acute otitis media
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Acute Otitis MediaAcute Otitis Media
Dr. Hamid RahimiDr. Hamid Rahimi
Pediatric Infectious Disease SpecialistPediatric Infectious Disease Specialist
Acute Otitis MediaAcute Otitis Media
The most common infection for which antibacterial agents The most common infection for which antibacterial agents
are prescribed for children in the USare prescribed for children in the US
1/3 1/3 of office visits to pediatriciansof office visits to pediatricians
Peak incidence 6 – 12 months old Peak incidence 6 – 12 months old
≈ ≈ 2/3 of children experience at least one episode by 1 year old2/3 of children experience at least one episode by 1 year old
Acute Otitis Media - DefinitionsAcute Otitis Media - DefinitionsAOM is an inflammation of the middle ear associated with a collection AOM is an inflammation of the middle ear associated with a collection of fluid in the middle ear space (effusion) or a discharge (otorrhea)of fluid in the middle ear space (effusion) or a discharge (otorrhea)
Recurrent otitis Recurrent otitis >3 episodes of AOM within 6 months that middle ear is normal, without >3 episodes of AOM within 6 months that middle ear is normal, without effusions, between episodeseffusions, between episodesMost children with recurrent acute otitis media are otherwise healthyMost children with recurrent acute otitis media are otherwise healthy
Otitis proneOtitis proneSix or more acute otitis media episodes in the first 6 years of lifeSix or more acute otitis media episodes in the first 6 years of life12% of children in the general population 12% of children in the general population
Persistent Middle-Ear EffusionPersistent Middle-Ear EffusionWhen an episode of otitis media results in persistence of middle-ear fluid When an episode of otitis media results in persistence of middle-ear fluid for 3 months, & TM remains immobilefor 3 months, & TM remains immobileMore common in white children & < 2 yoMore common in white children & < 2 yo
AOM vs. COMAOM vs. COM
Chronic otitis mediaChronic otitis mediaCalled chronic serous otitis in the past, this pattern is usually defined as Called chronic serous otitis in the past, this pattern is usually defined as a middle-ear effusion that has been present for at least 3 months.a middle-ear effusion that has been present for at least 3 months.
Some sort of eustachian tube dysfunction is the principal predisposing Some sort of eustachian tube dysfunction is the principal predisposing factor.factor.
Persistent structural changes, such as a persistent eardrum perforation, Persistent structural changes, such as a persistent eardrum perforation, imply past otitis but not necessarily chronic infection. imply past otitis but not necessarily chronic infection.
Acute otitis media is commonly defined as…Acute otitis media is commonly defined as…1. Presence of a middle ear effusion (MEE) 1. Presence of a middle ear effusion (MEE) 2. TM inflammation 2. TM inflammation 3. Presenting with a rapid onset of symptoms such as fever, irritability, or 3. Presenting with a rapid onset of symptoms such as fever, irritability, or
earache earache
Diagnosis Diagnosis
Etiologic diagnosisEtiologic diagnosis
Clinical diagnosisClinical diagnosis
Case one
History History One year old boy brought with cough, runny nose, and One year old boy brought with cough, runny nose, and
fever. fever.
He is also tugging at his ear and appears to be very fussy. He is also tugging at his ear and appears to be very fussy.
Physical ExamPhysical Exam T= 38 T= 38 00C C Ax.Ax.
Upper respiratory tract sign & symptomUpper respiratory tract sign & symptom
Normal TMNormal TM
Gray Gray Pink Pink
Describe TM appearance Describe TM appearance
What’s your advice?What’s your advice?
1. Tell mother that he has a viral upper respiratory infection or cold that will not benefit from treatment with antibiotics at this time as he does not have an ear infection.
2. Tell mother that he has an ear infection that requires treatment with antibiotics.
3. Explain to mother that he has a red ear drum. The redness is probably caused by his cold but may also be the beginning of an ear infection. You will need to examine him again in 2 days to determine if he has an ear infection and needs antibiotics.
4. Explain to mother that you aren't sure whether Robert is developing an ear infection. Since he has a fever you would prefer to treat him with antibiotics. Something might be brewing.
Clinical diagnosis Clinical diagnosis
A diagnosis of AOM can be established if acute purulent A diagnosis of AOM can be established if acute purulent otorrhea is present and otitis externa has been excluded.otorrhea is present and otitis externa has been excluded.
Presence of a middle ear effusion Presence of a middle ear effusion & & acute signs of middle acute signs of middle ear inflammation ear inflammation in presence of in presence of acute onset of signs & acute onset of signs & symptomssymptoms
History History
Children with AOM usually present with …Children with AOM usually present with …History of rapid onset of otalgia (or pulling of the ear in an History of rapid onset of otalgia (or pulling of the ear in an infant), irritability, poor feeding in an infant or toddler, otorrhea, infant), irritability, poor feeding in an infant or toddler, otorrhea, and/orand/or fever fever
Except otorrhea other findings are nonspecific i.e. Except otorrhea other findings are nonspecific i.e.
Fever, earache, and excessive crying present in Fever, earache, and excessive crying present in children …children …
90% 90% with AOM with AOM
72% 72% without AOMwithout AOM
Laboratory testsLaboratory tests
Routine laboratory studies, including complete Routine laboratory studies, including complete blood count and ESR, are not useful in the blood count and ESR, are not useful in the evaluation of otitis media. evaluation of otitis media.
Otoscopy Otoscopy
The key to distinguishing AOM from OME is the The key to distinguishing AOM from OME is the performance of performance of pneumatic otoscopy pneumatic otoscopy using using appropriate tools and an adequate light sourceappropriate tools and an adequate light source
Use of visual otoscopy alone is discouragedUse of visual otoscopy alone is discouraged
Pneumatic otoscope - equipment Pneumatic otoscope - equipment
Technique Technique
Systematic assessment Systematic assessment of the TM by the use of the of the TM by the use of the COMPLETES mnemonicCOMPLETES mnemonic
Color Color
Other conditions Other conditions
Mobility Position Mobility Position
Lighting Lighting
Entire surface Entire surface
Translucency Translucency
External auditory canal and auricle External auditory canal and auricle
Seal Seal
Normal tympanic membraneNormal tympanic membrane
Middle-Ear EffusionMiddle-Ear Effusion
MEE is commonly confirmed …MEE is commonly confirmed …
Directly by…Directly by…Tympanocentesis Tympanocentesis
Presence of fluid in the external auditory canalPresence of fluid in the external auditory canal
Indirectly by… Indirectly by… Pneumatic otoscopy Pneumatic otoscopy
Tympanometry Tympanometry
Acoustic reflectometryAcoustic reflectometry
Signs of presence of MEESigns of presence of MEE
Signs of presence of MEESigns of presence of MEE
Fluid levelFluid level BobblesBobbles
Signs of presence of MEESigns of presence of MEE
Perforation Perforation Cobble stoningCobble stoning
Normal TMNormal TM
TranslucentTranslucent
Signs of presence of MEESigns of presence of MEE
OpaqueOpaqueSemi-opaqueSemi-opaque
Normal TMNormal TM
Pink Pink Gray Gray
Signs of presence of MEESigns of presence of MEE
White White Pale yellowPale yellow
Signs of presence of MEESigns of presence of MEE
Pneumatic otoscopyPneumatic otoscopyReduced or absent mobility of the tympanic membrane is Reduced or absent mobility of the tympanic membrane is additional evidence of fluid in the middle earadditional evidence of fluid in the middle ear
Tympanometry or acoustic reflectometryTympanometry or acoustic reflectometryCan be helpful in establishing a diagnosis when the presence of Can be helpful in establishing a diagnosis when the presence of middle-ear fluid is difficult to determinemiddle-ear fluid is difficult to determine
Tympanometry Tympanometry
OME vs. AOMOME vs. AOM
Major challenge Major challenge
Otitis Media with Effusion Otitis Media with Effusion
Vs.Vs.
Acute Otitis MediaAcute Otitis Media
Signs & symptoms of middle-ear inflammationSigns & symptoms of middle-ear inflammation
Signs or symptoms of middle-ear inflammation indicated Signs or symptoms of middle-ear inflammation indicated by …by …
a.a. Non – otoscopic findingsNon – otoscopic findings
a.a. Distinct otalgia (discomfort clearly referable to the ear[s] that Distinct otalgia (discomfort clearly referable to the ear[s] that results in interference with or precludes normal activity or results in interference with or precludes normal activity or sleep) sleep)
b.b. However, these symptoms must be accompanied by abnormal However, these symptoms must be accompanied by abnormal otoscopic findings otoscopic findings
b.b. Otoscopic findingsOtoscopic findings
Acute inflammation – otoscopic findings Acute inflammation – otoscopic findings
Signs of acute inflammation are necessary to differentiate AOM from Signs of acute inflammation are necessary to differentiate AOM from OME. OME.
Distinct fullness or bulgingDistinct fullness or bulgingThe best and most reproducible sign of acute inflammationThe best and most reproducible sign of acute inflammation
Marked redness of the tympanic membraneMarked redness of the tympanic membraneMarked redness of the tympanic membrane without bulging is an unusual finding Marked redness of the tympanic membrane without bulging is an unusual finding in AOM. in AOM.
Normal TMNormal TM
Neutral Neutral
Signs of presence of MEESigns of presence of MEE
BulgingBulgingDistinct fullnessDistinct fullness
Normal TMNormal TM
Pink Pink Gray Gray
Signs of middle-ear inflammationSigns of middle-ear inflammation
Marked rednessMarked rednessInjectionInjection
Usefulness of findingsUsefulness of findings
Findings Adjusted LR 95% CI
Bulging tympanic membrane 51 36-73
Cloudy tympanic membrane 34 28-42
Distinctly impaired tympanic membrane mobility 31 26-37
Distinctly red tympanic membrane (hemorrhagic, strongly, or moderately red)
8.4 6.7-1
Predictive value of combinations of otoscopic findings Predictive value of combinations of otoscopic findings in children with acute ear symptomsin children with acute ear symptoms
Normal TMNormal TM
Neutral Neutral
Signs of presence of MEESigns of presence of MEE
BulgingBulgingDistinct fullnessDistinct fullness
Established acute otitis mediaEstablished acute otitis media
Differential diagnosis - 2Differential diagnosis - 2
Other conditions Other conditions Redness of tympanic membrane Redness of tympanic membrane
AOMAOM
CryingCrying
Upper respiratory infection with congestion and inflammation of the mucosa lining the Upper respiratory infection with congestion and inflammation of the mucosa lining the entire respiratory tractentire respiratory tract
Trauma and/or cerumen removalTrauma and/or cerumen removal
Decreased or absent mobility of tympanic membrane Decreased or absent mobility of tympanic membrane AOM and OMEAOM and OME
Tympanosclerosis Tympanosclerosis
A high negative pressure within the middle ear cavityA high negative pressure within the middle ear cavity
Ear pain Ear pain Otitis externa Otitis externa
Ear traumaEar trauma
Throat infectionsThroat infections
Foreign bodyForeign body
Temporomandibular joint syndromeTemporomandibular joint syndrome
Uncertainty in diagnosis of AOMUncertainty in diagnosis of AOM
The diagnosis of AOM, particularly in infants and The diagnosis of AOM, particularly in infants and young children, is often made with a degree of young children, is often made with a degree of uncertainty. uncertainty.
Common factors …Common factors …Inability to sufficiently clear the external auditory canal of Inability to sufficiently clear the external auditory canal of cerumencerumen
Narrow ear canalNarrow ear canal
Inability to maintain an adequate seal for successful Inability to maintain an adequate seal for successful pneumatic otoscopy or tympanometrypneumatic otoscopy or tympanometry
An uncertain diagnosis of AOM is caused most often An uncertain diagnosis of AOM is caused most often by inability to confirm the presence of MEE. by inability to confirm the presence of MEE.
Management Management
Case twoCase two
A 1.5 year old boy, is brought into your office A 1.5 year old boy, is brought into your office because of cough, runny nose, and fever. because of cough, runny nose, and fever.
Physical ExamPhysical Exam T= 39 T= 39 00C C Ax.Ax.
Upper respiratory tract sign & symptomUpper respiratory tract sign & symptom The finding of pneumatic otoscopy are shown in next The finding of pneumatic otoscopy are shown in next
slide… slide…
Describe TM appearance & Describe TM appearance & mobilitymobility
How would you manage this How would you manage this illness episode? illness episode?
1. Tell mother that his son has a viral upper respiratory 1. Tell mother that his son has a viral upper respiratory infection or cold that will not benefit from treatment with infection or cold that will not benefit from treatment with antibiotics at this time as he does not have an ear infection.antibiotics at this time as he does not have an ear infection.
2. Tell mother that his son has an ear infection that requires 2. Tell mother that his son has an ear infection that requires treatment with antibiotics. treatment with antibiotics.
3. Tell mother that his son has an ear infection but doesn't need 3. Tell mother that his son has an ear infection but doesn't need treatment with antibiotics. treatment with antibiotics.
Clinical CourseClinical Course
The systemic and local signs and symptoms of AOM usually resolve in 24 The systemic and local signs and symptoms of AOM usually resolve in 24 to 72 hours with appropriate antimicrobial therapy, and somewhat more to 72 hours with appropriate antimicrobial therapy, and somewhat more slowly in children who are not treated. slowly in children who are not treated.
However, middle ear effusion persisted for weeks to months after the However, middle ear effusion persisted for weeks to months after the onset of AOM …onset of AOM …
Among children who were successfully treated…Among children who were successfully treated…70% resolution of effusion within two weeks 70% resolution of effusion within two weeks
90% up to 3 months90% up to 3 months
Symptomatic therapy - 1Symptomatic therapy - 1
Pain remedies Pain remedies PO analgesicsPO analgesics
Ibuprofen and acetaminophen Ibuprofen and acetaminophen
The efficacy of a topical agentThe efficacy of a topical agent Auralgan (combination of antipyrine, benzocaine, and Auralgan (combination of antipyrine, benzocaine, and glycerin) glycerin)
The topical herbal extract Otikon Otic solutionThe topical herbal extract Otikon Otic solution
Remedies such as distraction, external application of heat or Remedies such as distraction, external application of heat or cold, and oil instilled into the external auditory canal have been cold, and oil instilled into the external auditory canal have been proposed, but there are no controlled trials that directly address proposed, but there are no controlled trials that directly address the effectiveness of these remediesthe effectiveness of these remedies
Symptomatic therapy - 2Symptomatic therapy - 2
Decongestants and antihistamines Decongestants and antihistamines Alone or in combination were associated with…Alone or in combination were associated with…
Increased medication side effects Increased medication side effects
Did not Did not improve healing or prevent surgery or other improve healing or prevent surgery or other complications in AOM complications in AOM
Not approved by AAP for < 2 year oldNot approved by AAP for < 2 year old
In addition, treatment with antihistamines may In addition, treatment with antihistamines may prolong the prolong the duration of middle ear effusionduration of middle ear effusion
Comparative AOM Outcomes for Comparative AOM Outcomes for Observation Observation vs vs Antibacterial AgentAntibacterial Agent
AOM Outcome Antibacteral Rx
Observation
P Value
Relief at 24 hours 60% 59% NS
Relief at 2-3 days 91% 87% NS
Relief at 4-7 days 79% 71% NS
Clinical Resolution 82% 72% NSMastoiditis/
Complication0.59% 0.17% NS
Persistent MEE 4-6 wks 45% 48% NSPersistent MEE 3 mo. 21% 26% NS
Diarrhea/Vomiting 16% - -
Skin Rash/Allergy 2% - -
Number Need to Treat (NNT)Number Need to Treat (NNT)
NNT for antibiotic therapy in AOMNNT for antibiotic therapy in AOM7 to 8 children with AOM would have to be treated with 7 to 8 children with AOM would have to be treated with antibiotics to prevent one case of clinical failure by 1 week. antibiotics to prevent one case of clinical failure by 1 week.
One review estimated the need to treat 17 children in order for 1 One review estimated the need to treat 17 children in order for 1 child to have improved pain at 2 days. child to have improved pain at 2 days.
In addition, antibiotics were associated with almost twice the rate In addition, antibiotics were associated with almost twice the rate of vomiting, diarrhea, and rashes. of vomiting, diarrhea, and rashes.
Watch & See protocol Watch & See protocol
Observation without use of antibacterial agents in Observation without use of antibacterial agents in a child with uncomplicated AOM is an option for a child with uncomplicated AOM is an option for selected children selected children
In this protocol … In this protocol … Deferring antibacterial treatment of selected children for Deferring antibacterial treatment of selected children for 48 -72 hrs & limiting management to symptomatic relief48 -72 hrs & limiting management to symptomatic relief
Observation option is based on …Observation option is based on …Diagnostic certaintyDiagnostic certainty
AgeAge
Illness severityIllness severity
Assurance of follow-upAssurance of follow-up
Age Age Certain DiagnosisCertain Diagnosis Uncertain DiagnosisUncertain Diagnosis
<6 mo<6 mo Antibacterial therapyAntibacterial therapy Antibacterial therapyAntibacterial therapy
6mo – 2 yr6mo – 2 yr Antibacterial therapyAntibacterial therapy
Antibacterial therapy if Antibacterial therapy if severe illnesssevere illnessObservation option if Observation option if non-severe illness non-severe illness
>2 yr>2 yr
Antibacterial therapy if Antibacterial therapy if severe illnesssevere illnessObservation option if Observation option if non-severe illnessnon-severe illness
Observation optionObservation option
Criteria for initial antibacterial-agent treatment or Criteria for initial antibacterial-agent treatment or observation in children with AOMobservation in children with AOM
Definitions Definitions
Non-severe illness is …Non-severe illness is …Mild otalgia Mild otalgia & & fever <39°C in the past 24 hoursfever <39°C in the past 24 hours
Severe illness isSevere illness isModerate to severe otalgia Moderate to severe otalgia OROR fever fever 39°C 39°C
A certain diagnosis of AOM meets all 3 criteria …A certain diagnosis of AOM meets all 3 criteria …1) Rapid onset1) Rapid onset
2) Signs of MEE2) Signs of MEE
3) Signs and symptoms of middle-ear inflammation. 3) Signs and symptoms of middle-ear inflammation.
Age Age Certain DiagnosisCertain Diagnosis Uncertain DiagnosisUncertain Diagnosis
<6 mo<6 mo Antibacterial therapyAntibacterial therapy Antibacterial therapyAntibacterial therapy
6 mo – 2 yr6 mo – 2 yr Antibacterial therapyAntibacterial therapy
Antibacterial therapy if Antibacterial therapy if severe illnesssevere illnessObservation option if Observation option if non-severe illness non-severe illness
>2 yr>2 yr
Antibacterial therapy if Antibacterial therapy if severe illnesssevere illnessObservation option if Observation option if non-severe illnessnon-severe illness
Observation optionObservation option
Criteria for initial antibacterial-agent treatment or Criteria for initial antibacterial-agent treatment or observation in children with AOMobservation in children with AOM
ObservationObservation
Observation is only appropriate when …Observation is only appropriate when …
Follow-up can be ensured and antibiotic therapy initiated Follow-up can be ensured and antibiotic therapy initiated if symptoms persist or worsenif symptoms persist or worsen
Specific follow-up system i.e. Specific follow-up system i.e. Reliable parent / caregiver Reliable parent / caregiver
Convenient obtaining medications if necessaryConvenient obtaining medications if necessary
ObservationObservation
Antibiotics should be prescribed when the patient does not Antibiotics should be prescribed when the patient does not improve with observation for 48 to 72 hoursimprove with observation for 48 to 72 hours
Adequate follow-up may include …Adequate follow-up may include …1 - A parent-initiated visit or phone contact if symptoms worsen or do 1 - A parent-initiated visit or phone contact if symptoms worsen or do
not improve at 48 -72 hrsnot improve at 48 -72 hrs
2 - A scheduled follow-up appointment in 48 -72 hrs2 - A scheduled follow-up appointment in 48 -72 hrs
3 - Giving parents an antibiotic prescription that can be filled if 3 - Giving parents an antibiotic prescription that can be filled if illness does not improve in this time frame. illness does not improve in this time frame.
Which antibiotic ???Which antibiotic ???
AmoxicillinAmoxicillin Ammoxicillin + ClavulanateAmmoxicillin + Clavulanate AzithromycinAzithromycin CefiximeCefixime CefuroximeCefuroxime CeftriaxoneCeftriaxone ClarithromycinClarithromycin ClindamycinClindamycin Erythromycin Erythromycin CotrimoxazoleCotrimoxazole Erythromycin + CotrimoxazoleErythromycin + Cotrimoxazole Penicillin V / GPenicillin V / G Penicillin Procain 800.000 / 400.000Penicillin Procain 800.000 / 400.000 Penicillin 6:3:3 / 1.200.000Penicillin 6:3:3 / 1.200.000 Gentamicin / Amikacin Gentamicin / Amikacin CephalexinCephalexin CloxacillinCloxacillin MetronidazoleMetronidazole
Microbiology of Microbiology of AOMAOM
Bacterial Species Frequency Major Mechanism of
Resistance What we can do?
S. pneumoniae +++ penicillin-resistant (PBP2a) High Dose PCN
H. influenzae ++beta-lactamase
35-50% beta-lactamase Inhibitors (clavulanate)M. catarrhalis ++
beta-lactamase55-100%
Antibacterial therapyAntibacterial therapy
If a decision is made to treat with an antibacterial agent, If a decision is made to treat with an antibacterial agent, the clinician should prescribe amoxicillin for most the clinician should prescribe amoxicillin for most children. children.
When amoxicillin is used, the dose should be When amoxicillin is used, the dose should be 80 - 90 mg/kg/day 80 - 90 mg/kg/day
Predicted treatment failure rates Predicted treatment failure rates based on PD breakpoints for for expected pathogens in low- or high-risk AOMexpected pathogens in low- or high-risk AOM
AOM high risk for amoxicillin-resistant organismAOM high risk for amoxicillin-resistant organism
In patients who have severe illness In patients who have severe illness
&&
AOM high risk for amoxicillin-resistant organismAOM high risk for amoxicillin-resistant organismChildren who were received antibiotics in the previous 30 days Children who were received antibiotics in the previous 30 days
Children with concurrent purulent conjunctivitis (otitis-conjunctivitis Children with concurrent purulent conjunctivitis (otitis-conjunctivitis syndrome) syndrome)
Children receiving amoxicillin for chemoprophylaxis of recurrent AOM Children receiving amoxicillin for chemoprophylaxis of recurrent AOM (or urinary tract infection) (or urinary tract infection)
High-dose amoxicillin-clavulanate High-dose amoxicillin-clavulanate (90 mg/kg per day of amoxicillin & 6.4 mg/kg / day of clavulanate )(90 mg/kg per day of amoxicillin & 6.4 mg/kg / day of clavulanate )
In allergy to amoxicillin In allergy to amoxicillin
If allergic reaction was not a type I hypersensitivity reaction (urticaria If allergic reaction was not a type I hypersensitivity reaction (urticaria or anaphylaxis)or anaphylaxis)
Cefuroxime (30 mg/kg per day in 2 divided doses)Cefuroxime (30 mg/kg per day in 2 divided doses)
If type I reactionsIf type I reactionsAzithromycin (10 mg/kg / day on day 1 followed by 5 mg/kg / day for 4 Azithromycin (10 mg/kg / day on day 1 followed by 5 mg/kg / day for 4 days as a single daily dose) days as a single daily dose)
Clarithromycin (15 mg/kg per day in 2 divided doses) Clarithromycin (15 mg/kg per day in 2 divided doses)
Other possibilities include Other possibilities include Erythromycin-sulfisoxazole (50 mg/kg per day of erythromycin) or Erythromycin-sulfisoxazole (50 mg/kg per day of erythromycin) or sulfamethoxazole-trimethoprim (6 - 10 mg/kg per day of trimethoprim). sulfamethoxazole-trimethoprim (6 - 10 mg/kg per day of trimethoprim).
In daily clinical practice…In daily clinical practice…
Month of year ( mehr vs. farvardin)Month of year ( mehr vs. farvardin)
Previous antibacterial treatmentPrevious antibacterial treatment
When returnWhen return
In daily clinical practice…In daily clinical practice…
q8hq8hAmoxicillin Amoxicillin (2/3)(2/3) Co-Amoxiclav. Co-Amoxiclav. (1/3)(1/3)
125 125 156(125+31)156(125+31)
250250 312(250+62)312(250+62)
BidBidFaramox Faramox (1/2)(1/2) Farmentin Farmentin (1/2)(1/2)
200200 228(200+28)228(200+28)
400400 456(400+56)456(400+56)
In daily clinical practice…In daily clinical practice…
Previous antibacterial treatmentPrevious antibacterial treatment
Amoxicillin 45 mg/kgAmoxicillin - Clavul.
90mg/kg
AzithromycinCefixime
Cotri-ErythroCefuroxime
AzithromycinCefixime
Cotri-ErythroCefuroxime
Amoxicillin - Clavul. 30mg/kg
Amoxicillin - Clavul. 90mg/kg
Amoxicillin 90mg/kg
Duration of therapyDuration of therapy
For children ≥ 6 years of age with mild to For children ≥ 6 years of age with mild to moderate disease 5 -7 days is appropriate moderate disease 5 -7 days is appropriate
For younger children and for children with severe For younger children and for children with severe disease, a standard 10-day course is recommendeddisease, a standard 10-day course is recommended
Acute Otitis MediaAcute Otitis Media Management - Tympanocentesis Management - Tympanocentesis
Indications for a tympanocentesis or myringotomy are…Indications for a tympanocentesis or myringotomy are…
1. AOM in an infant <61. AOM in an infant <6 wks with a past NICUadmissionwks with a past NICUadmission
2. AOM in a patient with compromised host resistance2. AOM in a patient with compromised host resistance
3. Unresponsive AOM despite courses of 2-4 different antibiotics3. Unresponsive AOM despite courses of 2-4 different antibiotics
4. Acute mastoiditis or suppurative labyrinthitis4. Acute mastoiditis or suppurative labyrinthitis
5. Severe pain5. Severe pain
Algorithm to distinguish AOM from OMEAlgorithm to distinguish AOM from OME
Malpractice Malpractice
Administering PCN 6:3:3 in treatmentAdministering PCN 6:3:3 in treatment
Decongestants may decreased blood flow to the respiratory Decongestants may decreased blood flow to the respiratory mucosa, which may impair delivery of antibiotics mucosa, which may impair delivery of antibiotics
Antihistamines may Antihistamines may prolong the duration of middle ear prolong the duration of middle ear effusioneffusion
Prevention Prevention
Continue exclusive breastfeeding as long as Continue exclusive breastfeeding as long as possiblepossible
NO "bottle-propping" or taking a bottle to bed NO "bottle-propping" or taking a bottle to bed
Smoke-free environmentSmoke-free environment
IF high-risk for recurrent acute otitis media IF high-risk for recurrent acute otitis media Prolonged courses of antimicrobial prophylaxisProlonged courses of antimicrobial prophylaxis
Amoxicillin (20 to 30 mg/kg/day) or sulfisoxazole (50 mg/kg/day) Amoxicillin (20 to 30 mg/kg/day) or sulfisoxazole (50 mg/kg/day) given once daily at bedtime for 3 to 6 months or longer given once daily at bedtime for 3 to 6 months or longer
Pneumococcal vaccine & influenza vaccine Pneumococcal vaccine & influenza vaccine marginally benefitmarginally benefit
Pneumococcal vaccine reduce all otitis media by 6%. Pneumococcal vaccine reduce all otitis media by 6%.
Case 3Case 3
You are seeing a 18 month old infant at your office. His mother is concerned about his frequent ear infections.
You note in his chart that he has had 4 ear infections; 3 of which occurred in the past 6 months. Two of the 4 infections were unresponsive and required multiple antibiotic courses. According to mother, the baby is now asymptomatic; eating and sleeping well.
Which risk factor you Which risk factor you consider??consider??1. Altered eustacian tube function1. Altered eustacian tube function
2. Frequent colds2. Frequent colds
3. Immune system3. Immune system
4. Smoking 4. Smoking
5. Hay fever and allergies 5. Hay fever and allergies
Management of Management of Recurrent Acute Otitis Media Recurrent Acute Otitis Media A child has recurrent acute otitis media (RAOM) when 3 new episodes
of AOM have occurred in 6 months or 4 episodes within 12 months. Approximately 20% of children younger than two years of age have RAOM.
Follow patients with RAOM monthly with pneumatic otoscopy, as AOM episodes are often asymptomatic.
Consider obtaining audiologic and speech evaluations in these cases when there are concerns about language development, and when appropriate begin a home language intervention program.
Antibiotic prophylaxis Antibiotic prophylaxis
Studies suggest that the benefits, if any, are quite marginal. While antibiotic prophylaxis reduced the AOM rate by 44%, the mean rate difference was only
about one and a third less episodes per patient year for patients receiving antibiotics compared to controls.
Consider antibiotic prophylaxis for certain time limited situations such as the time period between deciding to place ventilating tubes and the day surgery will be performed, or when surgery is being considered in late winter or spring and 1 or 2 months of prophylaxis may get the child out of the high risk season and avoid the surgery.
Therapeutic options include either continuous antibiotic prophylaxis or intermittent prophylaxis for colds especially during winter respiratory viral infection months.
Antibiotics used for prophylaxis include amoxicillin and sulfisoxazole (Gantrisin). Amoxicillin appears to be more effective in the current environment.The efficacy of these antibiotics is best documented with dosing twice/day, but daily doses may be effective. Consider referring patients for ventilating tubes after a first breakthrough episode of AOM on prophylaxis.
Immunoprophylaxis Immunoprophylaxis
Another approach to preventing recurrent AOM episodes is active immunization. Use of the conjugate pneumococcal vaccine, Prevenar, appears to reduce the overall frequency of AOM by 6-7% .
However, immunized children with RAOM experience more benefit; such as a 23% reduction in AOM episodes after the 12 month dose and a 20 % reduction in the need for ventilating tubes .
Immunize children older than 2 years who experience RAOM with 23 valent polysaccaride pneumococcal vaccine (Pneumovax) .
Immunize children older than 6 months who have had an AOM episode in the first 6 months of life or have RAOM with influenza vaccine when supplies are available. Clinically significant reductions in AOM episodes have been well documented .
Ventilating Tubes with or without Ventilating Tubes with or without Adenoidectomy Adenoidectomy
Ventilating tubes are indicated when a child has experienced 5 or more new AOM episodes within 12 months.
The decision to insert ventilating tubes for recurrent AOM should not be based on parental recall.
In selected patients, especially those with associated otitis media with effusion, performing an adenoidectomy as well as inserting tubes may reduce the likelihood of ventilating tube reinsertions and additional otitis media related hospitalizations.
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