Pediatric ID Flashcards
preventable AOM risk factors
child care, smoke exposure, pacifier, bottle-feeding, missed immunizations
non-preventable AOM risk factors
male, older siblings, family history, congenital anomalies, immune deficiency, onset of first episode before 6 months of age, lower socioecononmic status, season
otitis media with effusion
more common
middle ear fluid is sterile
resolves spontaneously over time
antibiotics are not indicated and are not beneficial
acute otitis media
bacterial infection is likely
antibiotics are indicated if symptomatic
anatomy of the ear
tympanic membrane (ear drum) separates middle ear from inner ear eustachian tube is supposed to drain fluid from ear canal to sinuses - in children, it is shorter and more horizontal - more likely for sinus fluid to move into inner ear canal and cause infection
pathogenosis of AOM
ineffective aeration of middle ear space causes eustachian tube dysfunction
inflammation and edema of mucosal linings and narrowing of eustachian tube lumen
resorption of air created vacuum and reverses flow of secretions drawing fluid into middle ear
bacteria multiply in fluid and stimulate inflammatory response
microbiology of AOM
most common: S. pneumo, H. influenzae, moraxella
other organisms include: staph aureus and gram-negative organisms
clinical signs and symptoms of AOM
otalgia (ear pain), holding or tugging at ear, fever, irritability, poor feeding/anorexia, disrupted sleep, malaise, otorrhea, sometimes asymptomatic
diagnosis of AOM
requires visualization of tympanic membrane
normal TM: Slightly concave, Pearly gray in color, Translucent, Moves easily in response to pressure
TM in otitis media: Bulging, Nonmobile, Erythematous (not conclusive), Definitive diagnosis is culture of middle ear fluid by tympanocentesis
Certain diagnosis requires:
-Acute onset of clinical signs and symptoms
-Presence of middle ear effusion
-Signs and symptoms of middle ear inflammation
severity of AOM
AOM can be classified as either:
Non-severe: Mild otalgia AND** Fever under 39 ˚C in past 24 hours
Severe: Moderate to severe otalgia OR** Fever ≥ 39˚C
management of AOM - observation
Deferment of antibiotics for 48 – 72 hours
Watch for resolution of symptoms
Provide symptomatic** relief
Decision to observe based on: Child’s age, Diagnostic certainty, Illness severity, Assurance of follow-up
criteria for initial antibacterial-agent treatment or observation in children with AOM
SEVERE: ALWAYS TREAT
UNDER 6 MONTHS: ALWAYS TREAT
6 mo-2 yr, non-severe and unilateral: observe option
2+ years and non-severe: observe option
observation failure
Must ensure close follow-up and prompt access to medical care if no improvement
What to do if observation fails:
-Communicate with physician
-Begin antimicrobial therapy
-Continue symptomatic therapy
Safety-Net Antibiotic Prescription (SNAP)
-Parents allow 1-2 days for infection to resolve
-If symptoms persist or worsen, fill prescription
antibiotic therapy for AOM
Efficacy Resistance Oral bioavailability Middle-ear penetration Safety Tolerability Likelihood of compliance
resistance
Risk factors include child care, recent receipt (less than 30 days) of antibiotic therapy, and age under 2 years
Haemophilus influenzae & Moraxella catarrhalis
-40% of H. flu strains and almost all M. catarrhalis strains are resistant to penicillins
-Due to β-lactamase production*
-Overcome by addition of ß-lactamase inhibitor
Streptococcus pneumoniae
-50% of strains are penicillin resistant
-Due to alterations in penicillin binding proteins*
-Overcome by higher concentrations of antibiotic at site
initial/delayed antibiotic treatment
1st line: amox or amox/clav
alternative if allergic: cefdinir, cefuroxime, cefpodoxime, ceftriaxone 1 or 3 days
treatment failure after 48-72 hours
1st line: amox/clav or ceftriaxone 3 days
alternative if allergic: ceftriaxone 3 days, clindamycin +/- 3rd gen ceph
if failed 2nd abx: clind + 3rd gen ceph
tympanocentesis - consult specialist
amox dosing for AOM
80-90 mg/kg/day in 2 divided doses
amox/clav dosing for AOM
90 mg/kg/day amox with 6.4 mg/kg/day clav in 2 divided doses
cefdinir dosing for AOM
14 mg/kg/day in 1 or 2 doses
cefuroxime dosing for AOM
30 mg/kg/day in 2 divided doses
cefpodoxime dosing for AOM
10 mg/kg/day in 2 doses
