Dowell S F, Butler J C, Giebink G S, Jacobs M R, Jernigan D, Musher D M, Rakowsky A, Schwartz B
Respiratory Diseases Branch, Centers for Disease Control and Prevention (CDC), Atlanta, GA 30333, USA.
Pediatr Infect Dis J. 1999 Jan;18(1):1-9.
To provide recommendations [corrected] for the management of acute otitis media (AOM) and the surveillance of drug-resistant Streptococcus pneumoniae (DRSP). Five questions were addressed: (1) Can amoxicillin remain the best initial antimicrobial agent for treating AOM in the current period of increasing prevalence of DRSP? (2) What are suitable alternative agents for use if amoxicillin fails? (3) Should empiric treatment of AOM vary by geographic region? (4) Where can clinicians learn about resistance patterns in their patient populations? (5) What modifications to laboratory surveillance would improve the utility of the information for clinicians treating AOM?
Experts in the management of otitis media and the DRSP Therapeutic Working Group. This group was convened by the CDC to respond to changes in antimicrobial susceptibility among pneumococci and includes clinicians, academicians and public health practitioners.
Published and unpublished data summarized from the scientific literature and experience from the experts present.
[corrected] After group presentations and review of background materials, subgroup chairs prepared draft responses to the five questions, discussed the responses as a group and edited those responses [corrected].
Oral amoxicillin should remain the first line antimicrobial agent for treating AOM. In view of the increasing prevalence of DRSP, the safety of amoxicillin at higher than standard dosages and evidence that higher dosages of amoxicillin can achieve effective middle ear fluid concentrations, an increase in the dosage used for empiric treatment from 40 to 45 mg/kg/day to 80 to 90 mg/kg/day is recommended. For patients with clinically defined treatment failure after 3 days of therapy, useful alternative agents include oral amoxicillin-clavulanate, cefuroxime axetil and intramuscular ceftriaxone. Many of the 13 other Food and Drug Administration-approved otitis media drugs lack good evidence for efficacy against DRSP. Currently local surveillance data for pneumococcal resistance that are relevant for the clinical management of AOM are not available from most areas in the United States. Recommendations to improve surveillance include establishing criteria for setting susceptibility breakpoints for clinically appropriate antimicrobials to ensure relevance for treating AOM, testing middle ear fluid or nasal swab isolates in addition to sterile site isolates and testing of drugs that are useful in treating AOM. The management of otitis media has entered a new era with the development of DRSP. These recommendations are intended to provide a framework for appropriate clinical and public health responses to this problem.
为急性中耳炎（AOM）的管理及耐药肺炎链球菌（DRSP）的监测提供建议。探讨了五个问题：（1）在DRSP患病率不断上升的当前时期，阿莫西林能否依然作为治疗AOM的最佳初始抗菌药物？（2）若阿莫西林治疗失败，合适的替代药物有哪些？（3）AOM的经验性治疗是否应因地理区域而异？（4）临床医生可从何处了解其患者群体中的耐药模式？（5）实验室监测需要做出哪些改进，以提高所获信息对治疗AOM的临床医生的实用性？
中耳炎管理专家及DRSP治疗工作组。该小组由美国疾病控制与预防中心召集，以应对肺炎球菌抗菌药物敏感性的变化，成员包括临床医生、学者和公共卫生从业者。
从科学文献中总结的已发表和未发表的数据，以及与会专家的经验。
在小组发言并审查背景资料后，各小组主席起草了对五个问题的答复，进行了小组讨论并对答复进行了编辑。
口服阿莫西林应依然作为治疗AOM的一线抗菌药物。鉴于DRSP患病率不断上升，高于标准剂量的阿莫西林的安全性，以及高剂量阿莫西林可在中耳液中达到有效浓度的证据，建议将经验性治疗的剂量从40至45毫克/千克/天增加至80至90毫克/千克/天。对于治疗3天后临床判定治疗失败的患者，有用的替代药物包括口服阿莫西林-克拉维酸、头孢呋辛酯和肌内注射头孢曲松。美国食品药品监督管理局批准的其他13种中耳炎药物中，许多药物缺乏针对DRSP的有效疗效证据。目前，美国大多数地区无法获得与AOM临床管理相关的肺炎球菌耐药性的本地监测数据。改进监测的建议包括为临床适用的抗菌药物设定敏感性断点制定标准，以确保与AOM治疗的相关性，除无菌部位分离株外，还应对中耳液或鼻拭子分离株进行检测，并对治疗AOM有用的药物进行检测。随着DRSP的出现，中耳炎的管理进入了一个新时代。这些建议旨在为针对这一问题采取适当的临床和公共卫生应对措施提供一个框架。
