Acute Otitis Media and Acute Bacterial Rhinosinusitis

Objectives

1. Determine whether antibiotic therapy is warranted for patients presenting with symptoms of acute otitis media (AOM) and acute bacterial rhinosinusitis (ABR).

2. Develop a patient-specific pharmacotherapy plan (drug, dose, route, frequency, and duration) for patients with AOM and ABR based on patient-specific factors:

   1. Age

   2. Symptoms and duration

   3. Previous treatment

   4. Medication allergies

3. Educate patients on the most likely adverse effects of antibiotic treatments used to treat AOM and ABR.

4. Provide appropriate counseling and monitoring recommendations for patients treated for AOM and ABR

Common Signs/Symptoms

• Otalgia

• Fever

• Sleep disturbances

• Hearing difficulties

• Ear tugging

• Bulging of tympanic membrane

• Otorrhea (discharge)

Presentation in Infants/Young Children

• Fussy/irritable

• Crying more than usual

• Trouble sleeping

• Pulling at ears

• Fever

• Otorrhea

Presentation in Older Children and Adults

• Otalgia

• Feeling of fullness or pressure in the ear

• Hearing impairment

• Vertigo, nystagmus, tinnitis

AAP Diagnostic Criteria

• Any 1 of the following

1. Moderate to severe bulging of the tympanic membrane

2. New onset of otorrhea not due to otitis externa

3. Mild bulging of the tympanic membrane with recent onset of ear pain or intense erythema

Severe symptoms

• Toxic-appearing

• Persistent ear pain lasting > 48 hours

• Temperature ≥102.2°F

When would you do watching waiting (observation)?

1. Children 6 months – 23 months with non-severe unilateral AOM without otorrhea

2. Children ≥ 2 years with non-severe bilateral or unilateral AOM without otorrhea

3. Initiate antibiotics if the child’s symptoms worsen or decline within 48-72 hours of symptom onset

**if they have discharge → they getting treatment

***Treat with antibiotics if severe symptoms, otorrhea, or adult

Antibiotic Therapy

1. Children ≥ 6 months with severe symptoms

   and/or otorrhea

2. Children 6-23 months with bilateral AOM

3. Adults with AOM

Antibiotics for AOM

• Amoxicillin

• Amoxicillin-Clavulanate

• Cefdinir, cefuroxime, cefpodoxime, ceftriaxone

• Azithromycin

What is first-line for AOM?

• Drug, dose, duration

Amoxicillin 80-90 mg/kg PO daily given as 2 doses

What criteria would patients have to be first line for Amoxicillin-Clavulanate?

• Amoxicillin use in last 30 days

• Concurrent purulent conjunctivitis

• History of recurrent infection unresponsive to amoxicillin

• Adult AOM

• Second line if symptoms worsen after 48-72 hours of initial antibiotic

What is the dose and duration for Amoxicillin-clavulanate?

• 90 mg/kg (Amoxicillin) PO daily given as 2 doses

• Adults: 875 mg/125 mg BID

What is second-line treatment for AOM? When would these be used?

• When would it be used as second line?

Cefdinir, cefuroxime, cefpodoxime, ceftriaxone (IM or IV only)

• Use as second-line treatment

• Or if patient has non-severe PCN allergy

Amoxicillin- clavulanate

• Symptoms worsen after 48-72 hours of initial antibiotic

What is Azithromycin first line for?

• What is the duration?

First-line for patients with type 1 PCN hypersensitivity

• 3 days

What is the duration of therapy based on age?

<2 years: 10 days

2-5 years: 7 days

≥6 years: 5-7 days

What should you avoid in type 1 PCN allergy?

beta-lactam antibiotics

What are ADR of penicillins?

• Dermatological reactions, GI ADRs (N/V/D)

• LFT elevations

• interstitial nephritis

• cytopenia

• hemorrhagic cystitis

• C. difficile infection

What are ADR of cephalosporins?

• Dermatological reactions, GI ADRs (N/V/D)

• LFT elevations

• interstitial nephritis

• hemolytic anemia

• cytopenias

• C. difficile infection

What are ADR of Macrolides?

• GI intolerance

• diarrhea

• prolonged QTc/torsade de pointes

• drug induced liver injury

• ototoxicity

• dermatological reactions

What are some counseling points for Amoxicillin?

• Shake suspension before each dose

• Take +/- food; suspension can be mixed with milk/juice

• Can be stored at room temp for up to 14 days

What are some counseling points for Amoxicillin-Clavulanate?

• Shake suspension before each dose

• Take with food; suspension can be mixed with milk/juice

• Should be stored in the fridge for up to 10 day

What is considered Recurrent AOM?

• 3 episodes in 6 months

• 4 episodes in 1 year with one episode in the preceding 6 months

• Concerning because recurrent episodes can lead to hearing loss and language and learning disabilities

How would you monitor for AOM?

• Clinical signs of improvement within 48-72 hours and usually asymptomatic within 7 days

• Reassess treatment plan if symptoms worsen or decline within 48-72 hours

  • If watchful waiting used initially, switch to antibiotics

  • If antibiotics used initially, switch antibiotic

• Continually monitor pain, fever, adverse effects/adherence to antibiotics

What are some prevention strategies?

• Breastfeeding

• Avoid second-hand smoke

• Eliminate bottle propping and pacifiers

• Check for undiagnosed allergies leading to chronic rhinorrhea

• Xylitol gum use

• Pneumococcal and annual influenza vaccine

Draw out AOM Treatment Algorithm

TIPS FOR ANTIBIOTIC USAGE

1. Amoxicillin first line at 80-90 mg/kg/day in 2 divided doses

2. Augmentin if risk factors for bacterial resistance or failure of amoxicillin therapy

3. Cephalosporins if non-severe PCN allergy/second line

4. Macrolides if type 1 PCN allergy

5. Ibuprofen and acetaminophen recommended for pain

6. Reassess treatment plan if symptoms worsen or decline within 48-72 hours

   1. If watchful waiting – start antibiotics

   2. If on antibiotics change regimen

   
   

7. Influenza and pneumococcal vaccines recommended for prevention

Signs and Symptoms Acute Bacterial Rhinosinusitis

(ABR)

• Purulent anterior nasal discharge

• Purulent or discolored posterior nasal discharge

• Nasal congestion or obstruction

• Facial congestion or fullness

• Facial pain or pressure

• Fever

• Headache

• Ear pain/pressure/fullness

• Halitosis

• Dental pain

• Cough

• Fatigue

Diagnosis of Acute Bacterial Rhinosinusitis

• Gold standard: Recovery of bacteria in high density from the cavity of the paranasal sinus (≥ 104 CFU/mL)

• Diagnosis typically via assessment of signs and symptoms and observation of pattern of illness

Distinguish between bacterial vs. viral infection

• What does the diagnosis of Acute Bacterial Rhinosinusitis contain?

Diagnosis consists of at least 2 major symptoms or 1 major and 2 minor symptoms

What are key differences in the characteristics of Bacterial vs. Viral SInusitis?

• Symptoms

• Nasal discharge

• Fever

• Other symptoms

• Peak symptom time

• Duration

When would you treat for ABR?

ANY ONE OF THE FOLLOWING

1. Onset with persistent signs/symptoms compatible with acute rhinosinusitis lasting for ≥ 10 days without any evidence of clinical improvement

2. Onset with high fever (39°C or 102.2°F) and purulent nasal discharge or facial pain lasting for at least 3-4 consecutive days at the beginning of illness

3. Onset of new fever, headache, or increase in nasal discharge following a typical viral URTI that lasted 5-6 days and was initially improving (“double sickening”)

What are some Symptomatic Management of ABR?

1. Relieve symptoms due to nasal drainage and obstruction

2. Analgesics for pain

3. Intranasal saline irrigation with either physiological or hypertonic saline

4. Intranasal corticosteroids, especially in those with a history of allergic rhinitis

5. Topical or oral decongestants or antihistamines are not recommended as these agents dry out mucosa and disturb clearance of mucosal secretions

In children with ABR

• What is the first line treatment?

• What is second line?

• What if they have Type 1 PCN allergy?

• What is they have a non-severe PCN allergy?

• Severe infection requiring hospitalization

• Risk for antibiotic resistance or failed initial therapy?

• What is the duration?

For children - High dose amoxicillin/clavulanate as initial treatment if:

• Immunocompromised

• attendance at day care

• < 2 years old, recent hospitalization

• antibiotic use in the last 30 days

• regions with high endemic rates of penicillin resistant S. pneumo, severe infection (systemic toxicity + ≥ 102.2°F + risk of suppurative complications)

In adults with ABR

• What is the first line treatment?

• What is second line?

• What if they have Type 1 PCN allergy?

• Severe infection requiring hospitalization

• Risk for antibiotic resistance or failed initial therapy?

• What is the duration?

For adults - High dose amoxicillin/clavulanate as initial treatment if:

• Immunocompromised, > 65 years old

• recent hospitalization

• antibiotic use in the last 30 days

• regions with high endemic rates of penicillin resistant S. pneumo

• severe infection (systemic toxicity + ≥ 102.2°F + risk of suppurative complications)

Antibiotics for ABR Adverse Drug Reactions

Monitoring for ABR

1. Reassess treatment plan if symptoms worsen or decline within 48-72 hours of initial antibiotic therapy

2. Reassess treatment plan if individuals fail to improve despite 3-5 days of initial antibiotic therapy

3. Evaluate for possibility of resistant pathogens, or other causes of treatment failure and consider alternative antibiotics

4. Alternative/initiation of antibiotics should be considered

5. Those who do not respond to first- or second-line therapies should be referred to a specialist

ABR Treatment Algorithm