Therapeutics - Otitis Media

Question 1

Why are children predisposed to OM?

Answer 1

• 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

Question 2

Prevention measures

Answer 2

• 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

Question 3

Sx of OM

Answer 3

• pain/earache (rubbing, tugging)
• fever up to 40.5
• irritable
• night restlessness
• poor feeding
• nausea/vomitting
• often associated with cough and rhinitis

Question 4

What are the 2 requirements of AOM?

Diagnostic factors of Bacterial OM?

Answer 4

1. Inflammation of middle ear
2. fluid in middle ear

• Bulging inflamed ear drug
• Purulent fluid behind ear drum or otorrhea
• Decreased mobility on pneymatoscopy

Question 5

What is Otitis Media with Effusion?

Answer 5

• fluid in middle ear w/o sx of AOM
• occurs following AOM
• Many children will still have post 3 months of AOM - reassess then

Question 6

Most common pathogens of AOM

Answer 6

H.influenzae (half of incidences)
S.pneumo (decreased due to vaccine
M.catarrhalis

Question 7

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?

Answer 7

80% of incidences

1. M.catarrhalis
2. H. influenzae
3. S. pneumoniae

-S.pneumoniae

Question 8

Name the primary reason why S.pneumo incidences have decreased so dramatically.

Answer 8

Routine vaccination of children with PCV13 conjugate vaccine has dramatically decreased number of AOM incidences, specifically those due to S. pneumoniae

Question 9

When is watchful waiting the recommended “treatment”? For how long

Answer 9

• 48-72hrs
• > 6 months of age
• sx can be managed with analgesics
• Follow up can be assured by caregiver

Question 10

What is the criteria for “watchful waiting”?

Answer 10

• 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

Question 11

When should AOM be treated with antibiotics?

Answer 11

• 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

Question 12

First line treatment of AOM

What if purulent conjunctivitis also present? Why does this matter?

Answer 12

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)

Question 13

What are some complications of OM?

How do you treat mild complicated OM?

Answer 13

Mastoiditis, vertigo, facial paralysis

Cefuroxime

Question 14

When do you use a duration of 10 days of abx treatment?

Answer 14

<2 years old
Perforated ear drum
recurrent AOM
non-responders
High Risk

Question 15

When should follow-up occur for AOM?

Answer 15

Follow-up visit at 3 months to assess for OME which may lead to hearing loss

Question 16

Is abx prophylaxis recommended for recurrent OM?

Why?

Answer 16

No longer recommended

• Only reduces incidences by 1 episode/year
• higher risk of resistant organims

Question 17

If penicillin allergy, how to treat?

Answer 17

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

Question 18

My child has a runny nose, earache, and cough, is irritable and has a fever >39.5. What should I do?

Answer 18

<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

Question 19

Advice to cool down a child from fever?

Answer 19

Undress child
Give child a lukewarm bath
Provide cool drink/popsicles
Acetaminophen

Question 20

What is a Serotype 19A S.pneumoniae?

Answer 20

-A multiresistant strain that is resistant to all approved abx for AOM, only very broad spectrum abx (vancomycin, fluoroquinolones) work

Question 21

What is Prevnar 13? Why is it important?

Answer 21

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

Question 22

What is considered failure of treatment?

How do you treat is first line failure of treatment occurs?

Answer 22

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