Streptococcus pneumoniae Disease
An abstract:
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Pediatric Infectious Disease Journal , January 1999;18:1-9
Acute Otitis Media - Management and Surveillance in an Era of Pneumococcal Resistance: A Report from the Drug-Resistant Streptococcus pneumoniae Therapeutic Working Group (DRSPTWG)
Scott F. Dowell, MD, MPH, Jay C. Butler, MD, G. Scott Giebink, MD, Michael R. Jacobs, MD, Daniel Jernigan, MD, Daniel M. Musher, MD, Alexander Rakowsky, MD, Benjamin Schwartz, MD, and the DRSPTWG*
Abstract
Objective
To provide consensus recommendations for the management of acute otitis media (AOM) and the surveillance of Drug-Resistant Streptococcus pneumoniae (DRSP). Five questions were addressed: 1)Can amoxicillin remain the best initial antimicrobial agent for treating AOM in the current period of increasing prevalence of DRSP? 2)What are suitable alternative agents for use if amoxicillin fails? 3)Should empiric treatment of AOM vary by geographic region? 4)Where can clinicians learn about resistance patterns in their patient populations? 5)What modifications to laboratory surveillance would improve the utility of the information for clinicians treating AOM?
Participants
Experts in the management of otitis media and the DRSP Therapeutic Working Group (DRSPTWG). This group was convened by CDC to respond to changes in antimicrobial susceptibility among pneumococci, and includes clinicians, academicians, and public health practitioners.
Evidence
Published and unpublished data summarized from the scientific literature and experience from the experts present.
Process
After group presentations and review of background materials, subgroup chairs prepared draft responses to the 5 questions, discussed the responses as a group, and edited those responses.
Conclusions
Oral amoxicillin should remain the first-line antimicrobial agent for treating AOM. In view of the increasing prevalence of DRSP, the safety of amoxicillin at higher than standard dosages, and in view of evidence that higher dosages of amoxicillin can achieve effective middle ear fluid concentrations, an increase in the dosage used for empiric treatment from 40-45 mg/kg/day to 80-90 mg/kg/day is recommended. For patients with clinically defined treatment failure after 3 days of therapy, useful alternative agents include oral amoxicillin-clavulanate, cefuroxime axetil, and intramuscular ceftriaxone. Many of the 13 other FDA-approved otitis media drugs lack good evidence for efficacy against DRSP. Currently, local surveillance data for pneumococcal resistance which are relevant for the clinical management of AOM are not available from most areas in the United States. Recommendations to improve surveillance include establishing criteria for setting susceptibility breakpoints for clinically appropriate antimicrobials to ensure relevance for treating AOM, testing middle ear fluid or nasal swab isolates in addition to sterile site isolates, and testing of drugs that are useful in treating AOM. The management of otitis media has entered a new era with the development of DRSP. These recommendations are intended to provide a framework for appropriate clinical and public health responses to this problem.
Table 1. Activity of ß-lactam drugs against DRSP causing acute otitis media. Compiled from references 12,13,20,21,37,46,58,59
Table 2. Activity of erythromycin, trimethoprim/sulfamethoxazole, and clindamycin against DRSP. Compiled from references 12,13,15,58,59
Table 3. Acute otitis media treatment recommendations* for children who have not or have received antimicrobial therapy during the prior month.
Table 4. Antimicrobial agents useful for AOM treatment which should be included in surveillance for pneumococcal resistance. |
