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346 > Otitis Media 2.0 > Flashcards

Otitis Media 2.0 Flashcards

1
Q

Treatment

A

Meta-analysis of 5400 children with AOM

  • Spontaneous recovery in 81%
  • Antibiotic therapy enhanced acute symptom relief by 13.7%

Watchful waiting recommended for 48 - 72 hrs before initiating antibiotic therapy if

  • > 6 months of age,
  • symptoms can be managed with analgesics, and
  • Follow-up can be assured
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2
Q

Treatment

Meta-analysis of 7 randomized controlled trials

A

Meta-analysis of 7 randomized controlled trials:
- Children ages 6 months – 12 years with otitis media

  • Small difference in symptom resolution between antibiotic treatment and non-treatment groups
  • Increased side effects in antibiotic group (diarrhea)
  • No other differences in effectiveness / safety outcomes
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3
Q

Treatment

Watchful Waiting
Canadian Pediatric Society (CPS) 2016

Children aged 6 months or older:
Most cases AOM resolve with symptomatic treatment alone
“Watchful waiting” period of 24-48 hours if ?

A
  • Mildly ill with fever <39 o C in absence of antipyretics
  • Mild otalgia

• child does not have
- Immunodeficiency
- Chronic cardiac or pulmonary disease
- Anatomical abnormalities of head or neck
- History of complicated otitis media (suppurative
complications or chronic perforation)

  • Parents capable of recognizing worsening illness and can and will seek medical help
  • Illness does not become worse
  • Reasonable to provide follow-up the next day
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4
Q

Watchful Waiting Treatment Decisions

Treat with Antibiotics?

A 
Children < 6 months
or
Children ≥ 6 months
  - With perforated ear drum
  - Unresponsive to analgesics
  - Unlikely to return for follow-up
  • CPS 2016 Moderately to Severely ill (irritable, difficulty sleeping, poor response to analgesics)
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5
Q

Watchful Waiting

Treat symptomatically 48 - 72hrs provided follow-up assured ?

If symptoms worsen or fail to respond to symptomatic therapy ?

A

Treat symptomatically 48 - 72hrs provided follow-up assured

  • acetaminophen, ibuprofen
  • Some experts believe antihistamines and decongestants beneficial when allergies play a role in etiology (TOP Guidelines 2008)

If symptoms worsen or fail to respond to symptomatic therapy,
- treat with antibiotics

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6
Q

Activity Against S. pneumoniae

A

Ampicillin / Amoxicillin > Cefuroxime
> Cefprozil > Cefixime* >
Cephalexin*

  • Cefixime or cephalexin not recommended if
    S. pneumoniae resistance suspected or in treatment of
    otitis media
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7
Q

T > MIC for S. pneumoniae in Middle Ear Fluid

A

see slide 33

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8
Q

Resistance Patterns

S. pneumoniae Edmonton Community

A

see slide 34

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9
Q

Resistance Patterns

H. influenzae Edmonton Community

A

see slide 35

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10
Q

Amoxicillin

Antibacterial of Choice

A
  • Adequate coverage for organisms involved in AOM
  • Best activity of all oral b -lactams against S. pneumoniae
  • Excellent middle ear concentrations / pharmacodynamics
  • Relatively few adverse effects
  • Lower potential for resistance
  • No other antibacterial proven superior in clinical trials
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11
Q

Treatment Acute Otitis Media

Bugs and Drugs App

(Healthy Child - Not High Risk)

A

see slide 37

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12
Q

Association of Recent Antimicrobial Use

and Carriage of Nonsusceptible S. pneumoniae (NSSP)

A

see slide 38

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13
Q

Treatment Acute Otitis Media

Bugs and Drugs app - Healthy Child

(No resolution in 48-72 hr or deterioration at any time)

A

see slide 39

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14
Q

Otitis Media- Complicated

A

Complications
- Mastoiditis, Vertigo, or Facial paralysis

Pathogens
- S. pneumoniae, M. catarrhalis, H. influenzae,
occasionally Grp A Strep, S. aureus

Treatment Complicated Otitis Media
  - Early/Mild
       Cefuroxime 150 mg/kg/d IV div q8h ≥14 days
  - Mod-severe
       Ceftriaxone 100 mg /kg IV daily
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15
Q

Duration of Therapy

A

Traditional duration of therapy was 10 days for all

Several well-designed randomized studies have compared 3 - 7 days Rx with 10 days

5 days treatment appears to have equivalent efficacy to 10 days in uncomplicated AOM

10 days if

  • Children < 2 yrs
  • perforated ear drum
  • recurrent AOM
  • non-responders
  • High risk

Complicated ≥ 14 days

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16
Q

Advantages of Reduced Duration of Therapy

A
  • Reduced potential to promote bacterial resistance
  • Reduced adverse effects
  • Increased compliance
  • Reduced cost
  • (Reduced parental stress with drug administration)
17
Q

Follow-up

A

• All AOM patients should have
• follow-up visit at 3 months to assess for OME, which may
lead to hearing loss
• Routine follow-up before 3 months not required

18
Q

Otitis Media With Effusion (OME)

A
  • Normally symptoms of AOM should resolve in 72 hours
  • 60 - 70 % of children will have middle ear effusion two weeks after successful treatment of acute otitis media
  • In 40 - 50% of patients, middle ear effusion may persist up to 1 month
  • In 10% - 25% of patients, middle ear effusion may persist up to 3 months
  • Prolonged effusion (3 months) may be associated with hearing loss

• Fluid in the middle ear without symptoms of acute
inflammation of the ear

• Most frequently occurs following an episode of acute otitis media, but may be unrelated

19
Q

Otitis Media with Effusion (picture)

A

see slide 46

20
Q

Otitis Media

Role of the pharmacist

A
  • Correct antibacterial and dosing
  • 5 day therapy when appropriate
  • Adequate analgesic
  • Handwashing
  • Education about prevention
  • Education about antibacterial
21
Q

Comparison Initial Treatment

A

see slide 48

22
Q

Dosing table for amoxicillin-clavulante plus amoxicillin to achieve 90 mg/kg/day of the amoxicillin component and 6.4 mg/kg/day of the clavulante component for acute otitis media that failed initial antimicrobial therapy

A

see slide 49

23
Q

Referral to ENT Specialist

A

• For consideration for myringotomy and tympanostomy tubes if:

  • OME for ≥3 mos with bilateral hearing loss ≥ 40dB
  • ≥ 3 episodes in 6 months
  • ≥ 4 episodes in 12 months (with at least one in past 6 months)
  • Retracted tympanic membrane
  • Cleft palate of craniofacial malformations
24
Q

Tympanostomy Tubes

A

see slide 52

25
Q

Advice to Parents

Alberta CPGs - Patient Information

A

My child has a runny nose, earache, and cough, is irritable and has a fever >38.5 o C. What should I do?
• If your child is < 3 months take them to physician that day.
• If > 3mos and < 2 yr and is no better after 24 hr, take them to physician.
• If your child is > 2 yr and not better (still has fever) after 3 days take them to physician.

Warning!!!
If your child seems more drowsy than usual or seems very sick and you have tried the tips for reducing fever, take your child to a physician.

To Reduce Fever:
• Undress your child
• Give your child a lukewarm bath
• Provide cool drinks/popsicles
• Acetaminophen is usually all that is needed to help with fever

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