Additions Warranted

Acute Otitis Media: A Structured Approach Dr. med. Jan Peter Thomas, Prof. Dr. med. Reinhard Berner, Prof. Dr. med. Dr. h.c. Thomas Zahnert, Prof. Dr. med. Stefan Dazert in issue 9/2014

The authors recommend intravenous antibiotic treatment in acute otitis media (AOM) occurring within two months after insertion of a cochlear implant (CI). In cases where the device was implanted more than two months prior, they recommend empirical treatment with amoxicillin and, if required, clavulanic acid, citing Rubin (1). As the authors did not recommend any further measures, we think some additions are warranted.

Rubin (1) recommends, independently of the time that has passed since the implantation procedure, paracentesis and microbiological work-up of middle-ear secretions, in order to target the treatment. Meningitis is a serious complication of AOM in patients with cochlear implants (1, 2). Rubin based his recommendation of treating AOM with oral antibiotics (in addition to paracentesis!) more than two months after implantation on the assumption that vaccinations protecting against meningitis were given before the implantation procedure. In addition to the 7-valent pneumococcal vaccine, Rubin lists the 13-valent vaccine in all children and a 23-valent vaccine in older children; furthermore, vaccination against Haemophilus influenzae—all of these should also be given to all family contacts living with the person with the cochlear implant. These vaccinations can drastically reduce the risk of meningitis due to H influenzae or pneumococci, which are among the most common pathogens causing AOM. In view of the fact that the protection conferred by the 23-valent pneumococcoal vaccine is present in only 56% of patients, Lalwani (2) recommends undertaking paracentesis and microbiological analysis of secretions at the start of antibiotic treatment. A glance at the recommendations from the Robert Koch-Institute (3) shows that in persons living in Germany, the vaccinations that form the basis of Rubin’s and Lalwani’s recommendations are unlikely to have been given. An additional risk is posed by infection of the implant (1) with biofilm formation and potential need for removal of the implant. This makes it even more urgently necessary to assess intravenous antibiotic therapy for AOM—which exceeds the efficacy of oral antibiotics—in all seriousness and, wherever possible, to administer such treatment.

DOI: 10.3238/arztebl.2014.0545a

Prof. Dr. med. Antje Aschendorff

Implant Centrum Freiburg

Prof. Dr. med. Wolfgang Maier

Univ.-HNO-Klinik Freiburg

References

1. Rubin LG: Prevention and treatment of meningitis and acute otitis media in children with cochlear implants. Otol Neurotol 2012, 31: 1331–3.

2. Lalwani AK, Cohen NL: Does meningitis after cochlear implantation remain a concern in 2011? Otol Neurotol 2011, 33: 93–5.

3. Ständige Impfkommission am Robert Koch-Institut (RKI): Empfehlungen der Ständigen Impfkommission (STIKO) am Robert Koch-Institut/Stand: August 2013. Epidemiologisches Bulletin 2013; 34: 313–44.

4. Thomas JP, Berner R, Zahnert T, Dazert S: Acute otitis media: a structured approach. Dtsch Arztebl Int 2014; 111: 151–60.