Mastoiditis medical therapy: Difference between revisions

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{{Mastoiditis}}
{{Mastoiditis}}


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==Overview==
==Overview==
Medical treatment for acute and subacute mastoiditis without intracranial complications consists of intravenous [[antibiotics]] and [[myringotomy]]. [[Antibiotics]] for acute mastoiditis must cover the most common bacterial pathogens: [[Streptococcus pneumoniae|''Streptococcus pneumoniae'']], [[Streptococcus pyogenes|''Streptococcus pyogenes'']], and [[Staphylococcus aureus|''Staphylococcus aureus'']] (including [[Methicillin-resistant staphylococcus aureus|methicillin-resistant ''S.'' ''aureus'']]). The empiric antibiotics are [[Ampicillin-Sulbactam|ampicillin-sulbactam]] or [[ampicillin]]; add [[vancomycin]] for severe infection with adjacent complications or suspicion of [[MRSA]]. For [[chronic]] mastoiditis, bacteria common covered are [[Pseudomonas aeruginosa|''Pseudomonas aeruginosa'']], [[Staphylococcus aureus|''Staphylococcus aureus'']], and [[anaerobes]]. Antibiotics include [[piperacillin-tazobactam]] or [[piperacillin]], and [[ofloxacin]] otic solution; add [[vancomycin]] for severe infection with adjacent complications or suspicion of [[MRSA]].


==Medical Therapy==
==Medical Therapy==
Medical treatment for acute and subacute mastoiditis without intracranial complications is intravenous antibiotics and myringotomy. With only antimicrobial therapy there is a possibility of progression of mastoiditis to further complications. In a study of 223 patients with mastoiditis, 8.5 percent developed complications during antimicrobial therapy <ref name="pmid11165635">{{cite journal |vauthors=Luntz M, Brodsky A, Nusem S, Kronenberg J, Keren G, Migirov L, Cohen D, Zohar S, Shapira A, Ophir D, Fishman G, Rosen G, Kisilevsky V, Magamse I, Zaaroura S, Joachims HZ, Goldenberg D |title=Acute mastoiditis--the antibiotic era: a multicenter study |journal=Int. J. Pediatr. Otorhinolaryngol. |volume=57 |issue=1 |pages=1–9 |year=2001 |pmid=11165635 |doi= |url=}}</ref>
Medical treatment for acute and subacute mastoiditis without intracranial complications consists of intravenous [[antibiotics]] and [[myringotomy]]. With only antimicrobial therapy, there is a possibility that mastoiditis will lead to further complications. In a study of 223 patients with mastoiditis, 8.5 percent developed complications during antimicrobial therapy. If the disease course worsens with [[antibiotics]] and [[myringotomy]], [[surgical procedures]] may be performed.<ref name="pmid11165635">{{cite journal |vauthors=Luntz M, Brodsky A, Nusem S, Kronenberg J, Keren G, Migirov L, Cohen D, Zohar S, Shapira A, Ophir D, Fishman G, Rosen G, Kisilevsky V, Magamse I, Zaaroura S, Joachims HZ, Goldenberg D |title=Acute mastoiditis--the antibiotic era: a multicenter study |journal=Int. J. Pediatr. Otorhinolaryngol. |volume=57 |issue=1 |pages=1–9 |year=2001 |pmid=11165635 |doi= |url=}}</ref><ref name="urlPediatric Guidelines: Head and Neck Infections - Mastoiditis | Infectious Diseases Management Program at UCSF">{{cite web |url=http://idmp.ucsf.edu/pediatric-guidelines-head-and-neck-infections-mastoiditis |title=Pediatric Guidelines: Head and Neck Infections - Mastoiditis &#124; Infectious Diseases Management Program at UCSF |format= |work= |accessdate=}}</ref>


=== Empiric antibiotic therapy ===
=== Empiric antibiotic therapy ===
for children with acute mastoiditis must cover the most common bacterial pathogens: S. pneumoniae, S. pyogenes, and S. aureus (including methicillin-resistant ''S. aureus'').
[[Antibiotics]] for acute mastoiditis must cover the most common bacterial pathogens: ''[[Streptococcus pneumoniae]], [[Streptococcus|Streptococcus pyogenes]]''[[Streptococcus|,]] and [[Staphylococcus aureus|''Staphylococcus aureus'']] (including [[Methicillin-resistant staphylococcus aureus|methicillin-resistant ''S. aureus'']]). If there is a history of recurrent [[acute otitis media]] or recent [[antibiotic]] usage, the intravenous [[antibiotic]] also should cover [[Pseudomonas aeruginosa|''Pseudomonas aeruginosa'']]. Depending on the patient's condition, antibiotic choices may differ as follows:<ref name="pmid11165635">{{cite journal |vauthors=Luntz M, Brodsky A, Nusem S, Kronenberg J, Keren G, Migirov L, Cohen D, Zohar S, Shapira A, Ophir D, Fishman G, Rosen G, Kisilevsky V, Magamse I, Zaaroura S, Joachims HZ, Goldenberg D |title=Acute mastoiditis--the antibiotic era: a multicenter study |journal=Int. J. Pediatr. Otorhinolaryngol. |volume=57 |issue=1 |pages=1–9 |year=2001 |pmid=11165635 |doi= |url=}}</ref><ref name="urlPediatric Guidelines: Head and Neck Infections - Mastoiditis | Infectious Diseases Management Program at UCSF">{{cite web |url=http://idmp.ucsf.edu/pediatric-guidelines-head-and-neck-infections-mastoiditis |title=Pediatric Guidelines: Head and Neck Infections - Mastoiditis &#124; Infectious Diseases Management Program at UCSF |format= |work= |accessdate=}}</ref>


If there is a history of recurrent acute otitis media or recent antibiotic usage the intravenous antibiotic also should cover the ''P. aeruginosa.''
==== Acute mastoiditis (<1 month duration), immunocompetent patient ====
Bacteria commonly covered are: [[Streptococcus pneumonia|''Streptococcus pneumonia'']], [[Group A streptococcus|Group A S''treptococcus'']], and [[Staphylococcus aureus|''Staphylococcus aureus''.]]
* Preferred regimen (1): [[Ampicillin-Sulbactam|Ampicillin-sulbactam]] IV 50mg/kg/dose '''<u>ADD</u>''' [[Vancomycin]] 15mg/kg/dose IV q6-8h (initial max 1g/dose) for severe [[infection]] with adjacent [[complications]], or suspicion of [[MRSA]]


In a child with either no previous history of AOM or a history of a remote episode (ie, >6 months before), empiric antimicrobial therapy with vancomycin alone (60 mg/kg per day divided every 6 hours with a maximum dose of 4 gm/day) will suffice as empiric treatment until microbiologic results
* Preferred regimen (2): [[Ampicillin]] IV q6h (max 2g ampicillin/dose) '''<u>ADD</u>''' [[Vancomycin]] 15mg/kg/dose IV q6-8h (initial max 1g/dose) for severe infection with adjacent complications, or suspicion of [[MRSA]]


Suggested empiric parenteral antibiotic regimens for the treatment of acute mastoiditis in children*
==== [[Chronic]] mastoiditis (>= 1 month duration, usually non-intact tympanic membrane) ====
{| class="wikitable"
Bacteria commonly covered are: ''[[Pseudomonas aeruginosa]], [[Staphylococcus aureus]]'', and [[anaerobes|anaerobes.]]
|Antibiotic
* Preferred regimen (1): [[Piperacillin-tazobactam]] (Zosyn) 100 mg/kg/dose IV, '''<u>PLUS</u>''' [[Ofloxacin]] Otic Solution 10 drops to affected ear BID, '''<u>ADD</u>''' [[Vancomycin]] 15mg/kg/dose IV q6-8h (initial max 1g/dose) for severe infection with adjacent complications, or suspicion of [[MRSA]].
|Dose
|-
| colspan="2" |For patients without a history of recurrent otitis media or recent antibiotic therapy
|-
|Vancomycin<sup>¶Δ</sup>
|60 mg/kg per day divided every 6 hours (maximum daily dose 4 g)
|-
| colspan="2" |For patients with a history of recurrent otitis media (last episode within 6 months) or recent antibiotic therapy
|-
| colspan="2" |For patients without penicillin allergy (two agents)
|-
|Ceftazidime<sup>¶</sup> '''OR'''
|150 mg/kg per day divided every 8 hours (maximum daily dose 6 g)
|-
|Cefepime<sup>¶</sup> '''OR'''
|150 mg/kg per day divided every 8 hours (maximum daily dose 4 g)
|-
|Piperacillin-tazobactam<sup>¶</sup>
|300 mg/kg per day of piperacillin component divided every 6 or 8 hours (maximum daily dose 16 g of piperacillin component)
|-
| colspan="2" |'''PLUS'''
|-
|Vancomycin<sup>¶Δ</sup>
|60 mg/kg per day divided every 6 hours (maximum daily dose 4 g)
|-
| colspan="2" |For patients with potential severe hypersensitivity (ie, anaphylaxis) to beta-lactam antibiotics (eg, penicillin, cephalosporin)<sup>◊</sup> (two agents)
|-
|Aztreonam<sup>¶</sup>
|120 mg/kg per day divided every 6 hours (maximum daily dose 8 g)
|-
| colspan="2" |'''PLUS'''
|-
|Vancomycin<sup>¶Δ</sup>
|60 mg/kg per day divided every 6 hours (maximum daily dose 4 g)
|-
| colspan="2" |For patients with non-anaphylactic hypersensitivity to penicillins (two agents)
|-
|Ceftazidime<sup>¶</sup> '''OR'''
|150 mg/kg per day divided every 8 hours (maximum daily dose 6 g)
|-
|Cefepime<sup></sup>
|150 mg/kg per day divided every 8 hours (maximum daily dose 4 g)
|-
| colspan="2" |'''PLUS'''
|-
|Vancomycin<sup>¶Δ</sup>
|60 mg/kg per day divided every 6 hours (maximum daily dose 4 g)
|}
<nowiki>*</nowiki> Table contains suggested antibiotic options for broad-spectrum initial empirical treatment. Consider local resistance data, including prevalence of extended-spectrum beta-lactamase (ESBL)-producing organisms that may require alternate empiric coverage, including a carbapenem. '''Selection and/or dosing should be modified based on the results of culture and sensitivity testing.''' See text.


¶ Dosage modification for renal insufficiency is necessary. See drug information topic.
* Preferred regimen (2): [[Piperacillin]] q6h (max 4g piperacillin/dose) IV, '''<u>PLUS</u>''' [[Ofloxacin]] Otic Solution 10 drops to affected ear BID, '''<u>ADD</u>''' [[Vancomycin]] 15mg/kg/dose IV q6-8h (initial max 1g/dose) for severe infection with adjacent [[complications]], or suspicion of [[MRSA]].
[[Antibiotic]] selection and dosing may be modified after obtaining the results of culture and [[antibiotic]] sensitivity.


Δ Monitor blood levels to insure efficacy and avoid toxicity.
=== Mastoiditis treatment follow up ===
 
Treatment response should be monitored by:
◊ Rapid desensitization and use of first-line agents may be preferred if feasible
* Serial examination of the postauricular region and the [[tympanic membrane]].
 
* Development of symptoms, such as [[fever]], [[otalgia]], [[Postauricular inflammation and swelling|postauricular]] tenderness, [[erythema]], [[swelling]], fluctuance, or [[mass]], and narrowing the [[external auditory canal]]
are available (table 1).
 
For children with a history of recurrent acute otitis media (most recent episode within six months) or recent antibiotic use, adequate coverage for gram-positive and gram-negative pathogens usually entails combination therapy (table 1). Additional antimicrobial agents may be warranted in patients with specific complications (eg, brain abscess) or if Gram stain of aspirated material demonstrates an unexpected finding. Antimicrobial therapy is adjusted as necessary when results of culture and susceptibility tests are available.
 
Upon diagnosis of the acute mastoiditis, initial antimicrobial typically is given intravenously. The patient can be switched to oral antibiotics when he or she has improved clinically and culture and susceptibility results are available [23-25]. In observational studies, the duration of treatment varies depending on the severity of the infection, with extended courses for children with intracranial complications [17,26]. We generally treat with intravenous antibiotics for 7 to 10 days and oral antibiotics to complete a four week course (the usual duration of infection for bone infection). (See "Hematogenous osteomyelitis in children: Management", section on 'Total duration'.)


==References==
==References==
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{{WH}}
{{WH}}
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[[Category:Emergency mdicine]]
[[Category:Disease]]
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[[Category:Infectious disease]]
[[Category:Otolaryngology]]
[[Category:Surgery]]

Latest revision as of 22:39, 29 July 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mehrian Jafarizade, M.D [2]

Overview

Medical treatment for acute and subacute mastoiditis without intracranial complications consists of intravenous antibiotics and myringotomy. Antibiotics for acute mastoiditis must cover the most common bacterial pathogens: Streptococcus pneumoniae, Streptococcus pyogenes, and Staphylococcus aureus (including methicillin-resistant S. aureus). The empiric antibiotics are ampicillin-sulbactam or ampicillin; add vancomycin for severe infection with adjacent complications or suspicion of MRSA. For chronic mastoiditis, bacteria common covered are Pseudomonas aeruginosa, Staphylococcus aureus, and anaerobes. Antibiotics include piperacillin-tazobactam or piperacillin, and ofloxacin otic solution; add vancomycin for severe infection with adjacent complications or suspicion of MRSA.

Medical Therapy

Medical treatment for acute and subacute mastoiditis without intracranial complications consists of intravenous antibiotics and myringotomy. With only antimicrobial therapy, there is a possibility that mastoiditis will lead to further complications. In a study of 223 patients with mastoiditis, 8.5 percent developed complications during antimicrobial therapy. If the disease course worsens with antibiotics and myringotomy, surgical procedures may be performed.[1][2]

Empiric antibiotic therapy

Antibiotics for acute mastoiditis must cover the most common bacterial pathogens: Streptococcus pneumoniae, Streptococcus pyogenes, and Staphylococcus aureus (including methicillin-resistant S. aureus). If there is a history of recurrent acute otitis media or recent antibiotic usage, the intravenous antibiotic also should cover Pseudomonas aeruginosa. Depending on the patient's condition, antibiotic choices may differ as follows:[1][2]

Acute mastoiditis (<1 month duration), immunocompetent patient

Bacteria commonly covered are: Streptococcus pneumonia, Group A Streptococcus, and Staphylococcus aureus.

  • Preferred regimen (2): Ampicillin IV q6h (max 2g ampicillin/dose) ADD Vancomycin 15mg/kg/dose IV q6-8h (initial max 1g/dose) for severe infection with adjacent complications, or suspicion of MRSA

Chronic mastoiditis (>= 1 month duration, usually non-intact tympanic membrane)

Bacteria commonly covered are: Pseudomonas aeruginosa, Staphylococcus aureus, and anaerobes.

  • Preferred regimen (1): Piperacillin-tazobactam (Zosyn) 100 mg/kg/dose IV, PLUS Ofloxacin Otic Solution 10 drops to affected ear BID, ADD Vancomycin 15mg/kg/dose IV q6-8h (initial max 1g/dose) for severe infection with adjacent complications, or suspicion of MRSA.
  • Preferred regimen (2): Piperacillin q6h (max 4g piperacillin/dose) IV, PLUS Ofloxacin Otic Solution 10 drops to affected ear BID, ADD Vancomycin 15mg/kg/dose IV q6-8h (initial max 1g/dose) for severe infection with adjacent complications, or suspicion of MRSA.

Antibiotic selection and dosing may be modified after obtaining the results of culture and antibiotic sensitivity.

Mastoiditis treatment follow up

Treatment response should be monitored by:

References

  1. ↑ 1.0 1.1 Luntz M, Brodsky A, Nusem S, Kronenberg J, Keren G, Migirov L, Cohen D, Zohar S, Shapira A, Ophir D, Fishman G, Rosen G, Kisilevsky V, Magamse I, Zaaroura S, Joachims HZ, Goldenberg D (2001). "Acute mastoiditis--the antibiotic era: a multicenter study". Int. J. Pediatr. Otorhinolaryngol. 57 (1): 1–9. PMID 11165635.
  2. ↑ 2.0 2.1 "Pediatric Guidelines: Head and Neck Infections - Mastoiditis | Infectious Diseases Management Program at UCSF".

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