Since the end of the last century we have been experiencing increased number of patients with intractable acute otitis media (AOM) mainly due to wide spread of drug resistant strains of its causative pathogens, Streptococcus pneumoniae and Haemophilus influenzae in Japan. This phenomenon has been considered to have a close relationship with inappropriate use of antibacterial agents. For the spread of the appropriate choice of antibiotics, the clinical practice guideline for AOM was published in 2006 (revised in 2009) and so was that for acute rhinosinusitis in 2010 in Japan. We could obtain the best treatment outcome by following the guidelines’ antibiotic choice in most of simple cases. For more intractable cases, such as persistent or recurrent AOM, we have at least 3 treatment options. The first one should be OPAT, outpatient parenteral antimicrobial treatment, the second one is the ventilation tube insertion, and the last one is the use of tebipenem (TBPM) or tosufloxacin (TFLX) recently commercialized for pediatric patients. TBPM shows excellent in vitro activity against penicillin resistant strains of S.pneumoniae (MIC50= 0.03 µg/mL, MIC90= 0.06 µg/mL). TFLX shows the best antibacterial activity against non-susceptible H. influenzae in vitro (MIC50= 0.0078 µg/mL, MIC90= 0.0078 µg/mL). The best option(s) to be chosen might be different for each clinician depending on his/her own medical environment. However, ventilation tube insertion is the best solution for the patients whose recurrent AOM cannot be controlled with antimicrobial therapy. When going to choose TBPM or TFLX, it is very important to remember that more use should cause more drug resistance. Because it is very difficult to have any newly developed antibacterial agents after TBPM and TFLX at least in a decade, very restricted use of these antibiotics is highly recommended.
