T5 - IE3 - Infectious Diseases I - Kang - Acute Otitis Media (AOM)

Epidemiology: most common diagnosis for which antimicrobial therapy is prescribed in ________ and _________

- infants

- children

50% of the children in the US will experience AOM

AOM

acute otitis media

AOM Epidemiology: highest incidence between ___ and _____ months of age

- 3

- 24 (months of age)

Acute Otitis Media

inflammation of the middle ear with fluid accumulation (effusion) accompanied by signs and symptoms of acute illness

Acute Otitis Media: __________ of the ______ ear with fluid accumulation (effusion) accompanied by signs and symptoms of acute illness

- inflammation

- middle (ear)

Acute Otitis Media: inflammation of the middle ear with ______ ____________ (______) accompanied by signs and symptoms of ______ illness

- fluid accumulation (effusion)

- acute (illness)

Eustachian tube: regulation of ____________ _________ between ______ sides of the tympanic membrane

- (regulation of) atmospheric pressure

- both (sides of the tympanic membrane)

Protection from nasopharyngeal secretions

Ear Anatomy

Eustachian tube: _____________ secretions from the middle ear into the nasopharynx

- draining (secretions)

Eustachian tube: draining __________ from the _________ ear into the nasopharyn

- (draining) secretions

- middle (ear)

AOM Pathophysiology Figure

The infant Eustachian tube is much ___________ in comparison to the adults and infants are more susceptible due to lack of _____________ ______

- (much) flatter

- (lack of) immune system

Risk Factors for AOM

age (pediatric)

day care / siblings

no breastfeeding

lower socioeconomic status

exposure to cigarette

winter

anatomic abnormality

- cleft palate

- down syndrome

1st episode when < 6 months

Bacterial Etiology of AOM

streptococcus pneumonia

haemophilus influenzae

moraxella catarrhalis

Viral Etiology of AOM

respiratory syncytial virus (RSV)

rhinovirus

parainfluenza virus

influenza virus

RSV

respiratory syncytial virus

Clinical presentation of AOM - symptoms

otalgia (ear pain)

otorrhea (discharge from the ear)

hearing impairment

fever

non-specifics: irritability, lethargy, anorexia, vomiting

Otalgia

ear pain

Otorrhea

discharge from the ear

Clinical presentation - physical exam (otoscopic exam)

middle ear effusion (MEE)

redness

bulging

opacity

immobility of the tympanic membrane

MEE

middle ear effusion

Pharmacotherapy - general recommendations: treatment considerations, initiate treatment in all __________ AOM cases

- (all) severe (AOM cases)

Severe AOM: Moderate to severe otalgia > 48 hours or fever ≥ 39°C

Severe AOM

moderate to severe otalgia > 48 hours

OR

fever ≥ 39°C

Severe AOM: __________ to ________ _______ > 48 hours

OR fever ≥ 39°C

- moderate

- severe otalgia (> 48 hours)

Severe AOM: moderate to severe otalgia > 48 hours OR fever ≥ ____°C

- (fever ≥) 39(°C)

Severe AOM: moderate to severe otalgia ___ ____ hours

- > 48 (hours)

Mild to moderate AOM

mild otalgia and a temperature of < 39°C

Mild to moderate AOM: _____ otalgia AND a temperature of ___ ______ °C

- mild (otalgia)

- < 39 (°C)

Initiate treatment in < 2 years; age ≥ 2 years reasonable to observe for 48 hour UNLESS bilateral AOM

Mild to moderate AOM - initiating treatment

Initiate treatment in patients <2 years

age ≥ 2 years reasonable to observe for 48 hour UNLESS bilateral AOM

- when antibiotics deferred, AOM resolves spontaneously in majority of patients (SNAP study, WASP)

Clavulanate is a ___-___________ ____________

- β-lactamase inhibitor

Thus, can help in combo with amoxicillin for the treatment of AOM; since gram negative bacterias produce β-lactamase

Gram negative bacteria produce _____-_________

- β-lactamase

So if patient fails amoxicillin for AOM, we can try Augmentin since it has clavulanate to inhibit the β-lactamase enzymes from gram negative bacteria if amoxicillin is not efficacious

We initiate treatment for mild to moderate AOM in patients ___ _____ years of age because these patients have a ______ ___________ immune system

- < 2 (years of age)

- less developed (immune system)

Patient JM, 2.5 year old, presents to the clinic with severe otalgia for the past 3 days and a fever of 38°C

Do we initiate treatment?

Yes

Although JM is 2.5 years old and his fever is only 38°C, he has severe otalgia for the past 3 days which is defined as SEVERE AOM.

Patient TS, 2 year old presents with some mild pain in the ear and discharge with a temperature of 38°C for the past day

Do we initiate treatment?

No

We should wait to observe for 48 hours.

TS is a 2 year old with mild pain and discharge with a temperature of 38°C, defined as mild to moderate acute otitis media. When antibiotics deferred, AOM resolves spontaneously in majority of patients.

Patient BL, 18 months presents to the clinic with some pain in her ear for the past 24 hours and a temperature of 38.6°C

Do we initiate treatment?

Yes

Although BL only has mild to moderate AOM, she is below 2 years old and requires treatment due to the lack of a developed immune system.

Patient TS, 3 year old presents to the clinic with some mild pain and discharge in both ears. He has a measured temperature of 37.4°C

Do we initiate treatment?

Yes

TS may have mild to moderate AOM but it presents as bilateral, we should initiate treatment

General recommendations: duration of treatment

Age < 2 years: 10 days

Age ≥ 2 years: 5-7 days

General recommendations - duration of treatment: age < 2 years

10 days

General recommandations - duration of treatment: age ≥ 2 years

5 - 7 days

Antibiotic therapy: if patient has NO antibiotics in the prior month, NO conjunctivitis, no h/o recurrent AOM, no risk factors

Amoxicillin (AMOXIL) high dose

or

Amoxicillin / clavulanate (AUGMENTIN) high dose

Amoxicillin

AMOXIL

Amoxicillin/Clavulanate

AUGMENTIN

Amoxicillin HIGH DOSE

90 mg / kg / day divided BID or TID

Amoxicillin/clavulanate (HIGH DOSE)

14:1 formulation

90 / 6.4 mg / kg / day

divided BID

If the patient has taken antibiotics in the past 30 days, failed response to Amoxicillin, concurrent conjunctivitis, history of recurrent AOM, risk of antibiotic resistance (day care, not vaccinated, living in area with a high prevalence resistance)

Preferred:

Amoxicillin / Clavulanate (AUGMENTIN) high dose

- 90/6.4 mg/kg/day divided BID

Recurrent AOM is defined as...

≥ 3 AOMs in 6 months or ≥ 4 AOMs in 12 months with at least 1 episode in the past 6 months

Recurrent AOM is defined as: __ ___ AOMs in 6 months or ___ ____ AOMs in 12 months with at least __ episode in the past __ months

- ≥ 3 (AOMs in 6 months)

- ≥ 4 (AOMS in 12 months)

- 1 (episode)

- (past) 6 (months)

Alternative therapies for AOM

Cefdinir (14 mg/kg/day PO divided BID or given daily)

Cefpodoxime proxetil (10 mg/kg/day PO divided BID)

Cefuroxime axetil (30 mg / kg / day PO divided BID)

Ceftriaxone (50 mg / kg IV or IM once daily x 3 days)

Cefdinir dosing for AOM

14 mg / kg / day PO divided BID or QD

Cefpodoxime proxetil

10 mg / kg / day PO divided BID

Cefuroxime axetil

30 mg / kg / day PO divided BID

Ceftriaxone

50 mg / kg IV

or

IM once daily for 3 days

Alternative therapy for AOM: Ceftriaxone is typically used for children with ____________ _______ or who are unable to __________ PO administration

- persistent vomiting

- tolerate (PO administration)

When antibiotics are prescribed for AOM, clinical improvement should be noted within ____-_____ _____

- 48-72 hours

Inadequate response to antibiotic treatment AFTER 48-72 hour of initial antibiotic treatment: IF failed amoxicillin...

may try high-dose Augmentin

If failed Augmentin or oral 3rd generation cephalosporins

Inadequate response to antibiotic treatment AFTER 48-72 hour of initial antibiotic treatment: IF failed amoxicillin and then FAILED Augmentin or oral 3rd generation cephalosporins...

May try Ceftriaxone (50 mg IM or IV for 3 days)

If failed series of antibiotics

- Tympanocentesis

- (Tympanocentesis is not available) clindamycin ± cefdinir, cefixime, or cefuroxime

Inadequate response to antibiotic treatment AFTER 48-72 hour or initial antibiotic treatment:

IF failed amoxicillin... FAILED Augmentin or oral 3rd generation cephalosporins

and FAILED Cetriaxone

May use...

tympanocentesis

If tympanocentesis is not available

clindamycin ± cefdinir, cefixime, or cefuroxime

Recommended Order for AOM

Amoxicillin

-> Augmentin or oral 3rd generation cephalosporin

-> Ceftriaxone

-> tympanocentesis or clindamycin ± cefdinir, cefixime, or cefuroxime

Tympanocentesis

puncture of the tympanic membrane with a needle to aspirate middle ear fluid

Penicillin Allergy: Cefdinir, cefuroxime, cefpodoxime, and ceftriaxone are __________ _______ to be associated with cross-reactivity with penicillin allergy

- highly unlikely

Other choices: clindamycin? macrolides?

Other choices for penicillin allergy patient for AOM

cilndamycin

macrolides

Pain relief options for AOM

acetaminophen PO

- 15 mg/kg/dose up to 4 times daily pen pain; NTE 1000 mg/day

ibuprofen

- 10 mg/kg/dose up to 4 times daily pen pain; NTE 2400 mg/day

Prevention of recurrent otitis media

Insertion of typanostomy tubes

vaccination

modification of risk factors

Prevention of recurrent otitis media - vaccination

pneumococcal conjugate vaccine

influenza vaccine annually

H. influenza vaccine (Hib)

Prevention of recurrent otitis media - modification of risk factors

minimize use of day care if possible

encourage exclusive breastfeeding for at least 6 months

encourage avoidance of tobacco smoke exposure

Prevention of recurrent otitis media - modification of risk factors: _____________ use of day care if possible

- minimize (use of day care)

Prevention of recurrent otitis media - modification of risk factors: encourage exclusive _____________ for at least 6 months

- breastfeeding (for at least 6 months)

Prevention of recurrent otitis media - modification of risk factors: encourage avoidance of _______________ __________ _________

- (avoidance of) tobacco smoke exposure