The most common infection for which antibacterial agents are prescribed for children in the US 13 of office visits to pediatricians Peak incidence 6 12 months old 23 of children experience at least one episode by 1 year old ID: 776619
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Slide1
In the Name of God
ACUTE OTITIS MEDIA
Slide2The most common infection for which antibacterial agents are prescribed for children in the US1/3 of office visits to pediatriciansPeak incidence 6 – 12 months old ≈ 2/3 of children experience at least one episode by 1 year old
Acute Otitis Media
Slide3AOM is an inflammation of the middle ear associated with a collection of fluid in the middle ear space (effusion) or a discharge (otorrhea)Recurrent otitis >3 episodes of AOM within 6 months that middle ear is normal, without effusions, between episodesMost children with recurrent acute otitis media are otherwise healthyOtitis proneSix or more acute otitis media episodes in the first 6 years of life12% of children in the general population Persistent Middle-Ear EffusionWhen an episode of otitis media results in persistence of middle-ear fluid for 3 months, & TM remains immobileMore common in white children & < 2 yo
Acute Otitis Media - Definitions
Slide4Chronic Serous otitis mediaThis pattern is usually defined as a middle-ear effusion that has been present for at least 3 months.Some sort of eustachian tube dysfunction is the principal predisposing factor.Acute otitis media is commonly defined as…1. Presence of a middle ear effusion (MEE) 2. TM inflammation 3. Presenting with a rapid onset of symptoms such as fever, irritability, or earache
AOM vs. CSOM
Slide5A diagnosis of AOM requires1) History of acute onset of signs and symptoms2) Presence of MEE3) Signs and symptoms of middle-ear inflammation
Definition of AOM
Slide6A diagnosis of AOM can be established if acute purulent otorrhea is present and otitis externa has been excluded.Presence of a middle ear effusion & acute signs of middle ear inflammation in presence of acute onset of signs & symptoms
Clinical diagnosis
Slide7Children with AOM usually present with …History of rapid onset of otalgia (or pulling of the ear in an infant), irritability, poor feeding in an infant or toddler, otorrhea, and/or feverExcept otorrhea other findings are nonspecific i.e. Fever, earache, and excessive crying present in children …90% with AOM 72% without AOM
History
Slide8Routine laboratory studies, including complete blood count and ESR, are not useful in the evaluation of otitis media.
Laboratory tests
Slide9The key to distinguishing AOM from OME is the performance of otoscopy using appropriate tools such as pnematic otoscopy.
Otoscopy
Slide10Pneumatic otoscope - equipment
Slide11Technique
Slide12Slide13MEE is commonly confirmed …Directly by…Tympanocentesis Presence of fluid in the external auditory canalIndirectly by… Pneumatic otoscopy Tympanometry
Middle-Ear Effusion
Slide14Pneumatic otoscopyReduced or absent mobility of the tympanic membrane is additional evidence of fluid in the middle earTympanometry or acoustic reflectometryCan be helpful in establishing a diagnosis when the presence of middle-ear fluid is difficult to determine
Signs of presence of MEE
Slide15Signs of presence of MEE
Slide16Anatomy of the tympanic membrane
Slide17Systematic assessment of theColor Mobility Position Translucency External auditory canal and auricle
Slide18Normal tympanic membrane
Slide19Normal TM
Translucent
Slide20Signs of presence of MEE
Fluid level
Bobbles
Slide21Signs of presence of MEE
Perforation
Cobble stoning
Slide22Signs of presence of MEE
Opaque
Semi-opaque
Slide23Normal TM
Gray
Pink
Slide24Signs of presence of MEE
Pale yellow
White
Slide25Tympanometry
Slide26Slide27Slide28Major challenge Otitis Media with Effusion Vs.Acute Otitis Media
OME vs. AOM
Slide29Signs or symptoms of middle-ear inflammation indicated by …Non – otoscopic findingsDistinct otalgia (discomfort clearly referable to the ear[s] that results in interference with or precludes normal activity or sleep) However, these symptoms must be accompanied by abnormal otoscopic findings Otoscopic findings
Signs & symptoms of middle-ear inflammation
Slide30Signs of acute inflammation are necessary to differentiate AOM from OME. Distinct fullness or bulgingThe best and most reproducible sign of acute inflammation Marked redness of the tympanic membraneMarked redness of the tympanic membrane without bulging is an unusual finding in AOM.
Acute inflammation –
otoscopic
findings
Slide31The main consideration … Otitis media with effusion
Differential diagnosis - 1
TM Changes
AOM
OME
Color
Red
yellow
Position
Bulging
Retracted or Neutral
Other
Pus behind
TM,
Perforated TM with purulent otorrhea,
Bullae on TM
Fluid level or Bubbles
Slide32Normal TM
Neutral
Slide33Signs of presence of MEE
Distinct fullness
Bulging
Slide34Signs of middle-ear inflammation
Marked redness
Injection
Slide35Established acute otitis media
Slide36Other conditions Redness of tympanic membrane AOMCryingUpper respiratory infection with congestion and inflammation of the mucosa lining the entire respiratory tractTrauma and/or cerumen removalDecreased or absent mobility of tympanic membrane AOM and OMETympanosclerosis A high negative pressure within the middle ear cavityEar pain Otitis externa Ear traumaThroat infectionsForeign bodyTemporomandibular joint syndrome
Differential diagnosis
Slide37The diagnosis of AOM, particularly in infants and young children, is often made with a degree of uncertainty. Common factors …Inability to sufficiently clear the external auditory canal of cerumenNarrow ear canalInability to maintain an adequate seal for successful pneumatic otoscopy or tympanometryAn uncertain diagnosis of AOM is caused most often by inability to confirm the presence of MEE.
Uncertainty in diagnosis of AOM
Slide38Management
Slide39The systemic and local signs and symptoms of AOM usually resolve in 24 to 72 hours with appropriate antimicrobial therapy, and somewhat more slowly in children who are not treated. However, middle ear effusion persisted for weeks to months after the onset of AOM …Among children who were successfully treated…70% resolution of effusion within two weeks 90% up to 3 months
Clinical Course
Slide40Pain remedies PO analgesicsIbuprofen and acetaminophen Remedies such as external application of heat or cold have been proposed, but there are no controlled trials that directly address the effectiveness of these remedies
Symptomatic therapy - 1
Slide41Oral Decongestants and antihistamines Alone or in combination were associated with…Increased medication side effects Did not improve healing or prevent surgery or other complications in AOM Not approved for < 2 year oldIn addition, treatment with antihistamines may prolong the duration of middle ear effusionTopical decojestant & steroids
Symptomatic therapy - 2
Slide42AOM OutcomeAntibacteral RxObservationP ValueRelief at 24 hours60%59%NSRelief at 2-3 days91%87%NSRelief at 4-7 days79%71%NSClinical Resolution82%72%NSMastoiditis/Complication0.09%0.17%NSPersistent MEE 4-6 wks45%48%NSPersistent MEE 3 mo.21%26%NSDiarrhea/Vomiting16%--Skin Rash/Allergy2%--
Comparative AOM Outcomes for
Observation
vs
Antibacterial Agent
Slide43Observation without use of antibacterial agents in a child with uncomplicated AOM is an option for selected children In this protocol … Deferring antibacterial treatment of selected children for 48 -72 hrs & limiting management to symptomatic relief
Watch & See protocol
Slide44Observation option is based on …Diagnostic certaintyAgeIllness severityAssurance of follow-up
Slide45Age Certain DiagnosisUncertain Diagnosis<6 moAntibacterial therapyAntibacterial therapy6mo – 2 yrAntibacterial therapyAntibacterial therapy if severe illnessObservation option if non-severe illness >2 yrAntibacterial therapy if severe illnessObservation option if non-severe illnessObservation option
Criteria for initial antibacterial-agent treatment or observation in children with AOM
Slide46Non-severe illness is …Mild otalgia & fever <39°C in the past 24 hoursSevere illness isModerate to severe otalgia OR fever 39°CA certain diagnosis of AOM meets all 3 criteria …1) Rapid onset2) Signs of MEE3) Signs and symptoms of middle-ear inflammation.
Definitions
Slide47Age Certain DiagnosisUncertain Diagnosis<6 moAntibacterial therapyAntibacterial therapy6 mo – 2 yrAntibacterial therapyAntibacterial therapy if severe illnessObservation option if non-severe illness >2 yrAntibacterial therapy if severe illnessObservation option if non-severe illnessObservation option
Criteria for initial antibacterial-agent treatment or observation in children with AOM
Slide48Observation is only appropriate when … Follow-up can be ensured and antibiotic therapy initiated if symptoms persist or worsenSpecific follow-up system i.e. Reliable parent / caregiver Convenient obtaining medications if necessary
Observation
Slide49Antibiotics should be prescribed when the patient does not improve with observation for 48 to 72 hoursAdequate follow-up may include …1 - A parent-initiated visit if symptoms worsen or do not improve at 48 -72 hrs2 - Giving parents an antibiotic prescription that can be filled if illness does not improve in this time frame.
Observation
Slide50AmoxicillinAmmoxicillin + ClavulanateAzithromycinCefiximeCefuroximeCeftriaxoneClarithromycinClindamycinErythromycin CotrimoxazoleErythromycin + CotrimoxazolePenicillin V / GPenicillin Procain 800.000 / 400.000Penicillin 6:3:3 / 1.200.000Gentamicin / Amikacin CephalexinCloxacillinMetronidazole
Which antibiotic ???
Slide51Bacterial SpeciesFrequency Major Mechanism ofResistance What we can do?S. pneumoniae+++penicillin-resistant (PBP2a)High Dose PCNH. influenzae++beta-lactamase35-50% beta-lactamase Inhibitors (clavulanate)M. catarrhalis++beta-lactamase55-100%
Microbiology of
AOM
Slide52If a decision is made to treat with an antibacterial agent, the clinician should prescribe amoxicillin for most children. When amoxicillin is used, the dose should be 80 - 90 mg/kg/day
Antibacterial therapy
Slide53Predicted treatment failure rates based on PD breakpoints for expected pathogens in low- or high-risk AOM
Slide54In patients who have severe illness &AOM high risk for amoxicillin-resistant organismChildren who were received antibiotics in the previous 30 days Children with concurrent purulent conjunctivitis (otitis-conjunctivitis syndrome) Children receiving amoxicillin for chemoprophylaxis of recurrent AOM (or urinary tract infection) High-dose amoxicillin-clavulanate (90 mg/kg per day of amoxicillin & 6.4 mg/kg / day of clavulanate )
AOM high risk for amoxicillin-resistant organism
Slide55Cefuroxime (30 mg/kg per day in 2 divided doses)Azithromycin (10 mg/kg / day on day 1 followed by 5 mg/kg / day for 4 days as a single daily dose) Clarithromycin (15 mg/kg per day in 2 divided doses) Other possibilities include Erythromycin-sulfisoxazole (50 mg/kg per day of erythromycin) or sulfamethoxazole-trimethoprim (6 - 10 mg/kg per day of trimethoprim).
In allergy to amoxicillin
Slide56Alternative therapy in the penicillin-allergic patient is clindamycin at 30 to 40 mg/kg per day in 3 divided doses. In the patient who is vomiting or cannot otherwise tolerate oral medication, a single dose of parenteral ceftriaxone (50 mg/kg) has been shown to be effective for the initial treatment of AOM.
In allergy to amoxicillin
Slide57In daily clinical practice…
Slide58Co-Amoxiclave + Amoxicillin 156/325 125/250 1/3 2/3Farmentin BD + Faramox 228/456 200/400 1/2 1/2
Slide59q8hAmoxicillin (2/3) Co-Amoxiclav. (1/3) 125 156(125+31) 250 312(250+62)BidFaramox (1/2) Farmentin (1/2) 200 228(200+28) 400 456(400+56)
In daily clinical practice…
Slide60For children ≥ 6 years of age with mild to moderate disease 5 -7 days is appropriate For younger children and for children with severe disease, a standard 10-day course is recommended
Duration of therapy
Slide61Indications for a tympanocentesis or myringotomy are… 1. AOM in an infant <6 wks with a past NICU admission 2. AOM in a patient with compromised host resistance 3. Unresponsive AOM despite courses of 2-4 different antibiotics 4. Acute mastoiditis or suppurative labyrinthitis 5. Severe pain
Acute Otitis Media
Management -
Tympanocentesis
Slide62Algorithm to distinguish AOM from OME
Slide63Administering PCN 6:3:3 in treatmentDecongestants may decreased blood flow to the respiratory mucosa, which may impair delivery of antibiotics Antihistamines may prolong the duration of middle ear effusion
Malpractice
Slide64Continue exclusive breastfeeding as long as possibleNO taking a bottle to bed Smoke-free environmentIF high-risk for recurrent acute otitis media Prolonged courses of antimicrobial prophylaxisAmoxicillin (20 to 30 mg/kg/day) given once daily at bedtime for 3 to 6 months or longer Pneumococcal vaccine & influenza vaccine marginally benefitPneumococcal vaccine reduce all otitis media by 6%.
Prevention
Slide65A 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 otoscopy, as AOM episodes are often asymptomatic. Consider obtaining audiologic and speech evaluations in these cases
Management of
Recurrent Acute Otitis Media
Slide66Ventilating tubes are indicated when a child has experienced 5 or more new AOM episodes within 12 months. 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.
Ventilating Tubes with or without Adenoidectomy
Slide67THANKS FOR ATTENTION