Pediatric Infectious Diseases - Acute Otitis Media Flashcards
Risk factors for AOM
-Smoke exposure
-Formula feeding
-Immunization status
-Atopy
-Daycare attendance
-Male gender
-Family history
-Onset of first episode before 6-12 months of age (earlier means higher risk)
-Whites
-Lower socioeconomic status
-Congenital anomalies
-Immune deficiency
What is otitis media with effusion (OME)?
-Middle ear fluid is sterile; no signs of acute infection
-Antibiotics not indicated and not beneficial
What is acute otitis media (AOM)?
-Bacterial infection likely
-Antibiotics indicated if symptomatic
Most common organisms in AOM
-Strep pneumoniae
-Heamophilus influenzae
-Moraxella catarrhalis
Which vaccine is recommended for all babies
Pneumococcal vaccine
Clinical manifestations of AOM
-Otalgia (ear pain)
-Holding or tugging at ear
-Fever
-Irritability
-Poor feeding/anorexia
-Disrupted sleep
-Malaise
-Otorrhea (ear discharge)
-Sometimes asymptomatic
How do you diagnose AOM?
Look at the tympanic membrane
What does a normal tympanic membrane look like?
-Slightly concave
-Pearly gray in color
-Transluscent
-Moves in response to pressure
What does a tympanic membrane look like in AOM?
-Bulging
-Cloudy or purulent effusion
-Immobile
What must be present to diagnose AOM?
-Acute onset
-Middle ear effusion
-Symptoms of middle ear inflammation
In what cases would you not treat AOM
-Non-severe, unilateral and between 6 months to 2 years old
-Non-severe older than 2 years old regardless of bilateral vs unilateral
What do you do when observing?
-Defer antibiotics for 48-72 hours
-Watch for resolution of symptoms
-Provide symptomatic relief
What do you do if observation fails?
-Communicate with physician
-Begin antimicrobial therapy
-Continue symptomatic therapy
What is a Safety-Net Antibiotic Prescription (SNAP)
Allows parents 1-2 days for infection to resolve and if it does not then they can fill the prescription
How are bacterial resistances overcome in the treatment of AOM?
-Strep pneumoniae penicillin resistance is overcome by using high dose amoxicillin (first line)
-Haemophilus influenzae and moraxella catarrhalis are overcome by using a beta-lactamase inhibitor like Augmentin (second line)
What is the first-line drug of choice for AOM?
High dose amoxicillin
Dose of first-line treatment of AOM
80-90 mg/kg/day divided Q12H for 5-10 days
Advantages of amoxicillin in AOM
-In the middle ear high dose amox concentrations exceed MIC in S. pneumoniae resistant to penicillin
-Safe, effective, inexpensive
-Half-life of 4-6 hours in middle ear (1 hour in serum)
When would we not use high dose amoxicillin in AOM?
-Known resistance
-Treatment failure
-Amoxicillin in last 30 days
-Allergy
-Concurrent conjunctivitis
What is second-line treatment for AOM?
-Augmentin
-Cefpodoxime (may be first if allergic to amoxicillin)
What is the Augmentin dose for AOM?
90 mg/kg/day of amox component divided Q12H
Advantages of Augmentin in AOM
Additional coverage for beta-lactamase producing organisms
Disadvantages of Augmentin in AOM
-May be more expensive
-Diarrhea associated with clavulanate (dose clavulanate at 10 mg/kg/day or less)
Which form of Augmentin must be picked?
ES version so that way clavulanate can stay under 10 mg/kg/day
Cefpodoxime dose
10 mg/kg/day divided Q12H
When is ceftriaxone used in AOM?
-Third line
-Only used in severe cases where oral treatment is not an option or oral treatment fails
Ceftriaxone dosing for AOM
-50 mg/kg daily IM
-One dose initial therapy
-Three doses if treatment failure
What are the alternative agents for AOM?
-Clindamycin
-Levofloxacin
-Macrolides (erythromycin and azithromycin)
-Bactrim
When would you use alternative therapy in AOM?
-Repeated treatment failure (get a culture)
-If cephalosporin anaphylaxis
Dosing for clindamycin
30-40 mg/kg/day divided TID
In what cases would you need to treat AOM for 10 days?
-Severe or recurrent AOM
-TM perforation
-Less than 2 years
What duration of therapy would you use for patients with AOM older than 2 years old or not severely ill?
5-7 days
What adjunctive therapy could you give to children with AOM?
-APAP PO
-Ibuprofen PO
-Lidocaine otic drops
APAP PO dosing for AOM
10-15 mg/kg/dose Q4-6H
Ibuprofen PO dosing for AOM
5-10 mg/kg/dose Q6-8H
When should you not use lidocaine otic drops?
-In ruptured TM or tubes
-Children less than 2 years old
What medications are not routinely recommended for patients with AOM?
-Decongestants/antihistamines (may be useful in URI, caution in under 4 years old)
-Dexamethasone (Not routine)
-Otikon otic solution (Need more data)
-Sweet oil (can cause bacterial growth)
When should you follow-up with young infants with severe episodes or any children with continuing pain?
Within days
When should you follow-up with infants or young children with history of frequent recurrences?
2 weeks
When should you follow-up with children who have sporadic episodes of AOM?
One month
When should you follow-up with older children?
No follow-up needed
How do you prevent AOM?
-Routine vaccination (pneumococcal and influenza)
-Reduction of preventable risk factors
-Prophylaxis
-Tympanostomy tubes
What are tympanostomy tubes?
Small ventilation tubes inserted through TM to provide drainage of eustachian tubes
When are tympanostomy tubes indicated?
-3 or more episodes in less than 6 month olds
-4 or more episodes in less than 12 month olds
What is chronic suppurative otitis media?
Perforated TM with persistent drainage lasting more than 6 weeks
What is the most common isolate in CSOM?
MRSA
How do you treat CSOM?
Ofloxacin or cipro ear drops for 2 weeks
What can cause acute otitis externa?
Trauma or trapped moisture
What organisms can be present in AOE?
-Pseudomonas
-S. aureus
-Consider fungal if no improvement
How do you treat AOE?
(treat with ear drops first)
-Polymyxin B, neomycin, and hydrocortisone
-Ofloxacin
-Cipro with hydrocortisone
