Mastoiditis medical therapy

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.

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:

Acute mastoiditis (<1 month duration), immunocompetent patient

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

• Preferred regimen (1): Ampicillin-sulbactam IV 50mg/kg/dose 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): 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:

• Serial examination of the postauricular region and the tympanic membrane.
• Development of symptoms, such as fever, otalgia, postauricular tenderness, erythema, swelling, fluctuance, or mass, and narrowing the external auditory canal