Mastoiditis medical therapy
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Mastoiditis Microchapters |
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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. 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 [1]
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 the Pseudomonas aeruginosa.
Depends on the patient condition, antibiotic choices may be differs as follows:
|Condition
|Major Pathogens
|First Choice Therapy
|Alternative Therapy
|Comments
|-
|Mastoiditis - acute
(<1 month duration), immunocompetent patient |Streptococcus pneumoniae
Group A streptococcus
Staphylococcus aureus |Ampicillin-sulbactam (Unasyn) 50mg/kg/dose 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 |Severe beta lactam allergy:
Consult ID/ASP |OHNS consult recommended
Consider ID consult
For intra-cranial extension, refer to Brain Abscess section for empiric therapy
Therapy may be tailored based on cultures from I&D |- |Mastoiditis - chronic
(>= 1 month duration, usually non-intact tympanic membrane), immunocompetent patient |Pseudomonas aeruginosa
Staphylococcus aureus
Anaerobes |Piperacillin-tazobactam (Zosyn) 100mg/kg/dose piperacillin IV q6h (max 4g piperacillin/dose)
AND 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 |Severe beta lactam allergy:
Consult ID/ASP |OHNS and ID consults recommended
Therapy may be tailored based on cultures from I&D |}
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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.
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* 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'.)
References
- ↑ 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.