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Phar455 > shevchuk- otitis media > Flashcards

shevchuk- otitis media Flashcards

1
Q

what is it

A

inflammation of the middle ear that may be caused by infection

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2
Q

how common is it in kids (%), when is peak incidence, when is it rare

A

most common pediatric disease for which attention is sought

  • at least 80% of cases
  • 2/3 of children have an episode by age 3
  • up to 90% have an episode by age 6
  • peak incidence is 6-36 months
  • rare after age 8
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3
Q

why can kids grow out of it

A

growth/lengthening/change/maturation of eustachian tubes- protects middle ear space from infection

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4
Q

what is the middle ear close to, what does the middle ear connect to

A

auditory bones

eustachian tubes

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5
Q

when will we say a child is or will be otitis prone

A

-first episode before 6 months
OR
-more than 3 episodes in previous 6 months

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6
Q

3 functions of the eustachian tube

A
  • equalize pressure on both sides of the tympanic membrane
  • protect the middle ear from nasopharyngeal secretions
  • draining middle ear secretions into nasopharynx
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7
Q

what is usually the first thing that happens before otitis media

A

viral upper respiratory tract infection

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8
Q

steps to development on otitis media

A
  • usually viral URTI causing vasodilation and edema of nose and nasopharynx
  • occlusion of eustachian tubes causing edema of eustachian mucosa
  • impaired middle ear ventilation (no drainage) leading to effusion (accumulation of fluid)
  • bacteria invade the warm fluid (connected to mouth) (ie normal flora from nasopharynx enter ETs and middle ear
  • effusion becomes colonized and infected
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9
Q

what causes the pain in OM

A

pus under pressure in a closed space (pressure on tympanic membrane)

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10
Q

non preventable risk factors

A
  • age- younger kids have shorter, wider ET (more horizontal)
  • gender (more in males)
  • race (more in first nations/inuit)
  • family history- possible genetic factor
  • low socioeconomic status (crowded living situations and less access to care)
  • other medical conditions causing anatomic differences (down’s syndome, cleft palate)
  • recurrent (or concurrent) URTI
  • allergies
  • reduced immunity (from drugs or conditions)
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11
Q

preventable risk factors

A
  • daycare (close contact, and increased resistance within)
  • exposure to tobacco smoke (increase inflammation of mucosal surfaces, and can impair mucociliary clearance which increases chance of infection)
  • lack of breastfeeding (immunoglobulins in breast milk are believed to boost immune system of infant and may last 4-12 months after stopping). Also, avoiding bottle feeding while baby is laying down prevents reflux into middle ear)
  • extended pacifier use (increases mucus production with prolonged use may cause reflux of flora into middle ear)- controversial
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12
Q

what is a recurrent infection

A

-at least 3 episodes of AOM within 6 months, or 4 within 12 months

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13
Q

what can recurrent infections lead to

A
  • alterations in middle ear mucosa
  • damage to tympanic membrane and ossicles (hammer, anvil, stirrup)
  • adhesions (may immobilize ossicles)
  • conductive hearing loss
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14
Q

what is the biggest concern with middle ear infections in kids

A

-could lead to hearing loss and as a consequence have trouble with speech and language development, causing potential slower learning

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15
Q

4 types of otitis media

A
  • acute otitis media
  • otitis media with effusion
  • persistent otitis media (usually happens when kids have tubes)
  • recurrent otitis media
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16
Q

elements needed to diagnose acute otitis media

A
  • red, painful, moderate-severe bulging TM/eardrum, loss of anatomical landmarks (opaque TM)
  • can have discharge from ear (otorrhea) not due to otitis externa- this would be severe AOM and tympanic membrane has ruptured
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17
Q

when are AOM sx seen

A

within 24-48 hours of pain

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18
Q

sx of AOM

A
  • pain (tugging ear, crying, irritable, altered sleep). Spontaneous rupture of tympanic membrane results in purulent discharge and pain relief
  • sometimes fever (high can indicate a more severe infection)
  • N/V/D
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19
Q

what is a pneumatic otoscope exam

A

another way to check for AOM- checks mobilty of TM

-poorly done by Drs

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20
Q

intracranial complication of AOM, how common?

A
  • not very common, rare
  • meningitis
  • subdural or brain absess
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21
Q

what % of AOM resolve spontaneously without tx

A

80%

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22
Q

extracranial complication of AOM

A
  • hearing loss, TM perforation, chronic OM, mastoiditis (infection spreading from mastoid process ie portion of skull behind ear)- more common but still not very common
  • very rare= facial paralysis, tympanosclerosis, labyrinthitis
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23
Q

top three causes of AOM

A
  • streptococcus pneumoniae
  • haemophilus influenzae
  • moraxella catarrhalis
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24
Q

if less than six weeks old, what likely causes AOM

A

E-Coli or group B strep

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25
Q

can AOM be viral?

A

yes, with or without concomitant bacteria- do culture, often see both and cannot be sure which is causing pain/sx

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26
Q

goals of treating AOM

A
  • reduction in signs/sx
  • eradication of infection
  • prevention of complications
  • avoid unnecessary AB prescribing (esp in light of problem of Strep pneumoniae resistance)
27
Q

what is antibiotic treatment selection based on

A
  • spectrum of activity
  • AEs
  • ability to penetrate middle ear
  • convenience
  • cost
28
Q

in a child 6 months or older with severe signs or symptoms (moderate to severe otalgia, or otalgia for at least 48 hours, or temperature of 39)- what to do

A

ABs

29
Q

unilateral AOM in children 6-23 months without severe signs and sx

A

ABs
OR
observation

30
Q

AOM in children 24 months or older without severe signs/sx

A

ABs
OR
observation

31
Q

what is observation (aka _________)

A
  • watchful waiting
  • AB tx is deferred for 48-72 hours
  • caregiver watches child for signs of worsening; if worsen of don’t improve at all then fill rx
32
Q

what % of AOM resolves without ABs? Which is least likely to go away?

A

80%, but strep pneumoniae is least likely to resolve on its own

33
Q

first line therapy for AOM, dose (what not to exceed), what it covers

A

amoxicillin: 80mg/kg/day BID or TID max 3g/day
- child: some references say use high dose ie 80mg/kg/day in everyone regardless of age, some references say 40mg/kg/day. Just don’t exceed 1.5g/dose
- covers strep pneumoniae and most of haemophilis (only 25% will produce beta lactamases and be resistant to it)

34
Q

why can we use such a high dose of amoxicillin?

A

-hard to get ABs to site of action in middle ear in adequate concentrations

35
Q

mechanism of resistance of strep pneum to amox ie penicillins

A

penicillins work by binding to penicillin binding proteins on cell so the mechanism of resistance is decreased binding affinity, but not lack of binding

36
Q

how do you overcome resistance to penicillin for AOM

A

giving more drug and flooding the organism with amoxicillin

-amox is still the most active against strep pneumoniae even with resistance

37
Q

why is amoxicillin first line?

A
  • good activity against strep pneumoniae, even resistant strains
  • has a fairly narrow spectrum
  • safe unless allergic to it
  • very cheap
38
Q

what is second line therapy for AOM? What is it? Dose?

A

amoxicillin/clavulanate: 40mg/kg/day divided BID

-has a beta lactamase inhibitor added on it; handles haemophilis (25% that is amox resistant) and moraxilla

39
Q

why is morexilla not cured by amox? Is this a problem?

A

resistant to it because almost all of it produces beta lactamases- but it is most likely to go away on its own

40
Q

why wouldn’t be just give everyone amox/clav?

A
  • more expensive
  • SEs= stomach upset, **diarrhea (clav causes a lot of this), GI distress, etc
  • if on amox and not responding, this can be a good second line
41
Q

in penicillin allergic patients, what is next therapy?

A
  • cefprozil 30mg/kg/day BID
  • Cefuroxime 30-40mg/kg/day BID
  • Clarithromycin 15mg/kg/day BID
  • azithromycin 10mg/kg/day for day one, then 5mg/kg/day for 4 days OR 10mg/kg/day for 3 days, OR 30mg/kg single dose
42
Q

why wouldn’t you want to use cephalosporins potentially in people who can’t take penicillin?

A
  • don’t have as good of activity against strep pneumoniae
  • more expensive
  • if it was a severe reaction or allergy, would be worried about cross allergy and wouldn’t take this either
43
Q

which tastes better- cefprozil or cefuroxime?

A

-cefPROzil tastes good, cefuroxime tastes bad

44
Q

why would you maybe not consider a macrolide AB for AOM?

A
  • resistance rates are much higher
  • major common side effect is GI upset (throw up common)
  • cannot up doses to overcome resistance because of SEs, and they don’t bind to penicillin binding proteins
  • they change mRNA binding and increased SEs
  • clarithromycin and erythromycin cover haemophilis, but clarity only does because of its metabolite
45
Q

which AB is not longer recommended due to resistance to all 3 organisms?

A
  • trimethoprim/sulfamethoxazole

- only recommended in some very specific patients

46
Q

why is it important to ask if kids have had AB in the past month before new treatment?

A

if had same class in the past month, more likely to have resistance to that organism

47
Q

when would you use clarithromycin and why

A
  • it only has activity against gram positive aerobes and some anaerobes- the only gram positive organism in AOM is strep pneu, so it will only be active against this
  • use if sure you are only dealing with strep pneu (has a very narrow spectrum)
  • good for pen allergic children
48
Q

how long should AB tx last

A
  • generally 10 days
  • 5 days may be enough for some (uncompicated AOM- not recurrent/chronic and no underlying disease, over 24 months, no perforation of eardrum)
49
Q

how long should under six months always be treated

A

10 days

50
Q

treating otitis externa vs AOM

A
  • externa needs drips

- AOM needs to get to site of infection so much be oral

51
Q

sx resolution with AB treatment within

A
  • 2-3 days improvement seen

- if persist or worsen, see Dr

52
Q

what will half of patients have remaining after treatment

A

effusion (fluid)- may persist for weeks (up to one month). This is normal and does not mean treatment failure, just takes body time to get rid of the effusion.
-fluid in ears is not a reason to put child on ABs

53
Q

non pharm tx for AOM

A
  • glycerin or vegetable oil (heat to body temp in pocket or with hands and drop in, soothing, DON’T DO IF RUPTURED TM (guidelines, prob still okay)
  • heating pad or warm wash cloth (soothing)
54
Q

pharm tx for AOM

A
  • don’t use Auralgan- it has an anesthetic but it can’t actually penetrate the middle ear, and quite a few people are allergic to it
  • pain relief (ibu, acet, NOT ASA- associated with Reyes syndrome
  • decongestants and antihistamines- thought to prevent occlusion and help clear it p, but most studies show no benefit. Can be used for other signs/sx. Stimulant effect can be more pronounced in kids
55
Q

what is reye’s syndrome

A

causes fatty liver and severe encephalopathy (brain swelling)

56
Q

what is otitis media with effusion

A

presence of middle ear effusion without any sign of infection- may be asymptomatic except a bit of hearing loss

57
Q

how can otitis media with effusion be further subdivided

A
  • acute (less than 3 weeks)
  • subacute (3 weeks to 3 months)
  • chronic (over 3 months)
58
Q

causes of otitis media with effusion

A
  • recent AOM (40-50% of cases) (often follows AOM and resolves in 6-12 weeks-should employ watchful waiting in the meantime)
  • allergic rhinitis
  • anatomic problems
59
Q

what might happen with recurrent OM with effusion

A
  • may decrease hearing which can impair language development over time
  • cause scarring of tympanic membrane
60
Q

how to treat otitis media with effusion

A
  • wait and see (may resolve spontaneously in 2-3 months)
  • 2nd trial of ABs- not really recommended, bacteria may be present in half of cases
  • decongestants and AHs not usually useful
  • corticosteroids orally- some studies show benefit, short courses should be used if used
  • surgical procedures- myringotomy (drain middle ear space), tympany tubes : these tend to be reserved for recurrent cases
61
Q

how to treat recurrent AOM

A
  • ABs for 10 days
  • prophylaxis no longer recommended
  • surgery
  • vaccines (pneumococcal vaccine-could prevent, but can’t guarantee because 70-80 strains of it and can only contain/target most prominent ones. Influenza vaccine can reduce AOM in children
62
Q

treatment outcomes for recurrent AOM

A
  • decrease frequency of AOM by at least one episode per year
  • does not affect the rate of effusion
  • good idea for kids under 2 to prevent long term complications, but this is not a generally acceptable statement for all people
  • must worry about resistance and compliance
63
Q

non pharm tx for recurrent ear infections

A

-insertion on tympanostomy tubes (T tubes)

64
Q

pharmacists role- what to recommend, what to avoid

A
  • recommend something for pain
  • avoid AHs/decongestant and drops
  • instruct on proper AB use and follow up

Phar455 (6 decks)

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