MIXED BAG
Case report
Otitis media : treatment guidelines
A previously healthy 17-month-old boy was referred
for treatment after having a cold, with rhinorrhoea and
fever (38 .8°C) . On the 5th day, he became `fussy' and
woke up crying many times at night. The following
day, his fever had resolved and physical examination
was normal, except for slight redness of the left tym-
panic membrane with no middle-ear fluid and a
bulging, right tympanic membrane with white fluid
behind it obscuring the umbo. How should this child
be treated?
Discussion
Otitis media is the most common reason for the pre-
scription of antibiotics for children in the USA. The
diagnosis of otitis is usually followed by antibiotic
treatment, despite a lack of direct evidence that it is
effective.
344 CME June 2003 Vol .21 No .6
The two requirements for the diagnosis of acute otitis
media are inflammation of and fluid in the middle ear.
A retracted drum which may be painful, is due to neg-
ative middle-ear pressure and not to bacteria . Bacterial
otitis media is characterised by a bulging eardrum that
has purulent fluid behind it or by purulent otorrhoea
after tympanic membrane perforation. A red tympanic
membrane without middle-ear fluid is not acute otitis .
Acute otitis must also be differentiated from effusion,
which is fluid in the middle ear without local or sys-
temic illness .
Once acute otitis, which may be viral, bacterial or
both, has been diagnosed the central issue is whether
antibiotic therapy is in the child's best interest . A
meta-analysis of randomised controlled trials (RCTs)
showed that acute otitis had resolved in 1 week in 81
of placebo recipients compared with 94% of antibiotic
recipients . The improvement tended to occur only after
the 3rd day of antibiotic therapy. Amoxicillin is at least
as effective as other antibiotics, despite evidence of
resistance in a proportion of Staphylococcus pneumoniae,
Haemophilus influenzae and Moraxella catarrhalis
strains.
Fifty per cent of children have middle-ear fluid for a
month after the resolution of acute otitis, whether they
received antibiotics or placebo. Fluid clears by 3
months in 90% of children, whether they have had
antibiotics or not.
Resistant, bacterial otitis media is recognised by the
persistence of fever, otalgia and red, bulging tympanic
membranes or by persistent otorrhoea after 3 or more
days of antibiotic therapy.
One strategy to minimise unnecessary prescribing of
antibiotics is to delay treatment for 48 - 72 hours after
diagnosis to determine if there is spontaneous clinical
improvement. A 7-day course of antimicrobial therapy
is begun only when there is no improvement in symp-
toms within 1 - 2 days in children younger than 2
years or within 3 days in children of 2 years or older.
Results of trials of the effectiveness of delayed therapy
showed that immediate use of antibiotics reduced the
duration of symptoms by about 1 day, and decreased
the use of acetaminophen . However, the benefit

occurred mainly after the first 24 hours when the
symptoms were diminishing anyway.
One impediment to the use of delayed therapy is the
fear of acute mastoiditis. Studies have shown that this
varies from 2 to 4 cases per 100 000 per year with the
usual therapy and is increased only to about twice the
rate with delayed therapy.
Recurrent otitis media (3 or more episodes within 6
months or 4 episodes within 12 months) can be
reduced by prophylaxis with trimethoprim-sulpha-
methoxazole or amoxicillin, but the reduction is so
small that it appears to be outweighed by the disad-
vantage of possibly promoting antibiotic resistance .
Placement of tympanostomy tubes significantly
reduced recurrence rates in one study, but had no
effect in another.
It remains unclear how to identify the small percent-
age of children who will benefit from antibiotic thera-
py. Nor is the optimal duration of therapy clear. A 7 -
10-day course has been the standard, but supportive
evidence is lacking. A 5-day course is thought by some
to be inadequate for severe cases.
Guidelines
Five principles have been devised by the Centers for
Disease Control and the American Academy for
Pediatrics :
The diagnosis of otitis media should not be made
unless fluid is present in the middle ear.
Otitis media should be classified as acute or otitis
media with effusion on the basis of the presence or
absence of signs and symptoms of acute illness.
Otitis media with effusion should not be treated
with an antibiotic .
Effusion is likely to persist after the treatment of
acute otitis and does not require repeated treatment.
Antibiotic prophylaxis for acute otitis media should
only be used in accordance with strict criteria .
(These guidelines were drawn up before the results of
the large trial of delayed antibiotic prescribing became
available and therefore do not address this strategy.)
Conclusions and recommendations
In patients with acute otitis media, bacteria are only
part of the problem of what is usually a self-limiting
disease, and antibiotic therapy can correct only the
part of the problem caused by bacteria .
MIXED BAG
Because the child described in the case vignette above
has bacterial otitis media, it is recommended that
immediate antibiotic therapy be commenced. High-
dose amoxicillin would be the first choice . Acute otitis
without bulging eardrums is likely to clear sponta-
neously . The use of the delayed antibiotic-prescribing
strategy is appropriate, especially for cases of recurrent
otitis media, because as parents become more familiar
with the pattern of the child's illness, they are able to
recognise that most episodes will resolve without
antibiotic therapy. Finally, antibiotic therapy for otitis
media with effusion is not in the child's best interest: .
(Hendley JO . N Engl J Med 2002 ; 347: 1169-1173 .)
SINGLE SUTURE
Exercise interventions for health
The prevalence of chronic diseases contributed
to by physical inactivity is escalating so rapidly
that their costs will exceed $1 trillion in the USA
during the next decade! The evidence for the
health benefits of physical activity is firmly estab-
lished, but people remain inactive . Given the
increased prevalence of chronic disease associat-
ed with physical inactivity, a renewed and com-
prehensive effort is essential. Governments can
no longer avoid this question, as they may be
missing their best opportunity to promote health
and increase productivity. Given the annual cost
of physical inactivity, the programmes and
research needed to test activity interventions
seem a blue-chip investment (Br _` Sports Med
2003; 37: 98-99) .
PIF
CME June 2003 Vol .21 No .6 345