Acute Otitis Media & Acute Bacterial Rhinosinusitis

Risk Factors for AOM

Daycare

Lack of PCV & annual influenza vaccines

Siblings f

No breastfeeding

FH

Feeding position

Smokers in household

Craniofacial abnormalities or cleft plate

Cochlear implants

Wintertime

Common AOM bacteria (can all possess Beta-lactam resistance)

Streptococcus pneumoniae*

Haemophilus influenzae

Moraxella catarrhalis

What are possible AOM complications

Tympanic membrane perforation

Mastoiditis

Labyrinthitis (inner ear)

Meningitis

Brain abscess

Hearing loss

Speech and language impairment

Common AOM signs and symptoms

Otalgia

Fever

Sleep disturbances

Hearing difficulties

Ear tugging

Bulging tympanic membrane

Otorrhea

Presentation of AOM in older children / adults

Otalgia

Fullness or pressure in the ear

Hearing impairment

Vertigo, Nystagmus (rapid, involuntary eye movements), Tinnitus

Severe AOM symptoms

Toxic-appearing

Persistent ear pain > 48 hours

>/= 102.2 F

AAP Diagnostic Criteria for AOM (any one of the following)

Moderate to severe tympanic membrane bulding

New onset of otorrhea

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

T/F: Oral pain meds are not recommended for AOM

False; Ibuprofen & Tylenol

Watchful waiting criteria for AOM

6-23 months: non-severe unilateral WITHOUT otorrhea

>2 yo: non-severe one or both ears WITHOUT otorrhea

If AOM symptoms worsen after ___ of symptom onset, start Abx

48-72 hours

AOM Abx therapy criteria

>/= 6 months: severe symptoms and/or otorrhea

6-23 months: Both ears

Adults (no watchful waiting)

What is the main first line treatment + dosing for AOM

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

What is the first line treatment + dosing for AOM in adults

Amoxicillin-clavulanate (Augmentin) 875mg / 125mg BID

What is the first line AOM treatment and dosing if following is present:

• used Amoxicillin past 30 days

• concurrent Purulent Conjunctivitis (pink eye)

• Hx of recurrent infection unresponsive to Amoxicillin

Amoxicillin-clavulanate 90mg/kg (amox) PO daily as 2 doses

What is the second line treatment and dosing if AOM symptoms worsen after 48-42 hours of Initial Abx

Amoxicillin-clavulanate 90mg/kg (amox) PO daily as 2 doses

What is the second line or if non-severe PCN allergy for AOM treatment + dosing

Ceftriaxone 50 mg/kg IM or IV SID for 3 days

Cefdinir

Cefuroxime

Cefpodoxime

Ceftriaxone

What is the first line AOM treatment and dosing for Type 1 PCN hypersensitivity

Azithromycin 10 mg/kg PO daily for 3 days

What is the AOM treatment DoT for < 2 yrs

10 days

What is the AOM treatment DoT for 2-5 yo

7 days

What is the AOM treatment DoT for >6 yo

5-7 days

Penicillins and Cephalosporins have what ADRs for AOM and ABR

Dermatological reactions, N/V/D

Macrolides have what ADRs for AOM

Diarrhea

Prolonged QTc / torsade de pointes

Fluoroquinolones have which ADRs for ABR

Photosensitivity

QTc prolongation

Tetracyclines have which ADRs for ABR

GI upset

N/V/D

Hepatotoxicity

Esophageal ulcerations

Photosensitivity

What can amoxicillin suspension be mixed for palatability

Milk or Juice

What is the storage duration for Amoxicillin suspension for AOM

room temp up to 14 days

What is the storage duration for Amoxicillin/Clavulanate (Augmentin) suspension for AOM

Fridge for up to 10 days

Which AOM medication is recommended to be taken with food

Amoxicillin/Clavulanate

Anesthetic ear drops (benzocaine, lidocaine) can be used for which age group

>/= 5 yo

T/F: Antihistamines and decongestants can be used for ear pain/irritability

False

Recurrent AOM criteria

3 episodes in 6 months

4 episodes in 1 year, one ep in the last 6 months

T/F: recurrent AOM should avoid using prophylactic Abx

True

What can be used for recurrent AOM for physical draining

Tympanostomy tubes

When do AOM symptoms alleviate after treatment

improvement within 48-72 hours

asymptomatic within 7 days

AOM Prevention strategies

Pneumococcal and annual influenza vaccine

Xylitol gum use

Avoid bottle propping and pacifiers

Avoid second-hand smoke

Breastfeeding

check for undiagnosed allergies leading to chronic rhinorrhea

What age groups is not recommended for watchful waiting in AOM

< 6 months

adults

Common viral pathogens for Acute Bacterial Rhinosinusitis (ABR)

Rhinovirus

Adenovirus

Influenza virus

Parainfluenza virus

Common bacteria pathogens for ABR

Streptococcus pneumoniae

Haemophilus influenzae

Moraxella catarrhalis

commonly Beta-lactamase producing

ABR signs and (major & minor) symptoms

Purulent Anterior nasal discharge

Purulent or discolored posterior nasal discharge

Nasal/Facial congestion/pressure

—

Fever

Halitosis (bad breath)

HA

Ear pain/pressure

Dental pain

cough

fatigue

What is the golden standard diagnosis for ABR

>/= 10 10^4 CFU/mL in cavity of paranasal sinus T

T/F: ABR diagnosis is typically made from S/Sx assessment and pattern of illness

True

T/F: ABR are mostly viral infections and does not need to be distinguished from bacterial

False

Sinusitis diagnosis criteria

2 + major symptoms

OR

1 major & 2 minor symptoms

Nasal discharge indicator for viral infection for ABR

Clear → Purulent → Clear again

Purulence until days 4/5

Nasal discharge indicator for bacterial infection for ABR

• Persistent purulent discharge (>10 days)

• Early and severe (first 3-4 days)

• Increased on day 5/6 after typical viral infection (double sickening)

T/F: Viral sinusitis can be indicated by a fever (10.2.2F) in first 3-4 days

False; bacterial

When to treat ABR

• Onset of S/Sx lasting >/= 10 days without evidence of improvement

• Onset with high fever (102.2F) and purulent nasal discharge or facial pain lasting for at least 3-4 days at beginning of illness

• Onset on new fever / HA / increased nasal discharge following typical viral URTI lasted 5-6 days and was initially improving (double sickening)

T/F: Topical/Oral decongestants/antihistamines are preferred over analgesics for ABR

False

T/F: Intranasal corticosteroids can preferred for first time ABR

False; Hx of allergy

T/F: ABR can use intranasal saline irrigation with either physiological or hypertonic saline

True

What is First Line Initial Empiric therapy + dosing for ABR in children

Amoxicillin / Clavulanate 45 mg/kg/day PO BID

What is Second Line Initial Empiric therapy + dosing for ABR in children or with risk for Abx resistance or failed initial therapy

Amoxicillin / Clavulanate 90 mg/kg/day PO BID

When is high dose Amox/Clav used as initial treatment for ABR

Immunocompromised

Daycare attendance

< 2 yo

Recent hospitalization

Abx used in last 30 days

Severe infection (systemic toxicity + 102.2F + risk of suppurative/pus complications)

DoT for children with ABR

10-14 days

ABR treatment for children with Type 1 PCN allergy

Levofloxacin

What is First Line Initial Empiric therapy + dosing for ABR in adults

Amox/Clav

500mg/125mg PO TID

OR

875mg/125mg PO BID

What is Second Line Initial Empiric therapy + dosing for ABR in adults

Amox/Clav 2000mg/125mg PO BID

OR

Doxycycline

What Initial Empiric therapy + dosing for ABR in adults with PCN allergy

Doxycycline

Levofloxacin OR Moxifloxacin

DoT for ABR in adults

5-7 days

When is high dose amox/clav used as initial treatment in adults

Immunocompromised

>65 yo

Recent hospitalization

Abx use last 30 days

Severe infection (systemic toxicity + > 102.2F + risk of pus production)

ABR monitoring

• Reassess treatment plan if symptoms worsen within 48-72 hrs of initial Abx Tx

• Reassess if failed to improve despite 3-5 days of initially Abx therapy

• No response to first/second line therapy → refer to specialist