文本框: MANAGEMENT OF ACUTE OTITIS MEDIA (AOM) IN AN ERA OF INCREASING ANTI-BACTERIAL RESISTANCE Klein, JO Maxwell Finland Laboratory for Infectious Diseases, Boston Medical Center, Boston, MA USA Objective: To review the pathogenesis, sequelae, microbiology, and the clinical implications of multi-drug resistance for choice of anti-bacterial drugs. Methods: Review of current literature and guidelines in the USA Results: S. pneumoniae and NT H. influenzae are the pathogens most frequently isolated from middle ear fluids of children with AOM. Multi-drug resistance confounds the choice of antimicrobial agents for AOM. The pattern of resistance in incremental for S. pneumoniae (modification of penicillin binding proteins) and can be overcome by high concentrations of drug in the middle ear such as achieved by high dose amoxicillin (80 mg/kg/day in 2 doses) or single dose IM ceftriaxone (50 mg/kg once). The resistance of NT H. influenzae to beta-lactam drugs is absolute due to the production of beta-lactamase which cleaves the beta-lactam ring of susceptible penicillins and renders the drug inactive. Working groups of the US Centers for Disease Control have developed guidelines for choice of antibacterial drugs for AOM: amoxicillin remains the drug of choice (high dose in areas with increased rates of non-susceptible S. pneumoniae); if amoxicillin fails use of amoxicillin-clavulanate, cefuroxime axetil or IM ceftriaxone is recommended. New approaches to the management of AOM include use of neuraminidase inhibitors of influenza virus infections (oseltamivir and zanamivir) and pneumococcal conjugate vaccines for prevention of pneumococcal AOM. Conclusions: The increasing rate of multi-drug resistant S. pneumoniae and beta-lactamase positive H. influenzae requires increased accuracy of diagnosis of AOM and careful choice of antibiotics based on local susceptibility patterns. Amoxicillin continues to be drug of choice for AOM in the US; amoxicillin-clavulanate, cefuroxime axetil and IM ceftriaxone should be considered for children who fail amoxicillin. Pneumococcal conjugate and influenzavirus vaccines and anti-influenzavirus drugs offer additional opportunities to prevent or treat AOM.