Shafkat AOM CHC

8/8/2019 Shafkat AOM CHC

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Acute Otitis

Media

Shafkat Anwar, M.D.Pediatric Resident Level 3

Childrens National Medical Center


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Objectives

Definition of AOM

Pain Management

Initial Observation vs. Antibacterial treatment Antibiotic Choice

Preventative Measures


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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


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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


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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


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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


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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


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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


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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


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TRANSLATION:

You have to dig out the earwax!You have to perform pneumatic otoscopy!!


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Pictures are worth 1000 words

Light Reflex

TM intact, noeffusion/erythema, nofluid level, no bulge

Ossicles


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7


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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.


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Recommendation 2: Pain

The management of AOM should include anassessment of pain. If pain is present, theclinician should recommend treatment to

reduce pain.


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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


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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


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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.


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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.


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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


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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.


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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.


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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.


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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.


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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.


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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


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Recommendation 6: Complementary tx

No recommendations for complementary and

alternative medicine (CAM) for treatment of AOM

are made based on limited and controversial

data.


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ummary

Diagnose AOM

Manage the pain

Decide on observation vs. antibacterialtreatment

Choose an antibiotic

Monitor and follow up

Encourage preventative measures


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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

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Shafkat AOM CHC