Mastoiditis medical therapy

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

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

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).

If there is a history of recurrent acute otitis media or recent antibiotic usage the intravenous antibiotic also should cover the P. aeruginosa.

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

Suggested empiric parenteral antibiotic regimens for the treatment of acute mastoiditis in children*

Antibiotic	Dose
For patients without a history of recurrent otitis media or recent antibiotic therapy
Vancomycin¶Δ	60 mg/kg per day divided every 6 hours (maximum daily dose 4 g)
For patients with a history of recurrent otitis media (last episode within 6 months) or recent antibiotic therapy
For patients without penicillin allergy (two agents)
Ceftazidime¶ OR	150 mg/kg per day divided every 8 hours (maximum daily dose 6 g)
Cefepime¶ OR	150 mg/kg per day divided every 8 hours (maximum daily dose 4 g)
Piperacillin-tazobactam¶	300 mg/kg per day of piperacillin component divided every 6 or 8 hours (maximum daily dose 16 g of piperacillin component)
PLUS
Vancomycin¶Δ	60 mg/kg per day divided every 6 hours (maximum daily dose 4 g)
For patients with potential severe hypersensitivity (ie, anaphylaxis) to beta-lactam antibiotics (eg, penicillin, cephalosporin)◊ (two agents)
Aztreonam¶	120 mg/kg per day divided every 6 hours (maximum daily dose 8 g)
PLUS
Vancomycin¶Δ	60 mg/kg per day divided every 6 hours (maximum daily dose 4 g)
For patients with non-anaphylactic hypersensitivity to penicillins (two agents)
Ceftazidime¶ OR	150 mg/kg per day divided every 8 hours (maximum daily dose 6 g)
Cefepime¶	150 mg/kg per day divided every 8 hours (maximum daily dose 4 g)
PLUS
Vancomycin¶Δ	60 mg/kg per day divided every 6 hours (maximum daily dose 4 g)

* 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.

Δ Monitor blood levels to insure efficacy and avoid toxicity.

◊ Rapid desensitization and use of first-line agents may be preferred if feasible

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'.)