A) Unasyn

C) Ceftriaxone

Here’s how others answered:

Q14 graph

Acute Mastoiditis

  • Most common infecting organisms include
    • S. pneumoniae
    • S. pyogenes (GAS)
    • S. aureus
  • Symptoms include the following:
    • Intense otalgia, retroauricular swelling, and a protruding ear caused by subperiosteal abscess formation
    • Commonly preceded by an acute otitis media
  • Antibiotic treatment has not been proven to prevent mastoiditis
  • Diagnosis is based on clinical exam, not radiologic exam

Management of Acute Mastoiditis

  • Antibiotic choice
    • Recommendations include Amp/sulbactam (Unasyn) or Amox/Clav (Augmentin) or 3rd generation cephalosporin (Ceftriaxone)
    • No need to cover for Pseudomonas unless growing out of culture
    • More common in patients with tympanostomy tubes and in recurrent AOM
      • Can consider antipseudomonal coverage in these situations (Cefepime or Zosyn)
    • Levofloxacin should not be used except in severe PCN allergy
    • Rates of MRSA are very low in acute cases of mastoiditis
      • In other words, empiric vancomycin is not necessary
  • Surgical management usually required
    • Myringotomy tubes
    • Drainage of abscess

Discussion of this case

  • The initial outpatient management was correct
    • Augmentin was a good choice, and he already had started to drain via a perforation
    • His failure was not because of incorrect outpatient antibiotic selection for this patient
  • This patient needed surgical drainage for management
    • Early surgical consult should be done
  • Continuation of Amp/Sulb (Unasyn) or ceftriaxone would have be the best options listed