Pediatric Infections - AOM Flashcards
Acute otitis media (AOM) Background
- More than 5 million AOM cases each year in US children
- Leads to > 10 million antibiotic prescriptions annually
- Most ___ indication for antibiotics in children
- 60% have at least one episode by 3 years, ~25% have ≥3 episodes of AOM
- common
AOM Risk Factors
◦ ___ exposure
◦ ___ feeding (vs breastfeeding)
◦ Immunization status
◦ Atopy
◦ ___ attendance
◦ ___ gender
◦ Family history - Sibling or parent w/ > 3 episodes AOM or tube surgery
◦ Onset of first episode before __ - ___ months of age (earlier = higher risk)
- Lower socioeconomic status
- Race: non-white/hispanic
- Congenital anomalies
- Immune deficiency
- smoke
- formula
- daycare
- male
- 6-12
Classification
Otitis media with effusion (OME)
- Middle ear fluid is ___ ; no signs of acute infection
- Antibiotics not indicated and not beneficial
Acute otitis media (AOM)
- Bacterial infection likely
- Antibiotics indicated if ___
- sterile
- symptomatic
Anatomical Differences
Infant eustachian tube is ___, more flexible and more ___ vs. adult
- shorter
- horizontal
Pathogenesis
1) Ineffective aeration of middle ear space = eustachian tube ___
2) Inflammation and edema of mucosal linings and ___ of eustachian tube lumen
3) Trapped air creates ___ reversing flow of secretions, drawing fluid into middle ear
4) Bacteria multiply in fluid and stimulate inflammation
pathologic bacteria are isolated from __ - __ % of well documented cases of AOM
1) dysfunction
2) narrowing
3) vacuum
65-75%
Microbiology AOM
___ - 35-45%
___ - 25-30%
___ - 20-25%
no pathogen - 20-30%
Streptococcus pyogenes (strep A) - 2-4%
Less common
- Staphylococcus aureus
- Gram-negative organisms
- Haemophilus influenzae
- Streptococcus pneumoniae
- Moraxella catarrhalis
Timeline of Pneumococcal Vaccination
Previous PCV versions:
* PCV7 = 2000 (DSC 2010)
* PCV13 = 2010 (DSC 2023)
Currently in peds can use either:
* PCV __ = 2022
* PCV __ = 2023
* Cover more serotypes
Usually given at 2, 4, 6, 12-15 months
- 15
- 20
Influence of Pneumococcal Vaccination
Serotype maturity takes __ + years after
new vaccine introduced
5+
AOM Clinical Manifestations
- Otalgia (ear ___ )
- Holding or tugging at ear
- Fever
- Irritability
- Poor feeding/anorexia
- Disrupted sleep
- Malaise
- Otorrhea (ear ___ )
- Sometimes ___
- pain
- discharge
- asymptomatic
Diagnosis of AOM
Visualize tympanic membrane (TM)
- ___
- Cloudy or ___ effusion
- ___ (normal moves in response to pressure)
Middle ear fluid culture via tympanocentesis
(infrequent) - eek
- bulging
- purulent
- immobile
Diagnosis of AOM
Diagnosis requires:
◦ ___ onset
◦ Middle ear ___
◦ ___ of middle ear inflammation
- acute
- effusion
- symptoms
Severity
Non-severe
◦ Mild ___
AND
◦ Fever __ 39 ̊C in past 24 hours
Severe
◦ Moderate to severe ___
OR
◦ Fever __ 39 ̊C
- otalgia
- <
- otalgia
- ≥
Criteria for Observation vs. Treatment
pretty much going to treat everyone immediately except the below: (observe option)
non-severe, unilaterial
- __ month - __ years
- ≥ __ years
non-severe, bilateral
- ≥ __ years
- 6, 2
- 2
Management of AOM
Observation
◦ Deferment of antibiotics for __ - __ 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
- 48-72
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
___ - __ Antibiotic Prescription (SNAP)
◦ Parents allow __ - __ days for infection to resolve
◦ If symptoms persist or worsen, fill prescription
Safety-Net
- 1-2
Resistance
Streptococcus pneumoniae
◦ __ % of strains are penicillin resistant
◦ Due to alterations in PBP
◦ Overcome by ___ concentrations of antibiotic at site (high-dose amox) - yay
Haemophilus influenzae & Moraxella catarrhalis
◦ 40-50% of H. flu strains and almost all M. catarrhalis strains produce ___ (amoxicillin resistant)
◦ Overcome by addition of ___ ___ (such as in amox/clav)
- 50%
- higher
- B-lactamase
- B-lactamase inhibitor
AOM Treatment
First Line:
- ___ __ - __ mg/kg/day divided Q12H x __ - __ days
Advantages:
◦ In middle ear, high dose amox concentrations exceeds MIC of ___ strains resistant to penicillin (all intermediate and many highly resistant)
◦ Safe, effective, inexpensive
◦ Half-life __ - __ hours in middle ear (vs 1 hr in serum)
- Amoxicillin, 80-90, 5-10
- S. pneumoniae
- 4-6
AOM: When do we NOT use amoxicillin?
- Known ___
- Treatment failure
- Amoxicillin in last ___ days
- Allergy
- Concurrent ___
- resistance
- 30
- conjunctivitis
Amoxicillin-clavulanate (Augmentin)
- 2nd line if amoxicillin failure
- 1st line if amox in last ___ days/ ___
Dose: __ mg/kg/day amox component divided Q12H
Advantages:
◦ Additional coverage for ___ -producing organisms
Disadvantages:
◦ May be more expensive
◦ ___ associated with clavulanate
◦ Dose clavulanate at ≤ __ mg/kg/day
- 30, conjunctivitis
- 90
- ß-lactamase
- Diarrhea
- 10
Amoxicillin-clavulanate (Augmentin)
Many available forms
◦ 125 mg amox/31.25 mg clav/5 mL
◦ 200 mg amox/28.5 mg clav/5 mL
◦ 250 mg amox/62.5 mg clav/5 mL
◦ 400 mg amox/57 mg clav/5 mL
◦ 600 mg amox/42.9 mg clav/5 mL
◦ ES-600
Which one do we choose?
- 600 mg amox/42.9 mg clav/5 mL
AOM - Oral Cephalosporins
2nd line (if allergy may be 1st)
___ :
◦ 3rd gen cephalosporin
◦ 10 mg/kg/day divided Q12H
◦ Tastes ___
◦ Better bioavailability; may work better than ___ but can be harder to get
___ (Omnicef®)
◦ 3rd gen cephalosporin
◦ 14 mg/kg/day divided Q12H to Q24H
◦ Tastes ___
- ___ bioavailability
Cefuroxime → liquid must be compounded
- Cefpodoxime, bad
- Cefdinir, good, poor
AOM Allergy
Cross-reactivity highest between penicillins and ___ generation cephalosporins
◦ Much lower w/ 2nd and 3rd generation cephalosporins; cefdinir, cefuroxime,
cefpodixime, ceftriaxone structurally very different from PCN
Reaction rate of ~0.1%
May skin test to assess
- 1st
AOM
Ceftriaxone (Rocephin)
For ___ cases if
◦ Oral treatment not option
◦ Initial oral treatment fails
Dosing
◦ 50 mg/kg daily IM
◦ ___ dose initial therapy
◦ ___ doses treatment failure
Advantages
◦ Broad spectrum
◦ As effective as ___ days of amoxicillin
◦ Compliance
Disadvantages
◦ Injection site pain
◦ Cost
◦ Avoid in < ___ month of age
◦ Cautions: ___ co-administration and ___
- severe
- 1, 3
- 10
- 1
- calcium, C. diff
AOM Alternartive Agents
Culture if repeated failure; may need alternative if cephalosporin anaphylaxis
___ (30-40 mg/kg/day divided TID)
◦ Not active against H. influenza
◦ May be option vs. PCN-resistant S. pneumoniae
___ or ___
◦ $$$, may be an option against certain resistant organisms
◦ Quinolones can lead to collateral resistance
___ (erythromycin and azithromycin) limited efficacy vs. H. influenza and S.pnuemoniae
- Azithromycin = resistance
___ / ___ = S. pneumo resistance; would not use for treatment failure (may be allergy option)
- Clindamycin
- levofloxacin, linezolid
- macrolides
- TMP/SMX
AOM Duration: Under 2 years old
520 children aged 6-23 months randomized to amox-clav for 10 days or 5 days + 5 days placebo
- Children treated for __ days were more likely to have clinical failure (34% vs 16%)
- Children w/ ___ AOM more likely to have failure (p<0.001)
- No increased resistance or ADRs found in __ day group
- 5
- bilateral
- 10
AOM - Duration: Over 2 years old
Exact effective duration is unknown
10 days of therapy for
◦ ___ or recurrent AOM
◦ ___ perforation
◦ < __ years
Shorter courses (5-7 days) may be used in children ≥ __ years of age
- severe
- TM
- 2
- 2
Adjunctive Therapy
Analgesics
◦ ___ PO
◦ 10-15 mg/kg/dose Q4-6H (max 75 mg/kg/day)
◦ ___ PO
◦ 5-10 mg/kg/dose Q6-8H if older than 6 months
◦ Usually avoid alternating Q3H (confusing)
___ otic drops
◦ Do not use in ruptured TM or tubes
◦ May consider in children 2 and up
◦ 2-4 drops in affected ear TID-QID
- APAP
- Ibuprofen
- lidocaine
AOM - Not Routinely Recommended
Decongestants/ ___ – may be useful in URI, caution in < 4 years
___ – not routine, more common in acute otitis externa
Otikon otic solution – natural product, need more data
Sweet oil
◦ Avoid, can worsen bacterial growth
- antihistamines
- Dexamethasone
Follow-up AOM
Within ___ for young infants with severe episode or children of any age with continuing pain
Within __ weeks for infants or young children with history of frequent recurrences
__ month after initial examination for children with only a sporadic episode of AOM
No follow-up may be necessary for ___ children
- days
- 2
- 1
- older
Prevention AOM
Routine ___
◦ Pneumococcal
◦ Influenza
Reduction of preventable risk factors
Prophylaxis
___ tubes
vaccination
Tympanostomy
Antibiotic Prophylaxis
Controversial → risk of ___ , ADRs, cost
May decrease ___ in children w/recurrent AOM
- Most benefit if ≥ __ episodes in previous year
- resistance
- frequency
- 6
Tympanostomy Tubes
Small ventilation tubes inserted through TM to provide drainage for eustachian
tubes
Indicated in ___ AOM
◦ __ or more episodes in < 6 mo
◦ __ or more episodes in < 12 mo
Treatment of uncomplicated otorrhea
◦ Topical ___ drops = (or better than) oral therapy
◦ Ofloxacin, ciprofloxacin
4-5 drops in affected ear BID x 5-7 days
Some controversy about steroids; combo drops commonly used
May consider watchful waiting, but should treat if does not resolve within ___ week
Topical quinolones can increase risk of ___ in patients without tubes
- recurrent
- 3
- 4
- quinolone
- 1
- performation
Chronic Suppurative Otitis Media
CSOM = most ___ form
Characterized by ___ TM w/persistent drainage lasting > __ weeks
MRSA = most common isolate
◦ Others include MSSA, Pseudomonas, Proteus, anerobes, fungi
Can be complication of ___ tube
May result in abscess or ___ loss
Initial treatment ___ or ___ ear drops x 2 weeks
If treatment failure, culture is indicated (potentially requiring IV therapy or
surgery)
- severe
- perforated, 6
- tympanostomy
- hearing
- ofloxacin, ciprofloxacin
Acute Otitis Externa (Swimmer’s Ear)
- Limited to ___ ear canal
- Can be caused by trauma or trapped moisture - 5x more common in swimmers
- Organisms are different (Pseudomonas, S. aureus; consider fungal if no improvement)
Treat with ear drops first; examples include
◦ ___ , neomycin, and hydrocortisone
◦ Ofloxacin
◦ ___ with hydrocortisone
- external
- Polymyxin B
- Ciprofloxacin
