Mastoiditis

Usual Preferred IV Alternate IV PO Therapy or IV-to-PO

Subset
Pathogen Therapy Therapy Switch
Acute S. pneumoniae Ceftriaxone 1–2 Moxifloxacin 400 Moxifloxacin 400 mg (PO)
H . influenzae gm (IV) q24h × 2 mg (IV) q24h × 2 q24h × 2 weeks
S . aureus weeks weeks
(MSSA) or
or or
Levofloxacin 500 mg (PO)
Cefotaxime Levofloxacin 500 q24h × 2 weeks
2 gm (IV) q6h mg (IV) q24h × 2
× 2 weeks weeks or

or or Doxycycline 100 mg (PO)

q12h × 2 weeks
Cefepime 2 gm Doxycycline 200
(IV) q12h mg (IV) q12h × 3
× 2 weeks days, then 100 mg
(PO) q12h × 2
weeks
Chronic S . pneumoniae Meropenem Moxifloxacin 400 Moxifloxacin 400 mg (PO)
H . influenzae 1 gm (IV) q8h mg (IV) × 4–6 × 4–6 weeks
P . aeruginosa × 4 weeks weeks
S . aureus
(MSSA) or or
Oral anaerobes
Cefepime 2 gm Levofloxacin 750
(IV) q8h × 4 mg (IV) q24h
weeks
Duration of therapy represents total time IV, PO, or IV + PO . Most patients on IV therapy able to take
PO meds should be switched to PO therapy soon after clinical improvement (usually < 72 hours) .

Acute Mastoiditis
Clinical Presentation: Pain/tenderness over mastoid with fever .
Diagnostic Considerations: Diagnosis by CT/MRI showing mastoid involvement .
Pitfalls: Obtain head CT/MRI to rule out extension into CNS presenting as acute bacterial meningitis .
Prognosis: Good if treated early .

Chronic Mastoiditis
Clinical Presentation: Subacute pain/tenderness over mastoid with low-grade fever .
Diagnostic Considerations: Diagnosis by CT/MRI showing mastoid involvement . Rarely secondary to TB
(diagnose by AFB smear/culture of bone biopsy or debrided bone) .
Pitfalls: Obtain head CT/MRI to rule out CNS extension .
Therapeutic Considerations: Usually requires surgical debridement for cure . Should be viewed as
chronic osteomyelitis . If secondary to TB, treat as skeletal TB .
Prognosis: Progressive without surgery . Poor prognosis with associated meningitis/brain absc