Acute Otitis Media

Question 1

What is acute otitis media?

Answer 1

Infection of the middle ear

Question 2

What are signs and symptoms of acute otitis media?

Answer 2

Otalgia
Fever
Middle ear effusion
Red, bulging tympanic membrane

Question 3

Is AOM caused by viral or bacterial pathogens?

Answer 3

May be both viral or bacterial

Question 4

AOM is often preceded by a viral upper respiratory tract infection. Why is this?

Answer 4

Respiratory tract defences are disturbed (impaired mucociliary clearance and epithelium). Leads to eustachian tube dysfunction. Allows bacterial pathogens to colonize the nasopharynx and invade middle ear

Question 5

What are prevention strategies for AOM?

Answer 5

• Vaccination against AOM pathogens
• Avoid exposure to tobacco smoke
• Breastfeeding

Question 6

Fever and otalgia are common manifestations for AOM.
Ear pain is not always easily communicated by infants and toddlers. What are some clues to diagnosis?

Answer 6

Disturbed sleep
Irritability
Tugging the ear
Rubbing the head

Question 7

What are four key features of the tympanic membrane that would indicate AOM?

Answer 7

Red
Displaced/bulging
Opaque
Immobile tympanic membrane

Question 8

When do we refer cases of AOM?

Answer 8

1. Multiple treatment failures
2. Recurrences that are unresponsive to therapy
3. Frequent recurrent episodes (≥3 episodes in 6 months or ≥4 episodes in 12 months)
4. Hearing loss
5. <6 weeks of age

Question 9

Which vaccines are good prevention of AOM?

Answer 9

Influenza
Streptococcus pneumoniae

Question 10

A high income countries, 60% of AOM cases were found to resolve spontaneously within ____ hours regardless of antibiotic use.

Answer 10

24 hours

Question 11

When can we recommend the watchful waiting method?

Answer 11

If patient is over 6 months of age and:
- non-severe (fever <39ºC, mild otalgia)
- Uncomplicated AOM (no episode in preceding month)
- No craniofacial anomalies, immunodeficiencies, cardiac or pulmonary disease
- Parents capable of monitoring and medical care is accessible

Question 12

Providing adequate analgesia in early stages of infection is importation. What are the two drugs of choice? Dosing?

Answer 12

1. Acetaminophen
   - 10-15mg/kg q4-6h
   - Max= 75mg/kg/day
   - Max= 4000mg/day
2. Ibuprofen
   - 10mg/kg q6-8h
   - Max=40mg/kg/day
   - Max= 2400mg/da

Question 13

What are the bacterial pathogens involved in AOM?

Answer 13

Streptococcus pneumoniae
Haemophilus influenzae
Moraxella catarrhalis

Question 14

Of the three pathogens, which has the lowest and highest spontaneous resolution rates?

Answer 14

Lowest= streptococcus
Highest= Moraxella

Question 15

With the introduction of pneumococcal conjugate vaccine, how is epidemiology changing?

Answer 15

Decrease in pneumococcal serotypes and increase in others
Decrease in penicillin resistant S. pneumoniae
Decreased incidence of AOM

Question 16

What are risk factors for drug-resistant organisms in AOM?

Answer 16

• Recent antibiotic use (<3 months)
• Daycare attendance
• Recent episode of AOM
• Treatment failure
• Early recurrence

Question 17

What is considered treatment failure in AOM?

Answer 17

No symptom improvement after 72 hours of treatment.

Question 18

How do we manage penicillin resistant S. pneumoniae?

Answer 18

Doubling dose of amoxicillin

Question 19

Which pathogens in AOM have beta-lactamase production?

Answer 19

H. influenzae
M. catarrhalis

Question 20

How do we manage pathogens that have beta-lactamase production?

Answer 20

Add a beta-lactamase inhibitor like clavulanate

Question 21

What is first-line in AOM?

Answer 21

Amoxicillin

Question 22

What are alternative first-line antibiotics? When should they be used?

Answer 22

1. Amoxicillin/clavulanate
   - treatment failure or recurrence
2. Cefuroxime or cefprozil
   - second-line
   - reasonable against H. influenzae and M. catarrhalis. Less effective for penicillin resistant s. pneumoniae
3. Ceftriaxone
   - most effective cephalosporin, but only available IV or IM
   - unnecessarily broad spectrum for 3 days
4. Azithromycin and clarithromycin
   - save for those with type 1 hypersensitivity reactions (anaphylactic or IgE-mediated)
5. Clindamycin
   - also good for those with type 1 hypersensitivity reactions, but doesn’t cover H. influenzae or M. catarrhalis

Question 23

What’s the duration of therapy for children <2?

Answer 23

10 days

Question 24

What is duration for uncomplicated AOM in children ≥2 years?

Answer 24

5 days

Question 25

If patient has recurrent AOM, what’s the duration of treatment?

Answer 25

Amoxi-clav for 10 days

Question 26

Are nasal and oral decongestants with an antihistamine recommended for AOM?

Answer 26

No

Question 27

What’s the standard dosing of amoxicillin?

Answer 27

40-50 mg/kg/day

Question 28

What’s the high dose dosing for amoxicillin?

Answer 28

75-90mg/kg/day

Question 29

When prescribing high dose amoxi-clav, what’s the dosing ratio we should follow to reduce risk of diarrhea?

Answer 29

Amoxicillin 40mg/kg/day
+
7:1 Amoxi-Clav dosed at 40mg/kg/day of the amoxicillin component
(Clavulin 200 or Clavulin 400)

Avoid Clavulin 125F and Clavulin 250F