Inflammation of the Middle Ear (Otitis Media): Drug Therapy

Therapeutic targets

• Elimination of the pathogens
• Avoidance of complications

Therapy recommendations

Antibiotic administration can usually be omitted if:

• Uncomplicated otitis media is present (see table below).
• no complications are present, such as:
  • Immunodeficiency (immune deficiency).
  • Influenza (flu)
  • Cleft lip and palate
  • Severe underlying diseases
  • Cochlear implant wearer (hearing prosthesis)
• A good control by the doctor within the first three days is secured

Antibiotic therapy versus wait-and-see therapy (for uncomplicated otitis media) (modified from).

Age	Mild (unilateral, without otorrhea)	Medium (bilateral, without otorrhea)	Severe bilateral with severe symptoms (temperature > 39 °C during the past 48 h, persistent otalgia > 48 h) or otorrhea
<6 months	Antibiotic therapy (AB therapy) for 10 days
6-24 months	Wait-and-see behaviorIf necessary after 48-72 h of AB therapy for 10 days.	AB therapy for 10 days	AB therapy for 10 days
2-5th year of life	Wait-and-see behaviorIf necessary, after 48-72 h of AB therapy for 10 days.	Wait-and-see behaviorIf necessary after 48-72 h AB therapy for 7 days.	AB therapy for 10 days
≥ 6 years of age	Wait-and-see behaviorIf necessary, after 48-72 h of AB therapy for 5-7 days.	Wait-and-see behaviorIf necessary after 48-72 h AB therapy for 5-7 days.	AB therapy for 10 days

Note: Antibiotic therapy shows the greatest benefit in children <2 years of age. Further notes

• Ear drops are obsolete (no longer in use).
• Nasal drops may possibly improve the ventilation of the middle ear (e.g., in concomitant rhinosinusitis/simultaneous inflammation of the nasal mucosa (“rhinitis”) and the mucosa of the paranasal sinuses (sinusitis)), but there is no proven efficacy on the healing process.
• See also under “Further therapy”.

Antibiotic therapy including symptomatic therapy (antipyretics/drugs that have a fever-reducing effect: Paracetamol, first-line agent in children):

• Acute otitis media (AOM):
  • Amoxicillin (penicillin with ß-lactamase inhibitor; aminopenicillins), ampicillin + sulbactam (first-line agents).
  • Ceftriaxone (cephalosporins), clindamycin (lincosamides) (second-line agents).
  • Use in clearly occurred anaphylactic reaction to penicillin: azithromycin, erythromycin, clarithromycin (macrolides).
  • Duration of therapy (except azithromycin):
    • Children <2 years of age and children with severe disease: Therapy >10 dBeight: Shortening antibiotic therapy from ten to five days doubled the number of treatment failures or relapses in a randomized trial.
    • Children 2-6 years of age: therapy > 7 d.
    • From the age of 6: therapy 5-7 d

    Start antibiotics only when no improvement has occurred on the 3rd day after symptom onset (children < 2 years: on the 2nd day).

• Chronic otitis media:
  • Piperacillin + tazobactam (acylaminopenicillin with ß-lactamase inhibitor), cefepime or ceftazidime (cephalosporins), clindamycin (lincosamides); duration of therapy 5 d.

Caveat.

• The U.S. Food and Drug Administration advises caution in prescribing the antibiotic clarithromycin in patients with preexisting cardiac conditions. Results of a 10-year follow-up after 2-week treatment with clarithromycin showed increased all-cause mortality (hazard ratio 1.10; 1.00-1.21), and the rate of cerebrovascular disease (hazard ratio 1.19; 1.02-1.38) was also increased.
• Cefepime: With cefepime and creatinine clearance < 50 ml/min, there is a risk of encephalopathy (collective term for abnormal brain changes) with impaired consciousness, confusion, hallucinations, stupor (state of extreme mental and motor numbness), and coma; myoclonus (brief involuntary twitching of single muscles or muscle groups) and seizures (incl. Nonconvulsive status epilepticus/prolonged epileptic seizure) are possible.

Supplements (dietary supplements; vital substances)

Suitable supplements for natural defense should contain the following vital substances:

• Vitamins (A, C, E, D3, B1, B2 B3, B5, B6, B12, folic acid, biotin).
• Trace elements (chromium, iron, copper, manganese, molybdenum, selenium, zinc).
• Omega-3 fatty acids (eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA)).
• Secondary plant compounds (eg beta-carotene, flavonoids, lycopene, polyphenols).
• Probiotics

Note: The listed vital substances are not a substitute for drug therapy. Dietary supplements are intended to supplement the general diet in the particular life situation.