Selection of Antibiotic High dose amoxycillin Co-amoxyclav Cephalosporin Shorter courses?

To treat or not to treat persistent MEE with antibiotics MEE in 50% after treatment of AOM 90% resolve in 3 months Antibiotics not indicated Treat as for OME

Recurrent AOM 3 in 6 months or 4 in 12 months Prevention Smoking Crèche Vaccination – pneumococcal and flu Antibiotic prophylaxis Grommets Adenoidectomy