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==
The primary treatment for acute mastoiditis without [[osteitis]] is the administration of [[intravenous]] [[antibiotics]] after obtaining cultures. The choice of antimicrobial agents is similar to that for [[otitis media|acute otitis media]]—antibiotics against ''[[Streptococcus pneumoniae]]'' and ''[[Haemophilus influenzae]]''.  Additional coverage for ''[[Staphylococcus aureus]]'' and [[Gram-negative bacilli]] may be considered for protracted disease until the results of cultures become available.<ref name="pmid18092706">{{cite journal| author=Ramakrishnan K, Sparks RA, Berryhill WE| title=Diagnosis and treatment of otitis media. | journal=Am Fam Physician | year= 2007 | volume= 76 | issue= 11 | pages= 1650-8 | pmid=18092706 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18092706  }} </ref><ref>{{Cite book  | last1 = Mandell | first1 = Gerald L. | last2 = Bennett | first2 = John E. (John Eugene) | last3 = Dolin | first3 = Raphael. | title = Mandell, Douglas, and Bennett's principles and practice of infectious disease | date = 2010 | publisher = Churchill Livingstone/Elsevier | location = Philadelphia, PA | isbn = 978-0-443-06839-3 | pages = }}</ref> [[Ciprofloxacin]] (500 mg twice a day) may be considered in [[immunocompromised]] patients with [[diabetes]] or [[HIV infection]] or in infections involving the skin and periauricular areas.  Long-term antibiotics may be necessary to completely eradicate the infection.  [[Otalgia]] associated with otitis externa may be managed with topical anesthesic agent such as [[benzocaine]].
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>


===Antimicrobial Regimen===
=== Empiric antibiotic therapy ===
===Mastoiditis===
[[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>
*'''1. Acute Mastoiditis''' <ref>{{cite book | last = Gilbert | first = David | title = The Sanford guide to antimicrobial therapy | publisher = Antimicrobial Therapy | location = Sperryville, Va | year = 2015 | isbn = 978-1930808843 }}</ref>
:*'''1.1 Causative pathogens:'''
::*Streptococcus pneumoniae
::*Streptococcus pyogenes
::*Staphylococcus aureus
::*Hemophilus influenzae
::*Pseudomonas aeruginosa
:*'''1.2 Acute mastoiditis, outpatient'''
::*'''1.2.1 Empiric antimicrobial therapy'''
:::*Preferred regimen (no abx in past month): [[Amoxicillin]] 50 mg/kg/day PO q6h
:::*Preferred regimen (abx in past month): [[Amoxicillin-Clavulanate]] 90 mg/kg/day PO q12h {{or}} [[Cefdinir]] 14 mg/kg PO q24h {{or}} [[Cefpodoxime]] 10 mg/kg/day PO q12h (maximum dose is 400 mg/day) {{or}}  [[Cefprozil]] 30 mg/kg/day PO q12h (maximum dose is 1 g/day) {{or}} [[Cefuroxime]] 15 mg/kg/day PO q12h (Maximum dose is 1 g/day)
:::*Note: Duration of treatment in children <2 years-old is 10 days. In children ≥2 years, recommended duration is 5–7 days.
::*'''1.2.2 Pathogen-directed antimicrobial therapy'''
:::*'''1.2.2.1 Staphylococcus aureus (MSSA)'''
::::*Preferred regimen: [[Oxacillin]] 37 mg/kg IV q6h (maximum dose is 8-12 g/day)
:::*'''1.2.2.2 Staphylococcus aureus (MRSA)'''
::::*Preferred regimen: [[Vancomycin]] 40 mg/kg/day IV q6-8h
::::*Note: Maintain [[Vancomycin]] serum trough concentrations of 15-20 mcg/mL
:*'''1.3 Acute mastoiditis, inpatient'''
::*'''1.3.1 Empiric antimicrobial therapy'''
:::*Preferred regimen: [[Cefotaxime]] 1-2 g IV q4-8h {{or}} [[Ceftriaxone]] 1 g IV q24h
::*'''1.3.2 Pathogen-directed antimicrobial therapy'''
:::*'''1.3.2.1 Staphylococcus aureus (MSSA)'''
::::*Preferred regimen: [[Oxacillin]] 37 mg/kg IV q6h (maximum dose is 8-12 g/day)
:::*'''1.3.2.2 Staphylococcus aureus (MRSA)'''
::::*Preferred regimen: [[Vancomycin]] 40 mg/kg/day IV q6-8h
::::*Note: Maintain [[Vancomycin]] serum trough concentrations of 15-20 mcg/mL


*'''2. Chronic Mastoiditis'''<ref>{{cite book | last = Gilbert | first = David | title = The Sanford guide to antimicrobial therapy | publisher = Antimicrobial Therapy | location = Sperryville, Va | year = 2015 | isbn = 978-1930808843 }}</ref>
==== Acute mastoiditis (<1 month duration), immunocompetent patient ====
:*'''2.1 Causative pathogens:'''
Bacteria commonly covered are: [[Streptococcus pneumonia|''Streptococcus pneumonia'']], [[Group A streptococcus|Group A S''treptococcus'']], and [[Staphylococcus aureus|''Staphylococcus aureus''.]]
::*Polymicrobial
* 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]]
::*Enterobacteriaceae
 
::*Staphylococcus aureus
* 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]]
::*Pseudomonas aeruginosa
 
:*'''2.2 Empiric antimicrobial therapy'''
==== [[Chronic]] mastoiditis (>= 1 month duration, usually non-intact tympanic membrane) ====
::*Preferred regimen: [[Imipenem]] 0.5 g IV q6h {{or}} [[Piperacillin-Tazobactam]] 3.375 g IV q4-6h {{or}} [[Meropenem]] 1 g IV q8h {{or}} [[Ticarcillin-Clavulanate]] 3.1 g IV q6h
Bacteria commonly covered are: ''[[Pseudomonas aeruginosa]], [[Staphylococcus aureus]]'', and [[anaerobes|anaerobes.]]
::*Note: Treatment is reserved for acute exacerbations or perioperatively. It is recommended not to treat without surgical cultures
* 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]].
 
* 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.
 
=== Mastoiditis treatment follow up ===
Treatment response should be monitored by:
* 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]]


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

Latest revision as of 22:39, 29 July 2020

Mastoiditis Microchapters

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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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