Therapeutics - Otitis Media Flashcards
Why are children predisposed to OM?
- antibodies to bacterial polysacchardies not fully developed in children <2 years
- Eustachian tube connecting throat and middle ear is smaller and more horizontal in children
- more common colds in children due to daycare/other children (vUTRIs, exposure to resistant organisms)
- bottle feeding in supine position
- more allergies
Prevention measures
- handwashing
- cleaning shared toys
- BF even at 3 months
- avoid 2nd hand smoke
- avoid feeding in supine position
- reduce pacifier use in children >6yrs
- influenza vaccine
- routine pneumococcal conjugate PCV-13 vaccine
Sx of OM
- pain/earache (rubbing, tugging)
- fever up to 40.5
- irritable
- night restlessness
- poor feeding
- nausea/vomitting
- often associated with cough and rhinitis
What are the 2 requirements of AOM?
Diagnostic factors of Bacterial OM?
- Inflammation of middle ear
- fluid in middle ear
- Bulging inflamed ear drug
- Purulent fluid behind ear drum or otorrhea
- Decreased mobility on pneymatoscopy
What is Otitis Media with Effusion?
- fluid in middle ear w/o sx of AOM
- occurs following AOM
- Many children will still have post 3 months of AOM - reassess then
Most common pathogens of AOM
H.influenzae (half of incidences)
S.pneumo (decreased due to vaccine
M.catarrhalis
How often does spontaneous resolution happen?
Rate AOM pathogens in order of most to least spontaneous resolution
Which pathogen is associated with the most serious complications?
80% of incidences
- M.catarrhalis
- H. influenzae
- S. pneumoniae
-S.pneumoniae
Name the primary reason why S.pneumo incidences have decreased so dramatically.
Routine vaccination of children with PCV13 conjugate vaccine has dramatically decreased number of AOM incidences, specifically those due to S. pneumoniae
When is watchful waiting the recommended “treatment”? For how long
- 48-72hrs
- > 6 months of age
- sx can be managed with analgesics
- Follow up can be assured by caregiver
What is the criteria for “watchful waiting”?
- mildly ill with fever <39 in absence of antipyretics
- mild otalgia
- child does not have conditions that may complicate AOM
- Parents capable of recognizing worsening illness and can seek help
- illness does not become worse
- reasonable to provide follow-up next day
When should AOM be treated with antibiotics?
- Children <6months
- children >/= 6 months: perforated ear drum; unresponsive to analgesics; unlikely to return for follow-up
- “moderately to severely ill” - irritable, difficulty sleeping, poor response to analgesics
First line treatment of AOM
What if purulent conjunctivitis also present? Why does this matter?
Amoxicillin 40mg/kg/day tid x5days
OR: Recent abx use in p3m, <2 years, +/- daycare
Amoxicillin 90mg/kg/day bid-tid x5days
IF PURULENT CONJUNCTIVITIS:
Amoxi/clav 45mg/kg/day tid x5days
(probably an H.influenzae infection)
What are some complications of OM?
How do you treat mild complicated OM?
Mastoiditis, vertigo, facial paralysis
Cefuroxime
When do you use a duration of 10 days of abx treatment?
<2 years old Perforated ear drum recurrent AOM non-responders High Risk
When should follow-up occur for AOM?
Follow-up visit at 3 months to assess for OME which may lead to hearing loss
Is abx prophylaxis recommended for recurrent OM?
Why?
No longer recommended
- Only reduces incidences by 1 episode/year
- higher risk of resistant organims
If penicillin allergy, how to treat?
Non-type I reaction: If resistance <20%: Clindamycin 20mg/kg/d div tid x 5 days \+ cefixime 8 mg/kg/d div bid x5 days OR cefuroxime 30 mg/kg/d div bid x5days
Type I reaction: <8: TMP/SMX 8-12mg/kg/d bid x5 days >8: doxycycline 4mg/kg/d bid x5 days
My child has a runny nose, earache, and cough, is irritable and has a fever >39.5. What should I do?
<3 months old:
Take to doctor that same day
> 3 months old and <2 years old:
If no better after 24h, take to doctor
> 2 years:
If not better (still has fever) after 3 days, take to doctor
Advice to cool down a child from fever?
Undress child
Give child a lukewarm bath
Provide cool drink/popsicles
Acetaminophen
What is a Serotype 19A S.pneumoniae?
-A multiresistant strain that is resistant to all approved abx for AOM, only very broad spectrum abx (vancomycin, fluoroquinolones) work
What is Prevnar 13? Why is it important?
Prevnar 13 is a vaccination for S. pneumoniae that covers PCV-7 (just like the original Prevnar) as well as some additional serotypes, including 19A.
-Overall carriage of s. pneumo decreased, even those that are non-PCV-7, including 19A
What is considered failure of treatment?
How do you treat is first line failure of treatment occurs?
Persistent AOM (still symptomatic at 48-72h)
Amoxicillin 45mg/kg/day bid-tid x 10 days
+
Amoxi-clav (7:1 - Clavulin -200 or -400) 45mg/kd/day bid-tid x10 days
