shafkat aom chc
TRANSCRIPT
-
8/8/2019 Shafkat AOM CHC
1/29
Acute Otitis
Media
Shafkat Anwar, M.D.Pediatric Resident Level 3
Childrens National Medical Center
-
8/8/2019 Shafkat AOM CHC
2/29
Objectives
Definition of AOM
Pain Management
Initial Observation vs. Antibacterial treatment Antibiotic Choice
Preventative Measures
-
8/8/2019 Shafkat AOM CHC
3/29
Background
Acute otitis media (AOM) is the most commoninfection for which antibacterial agents areprescribed for children in the United States.
Office visits for OM (was) 16 million in 2000
802 antibacterial prescriptions per 1000 visits fora total of more than 13 million prescriptions in2000.
An individual course of antibacterial therapy canrange in cost from $10 to more than $100 3-5
-
8/8/2019 Shafkat AOM CHC
4/29
cope
Diagnosis and management of uncomplicated AOM.Based on the AAP Policy Statement: Diagnosis andManagement of Acute Otitis Media7
Ages 2 months to 12 years
No signs/symptoms of systemic illness unrelated tothe middle ear
Otherwise healthy child without underlying conditionsthat may alter the natural course of AOM
-
8/8/2019 Shafkat AOM CHC
5/29
Etiology
Pathogenic bacteria isolated in ~ 6575% ofcases
Three pathogens predominate:
Streptococcus pneumoniae (40%)nontypable Haemophilus influenzae (2530%)
Moraxella catarrhalis (1015%)
Respiratory viruses may also be found, eitheralone or, more commonly, in association withpathogenic bacteria 6
-
8/8/2019 Shafkat AOM CHC
6/29
Recommendation 1: Diagnosis
To diagnose AOMthe clinician should:
confirm a history ofacute onset
identify signs ofmiddle ear effusion
evaluate for the presence of signs and
symptoms ofmiddle-ear inflammation
-
8/8/2019 Shafkat AOM CHC
7/29
Diagnosis
Recent, usually abrupt and rapid onset of signs andsymptoms of middle-ear inflammation and MEE
Symptoms include:
Otalgia, or pulling of the ear in an infant
Irritability in an infant or toddler
Otorrhea, and/or fever
These findings, other than otorrhea, are nonspecificand
frequently overlap those of an uncomplicated viral URI
Therefore, clinical history alone is poorly predictive of thepresence of AOM, especially in younger children
-
8/8/2019 Shafkat AOM CHC
8/29
Definition of AOM: Middle Ear Effusion
The presence of MEE is indicated by any of the following:
a. Bulging of the tympanic membrane(highest predictive value for the presence of MEE)
b. Limited or absent mobility of the tympanic membrane
c. Air-fluid level behind the tympanic membrane
d. Otorrhea
-
8/8/2019 Shafkat AOM CHC
9/29
Definition of AOM: Middle Ear Inflammation
Signs or symptoms of middle-ear inflammation is indicated by:
a. Distinct erythema of the tympanic membrane or
b. Distinct otalgia: discomfort clearly referable to the ear[s]that results in interference withnormal activity or sleep
-
8/8/2019 Shafkat AOM CHC
10/29
TRANSLATION:
You have to dig out the earwax!You have to perform pneumatic otoscopy!!
-
8/8/2019 Shafkat AOM CHC
11/29
Pictures are worth 1000 words
Light Reflex
TM intact, noeffusion/erythema, nofluid level, no bulge
Ossicles
-
8/8/2019 Shafkat AOM CHC
12/29
7
-
8/8/2019 Shafkat AOM CHC
13/29
What if the kid is crying up a storm and the TM
is all red?
AAP: Redness of the tympanic membrane caused by inflammationmay be present and must be distinguished from the pinkerythematous flush evoked by crying or high fever, which isusually less intense and remits as the child quiets down.
-
8/8/2019 Shafkat AOM CHC
14/29
Recommendation 2: Pain
The management of AOM should include anassessment of pain. If pain is present, theclinician should recommend treatment to
reduce pain.
-
8/8/2019 Shafkat AOM CHC
15/29
Recommendation 3A: Observe vs. Treat
Observation without use of antibacterial agents ina child with uncomplicated AOM is an option forselected children based on:
diagnostic certainty
age
illness severity assurance of follow-up
-
8/8/2019 Shafkat AOM CHC
16/29
Observe v.s.Treat
Age Certain
Diagnosis
Uncertain
Diagnosis
< 6 mo Abic tx Abic tx
6 mo 2 y Abic tx Abic tx if severe illnessor observation if
nonsevere illness
> 2 y Abic tx if severeillness or
observation ifnonsevere illness
Observation
-
8/8/2019 Shafkat AOM CHC
17/29
oncerns regarding observation
The likelihood of recovery without antibacterial therapy differsdepending on the severity of signs and symptoms at initialexamination.
current evidence does not suggest a clinically importantincreased risk of mastoiditis in children when AOM ismanaged only with initial symptomatic treatment without
antibacterial agents.
-
8/8/2019 Shafkat AOM CHC
18/29
Monitoring and Follow-up is key!
When considering (observation), the clinician should verifythe presence of an adult who will reliably observe the child,recognize signs of serious illness, and be able to provideprompt access to medical care if improvement does notoccur.
If there is worsening of illness or if there is no improvement in48 to 72 hours while a child is under observation, institution
of antibacterial therapy should be considered.
-
8/8/2019 Shafkat AOM CHC
19/29
Recommendation 3B: Antibiotic Choice
If a decision is made to treat with an
antibacterial agent, the clinician should
prescribe ___________ for most children.
When amoxicillin is used, the dose should be
____________________.
Amoxicillin
80 to 90 mg/kg per day
-
8/8/2019 Shafkat AOM CHC
20/29
Amoxicillin vs. Augmentin
In patients who have severe illness (moderate to severeotalgia or fever > 39C) and in those for whom additionalcoverage for -lactamase-positive Haemophilus influenzaeand Moraxella catarrhalis is desired, therapy should beinitiated with high-dose amoxicillin-clavulanate.
Approximately 50% of isolates ofH flu and 100% of Mcatarrhalis from the upper respiratory tract are likely to be -lactamase (+). ~ 15% to 50% (average: 30%) of upperrespiratory tract isolates ofS pneumoniae are also not
susceptible to PCN.
-
8/8/2019 Shafkat AOM CHC
21/29
-
8/8/2019 Shafkat AOM CHC
22/29
ome Alternatives to Amoxicillin
If the patient is allergic to amoxicillin and the allergic reactionwas not a type I hypersensitivity reaction (urticaria oranaphylaxis), cefdinir, cefpodoxime, or cefuroxime can beused.
In cases of type I reactions, azithromycin or clarithromycincan be used.
Ceftriaxone X 3 consecutive days either IV or IM, can be usedin children with vomiting or situations that preclude
administration of PO antibiotics.
-
8/8/2019 Shafkat AOM CHC
23/29
Duration of therapy
For younger children and for children with severe disease, astandard 10-day course is recommended.
For children 6 years of age and older with mild to moderate
disease, a 5- to 7-day course is appropriate.
-
8/8/2019 Shafkat AOM CHC
24/29
Recommendation 4: Antibiotic Failure
If the patient fails to respond to the initialmanagement option within 48-72 hours, reassessthe patient to confirm AOM and exclude othercauses of illness.
If AOM is confirmed in the patient was initiallymanaged with observation, begin antibacterialtherapy.
If the patient was initially managed with anantibacterial agent, change the antibacterialagent.
-
8/8/2019 Shafkat AOM CHC
25/29
Antibiotic Failure
A patient who fails amoxicillin-potassium clavulanate shouldbe treated with a 3-day course of parenteral ceftriaxone.
If AOM persists, tympanocentesis should be recommendedto make a bacteriologic diagnosis.
If tympanocentesis is not available, a course of clindamycinmay be considered.
-
8/8/2019 Shafkat AOM CHC
26/29
Recommendation 5: Prevention
Clinicians should encourage the prevention ofAOMthrough reduction of risk factors
Administering the influenza vaccine
reducing the incidence of respiratory tract
infections by altering child care centerattendance
implementation of breastfeeding for at least thefirst 6 months, avoiding supine bottle feeding
reducing or eliminating pacifier use in the second6 months of life
eliminating exposure to passive tobacco smoke
-
8/8/2019 Shafkat AOM CHC
27/29
Recommendation 6: Complementary tx
No recommendations for complementary and
alternative medicine (CAM) for treatment of AOM
are made based on limited and controversial
data.
-
8/8/2019 Shafkat AOM CHC
28/29
ummary
Diagnose AOM
Manage the pain
Decide on observation vs. antibacterialtreatment
Choose an antibiotic
Monitor and follow up
Encourage preventative measures
-
8/8/2019 Shafkat AOM CHC
29/29
Works Cited
1. Niemela M, Uhari M, Jounio-Ervasti K, Luotonen J, Alho OP, Vierimaa E. Lack ofspecific symptomatology in children with acute otitis media.Pediatr Infect Dis J.1994;13 :765 768
2. Cummings. Acute Otitis Media. Otolaryngology: Head & Neck Surgery, 4th ed.,Copyright 2005 Mosby, Inc. p4451
3. Schappert SM. Office visits for otitis media: United States, 197590.Adv Data.
1992;214 :1 184. Cherry DK, Woodwell DA. National ambulatory medical care survey: 2000
summary.Adv Data. 2002;328 :1 32
5. McCaig LF, Besser RE, Hughes JM. Trends in antimicrobial prescribing rates forchildren and adolescents.JAMA. 2002;287 :3096 3102
6. Behrman. Acute Otitis Media. Nelson Textbook of Pediatrics, 17th ed., Copyright 2004 Saunders, An Imprint of Elsevier. P2138
7. Friedman, N. Selective use of antibiotics in acute otitis media. Pediatric Infectious
Disease Journal. 2006 Feb;25(2):101-7.
8. AAP Subcommittee on Management of Acute Otitis Media. Clinical PracticeGuideline. Pediatrics Vol. 133 No. 5, May 2004