REF: ACP Online PIER 2007
Antibiotic Drug Rx for Bacterial Sinusitis
Trimethoprim-sulfamethoxazole (Bactrim DS or Septra DS)
What role for antibiotics in otitis media and sinusitis?
Gurpreet S. Ahuja, MD Josette Thompson, MD (UC
In chronic suppurative otitis media :
Chronic sinusitis is caused by the same organisms associated with acute sinusitis. In addition, higher incidences of staphylococci and anaerobes are seen in chronically inflamed sinuses.
If the patient has received antibiotics in the past month or if resistant organisms are common within the community, use of a second-line agent should be considered, such as amoxicillin and clavulanate potassium (Augmentin), an extended-spectrum macrolide (azithromycin [Zithromax], clarithromycin [Biaxin]), or a second- or third-generation cephalosporin (eg, cefprozil [Cefzil], cefuroxime axetil [Ceftin], cefpodoxime proxetil [Vantin]). Also, switching to a second-line antibiotic may be necessary in patients who do not have a response to first-line treatment or those who have a breakthrough infection during antibiotic prophylaxis.
Quinolones (eg, ciprofloxacin [Cipro]) are not approved for use in children, and data on their efficacy in the treatment of acute otitis media in adults are equivocal. Some of the newer quinolones show increased activity against pneumococci.
Other studies (16,17) have shown that a single dose of intramuscular ceftriaxone sodium (Rocephin) may be as effective as a 10-day course of a common oral antimicrobial. However, its routine use as firstline therapy is not advisable.
Otitis media with effusion
Tympanostomy tubes are an alternative to antimicrobial prophylaxis (22). The principal indications for their use are: (1) chronic middle ear effusions that have not resolved with medical therapy after 3 months (both ears) or 6 months (one ear), especially when accompanied by hearing loss; (2) recurrent acute otitis media, particularly in patients in whom antibiotic prophylaxis has failed; (3) persistent eustachian tube dysfunction that may variably be associated with the development of a retraction pocket, hearing loss, tinnitus, or vertigo; and (4) suppurative complications of otitis media (eg, meningitis, facial nerve paralysis). The benefits of tympanostomy tubes include reduced rates of recurrence and earlier restoration of hearing.
The Task Force on Rhinosinusitis of the American Academy of Otolaryngology-Head and Neck Surgery recommends the same antibiotics for acute sinusitis and acute otitis media (23). The choice of a specific agent for both illnesses should be based on the same factors.
Antibiotics that do not cover the major causative organisms of sinusitis and are not recommended include penicillin, erythromycin, cephalexin (Biocef, Keflex), and tetracycline. Cefixime (Suprax) and ceftibuten (Cedax) have inadequate activity against S pneumoniae and are also not good choices for acute sinusitis.
Mild cases of acute sinusitis lasting 7 days or less usually are viral infections and should not be treated with antibiotics. In patients who meet the diagnostic criteria for acute sinusitis (table 1) and have progressive or nonresolving symptoms, a 10- to 14-day course of amoxicillin is appropriate initial therapy (24).
If symptoms progress after 72 hours of initial empirical therapy for either acute or chronic sinusitis, a broader-spectrum antibiotic (eg, a beta-lactamase-stable agent) may be indicated. Initiation of such treatment is recommended for severe acute sinusitis or prolonged, symptomatic chronic sinusitis. In difficult cases, a culture from the middle meatus or the sinus itself may be helpful.
Correspondence: Gurpreet S. Ahuja, MD, Department of Otolaryngology-Head and Neck Surgery, UCI Medical Center, 101 The City Dr S, Bldg 25, Orange, CA 92868. E-mail: email@example.com.
Otitis Media ACP Med 2006
The most common causes of purulent otitis media are the pneumococcus, nontypable strains of Haemophilus influenzae, and Moraxella catarrhalis; the previously important group A streptococci are now uncommon but may be more aggressive than other pathogens.1,2 Other organisms that can cause acute otitis media are coagulase-negative staphylococci and anaerobic bacteria. Gram-negative bacilli and Staphylococcus aureus can cause acute otitis media in neonates. Viruses and mycoplasmas are uncommon as the primary pathogens in acute otitis media, but in 41% of children with acute bacterial otitis, respiratory tract viruses are also present; respiratory syncytial virus is the most common causal organism, followed by parainfluenza and influenza viruses. Purulent nosocomial otitis is uncommon and occurs in only 4% of patients who have undergone endotracheal intubation; gram-negative bacilli are the responsible agents in this setting.
1. Palmu AAI, Herva E, Savolainen H, et al: Association of clinical signs and symptoms with bacterial findings in acute otitis media. Clin Infect Dis 38:234, 2004 [PMID 14699456]
2. Segal N, Givon-Lavi N, Leibovitz E, et al: Acute otitis media caused by Streptococcus pyogenes in children. Clin Infect Dis 41:35, 2005 [PMID 15937760]