From Evidence to Clinical Guidelines in Antibiotic Treatment in Acute Otitis Media in Children

Abstract

Acute otitis media (AOM) in children represents a public health concern, being one of the leading causes of health care visits and antibiotic prescriptions worldwide. The overall aim of this paper is to unravel the major current insights into the antibiotic treatment of AOM in children. Our approach is three-fold: 1. a preclinical evaluation of antibiotics in animal models of AOM stressing on the advantages of different species when testing for different schemes of antibiotics; 2. an overview on the new antimicrobial agents whose efficacy has been demonstrated in refractory cases of AOM in children; and 3. an analysis of the different guidelines stressing on the differences and similarities between the various schemes of antibiotic treatment. The preferred therapeutic agents remain amoxicillin and the amoxicillin-clavulanate combination for AOM caused by Streptococcus pneumoniae, whereas oral cephalosporin is preferred in AOM due to Moraxella catarrhalis and Haemophilus influenzae. As for the second and third line antimicrobial treatments, there is a wide variety of suggested antibiotic classes with variations in duration and posology. The decision to prescribe antimicrobial treatment as a first-line choice is based on the severity of the symptoms in 16 of the guidelines included in this review.

Keywords: acute otitis media; antibiotic treatment; clinical practice guidelines; preclinical evaluation of antibiotics; rodent models of acute otitis media.

Figure 1

In the determination of otitis media, pathogens such as Gram-positive and -negative bacteria are causative agents of the acute form; the Gram-negative bacterium is represented in the image because, from a structural and chemical point of view, it is more complex compared with the Gram-positive one. The cell wall contains two outer layers of the cytoplasmic membrane and above the peptidoglycan layer is an outer membrane present only in Gram-negative bacteria. Specific for these bacteria are the “porins” (transmembrane proteins) that allow the passage of antibiotic molecules. Clinically, acute otitis media (AOM) is characterized by inflammation, bulging of the tympanic membrane, accumulation of purulent secretion, otorrhea, and discomfort. The effectiveness of antibiotics in this condition has been proven in both preclinical and clinical studies through various mechanisms of action that affect the middle ear, such as inhibition of cell synthesis, nucleic acids and disruption of their function, inhibition of protein synthesis, and enzymes such as beta-lactamases.