Mastoiditis medical therapy
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Mastoiditis Microchapters |
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Diagnosis |
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Treatment |
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Case Studies |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:
Overview
Medical Therapy
Medical treatment for acute and subacute mastoiditis without intracranial complications is intravenous antibiotics and myringotomy.
ANTIMICROBIAL THERAPY — The treatment of mastoiditis requires parenteral antimicrobial therapy. However, antimicrobial therapy is not necessarily sufficient, particularly in the later stages of the disease process, when it may be difficult to achieve adequate antibiotic levels in the bony tissue [9]. Antimicrobial therapy may fail to prevent the development of complications of acute mastoiditis. In a series of 223 patients, 8.5 percent developed complications during antimicrobial therapy [9]. (See 'Treatment response' below.)
Empiric antimicrobial therapy for children with acute mastoiditis without a history of recurrent acute otitis media (AOM) or recent antibiotic administration should provide coverage for the most frequent bacterial pathogens: S. pneumoniae (including multiply resistant S. pneumoniae), S. pyogenes, and S. aureus (including methicillin-resistant S. aureus). Antibiotics active against P. aeruginosa should be included in the empiric regimen if the child has a history of recurrent AOM or has received antibiotics recently.
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 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'.)