-
A
PAGE 2| Introduction To The Updated Guidelines For The
Guidelines: Acute Otitis
Media Diagnosis And Management Of
Acute Otitis Media
T
PAGE 3| Assessment Of The
Guideline Methodology his issue of EM Practice Guidelines Update reviews the
2013 update of the guideline on the diagnosis and manage-
Selected Guideline ment of acute otitis media (AOM) for healthy children aged
PAGE 4| Recommendations,
6 months to 12 years. Published by the American Academy of
With Discussion Pediatrics (AAP) and the American Academy of Family Physicians
(AAFP), the guideline authors emphasize the use of a specific,
PAGE 8| References stringent definition of AOM to limit unnecessary treatment with an-
tibiotics in patients without a certain diagnosis. The management
recommendations outline which children should be treated with
PAGE 9| CME Questions antibiotics immediately and which children can be offered a watch
and wait approach. This review focuses on the recommendations
Editors Note: To read more about this publication most relevant to pediatric emergency medicine practice.
and the background and methodologies for practice
guideline development, go to:
http://www.ebmedicine.net/introduction Practice Guideline Impact
Emergency clinicians should make the diagnosis of AOM in
children who present with: (1) moderate to severe bulging of
the tympanic membrane (TM) or new-onset otorrhea not due
to acute otitis externa; or (2) mild bulging of the TM and re-
cent (< 48 h) onset of ear pain or intense erythema of the TM.
The management of AOM should include assessment and
treatment of pain.
Emergency clinicians should prescribe immediate antibiotic
treatment for AOM for children with otorrhea, children with
severe symptoms, and children aged 6 months to 2 years
with bilateral AOM.
Emergency clinicians can either start immediate antibiotic
treatment or offer observation (if there is good follow-up) for
children aged 6 to 23 months with nonsevere unilateral AOM
and children aged 24 months with nonsevere unilateral or
bilateral AOM.
May/June 2014
Volume 6, Number 3
Author
Kimberly Kahne, MD
Pediatric Emergency Medicine Fellow, Department of Emergency Medicine,
Icahn School of Medicine at Mount Sinai, New York, NY
Editor-In-Chief
Sigrid Hahn, MD, MPH
Assistant Professor of Emergency Medicine, Department of Emergency
Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
Editorial Board
Luke K. Hermann, MD
Associate Professor of Emergency Medicine, Director of Quality and Finance,
Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai,
New York, NY
Andy Jagoda, MD, FACEP
Professor and Chair, Department of Emergency Medicine, Icahn School of
Medicine at Mount Sinai, New York, NY
Eddy S. Lang, MDCM, CCFP (EM), CSPQ
Senior Researcher, Alberta Health Services; Associate Professor, University of
Calgary; Adjunct Professor, McGill University, Montreal, Quebec, Canada
Trevor Lewis, MD, FACEP
Medical Director, Emergency Department, Cook County Hospital; Associate
Professor of Emergency Medicine, Rush Medical College, Chicago, IL
Gregory M. Press, MD, RDMS
Emergency Ultrasound Director, Hutt Valley Hospital, Lower Hutt, New Zealand
Christopher Tainter, MD, RDMS
Critical Care Fellow, Department of Anesthesia, Critical Care, and Pain
Medicine, Massachusetts General Hospital/Harvard Medical School, Boston,
MA
Scott M. Silvers, MD
Chair, Department of Emergency Medicine, Mayo Clinic, Jacksonville, FL
Scott D. Weingart, MD, FCCM
Associate Professor, Department of Emergency Medicine, Director, Division of
ED Critical Care, Icahn School of Medicine at Mount Sinai, New York, NY
Prior to beginning this activity, see CME Information
on page 9.
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Introduction To The Guidelines: Acute Otitis Media

T
his issue of EM Practice Guidelines Update reviews the guideline
entitled The Diagnosis and Management of Acute Otitis Media,
published in Pediatrics in March 2013, available at:
http://pediatrics.aappublications.org/content/131/3/e964.long
AOM remains the leading condition for which antibiotics are prescribed
for children in the United States.1,2 It accounts for 13% of all emer-
gency department (ED) visits and 30 million clinic visits by children,
making it the second most common diagnosis in the pediatric ED after
upper respiratory infections.3 In May 2004, the AAP and AAFP pub-
lished the Clinical Practice Guideline: Diagnosis and Management of
Acute Otitis Media.4 This earlier guideline used a less-stringent defini-
tion of AOM that could have led to the misdiagnosis of children having
otitis media with effusion (OME) as having AOM. The 2004 guideline
also provided management recommendations for children with an
uncertain" diagnosis. The updated guidelines removed this category,
emphasizing the importance of good visualization of the TM and excel-
lent otoscopic skills for accurate diagnosis to guide management.
The recommendations in the 2004 guideline to observe rather than
to treat with antibiotics were based on studies that used nonspecific
inclusion criteria that did not represent a patient population with highly
certain AOM. Furthermore, older studies tended to exclude very young
children with severe disease and those with recent antibiotic treatment
or recent diagnosis of AOM. Thus, the studies were not reflective of
the full spectrum of patients covered by these guidelines.8 The 2013
update relied upon studies with stringent diagnostic criteria to ensure
that the patients, indeed, had AOM, and, based on these stronger
data, actually expand the recommendations for which patients can be
observed without antibiotic treatment.
The guideline authors acknowledge that the adherence to the 2004
guidelines was quite poor, and they comment that this, unfortunately,
parallels the impact of practice guidelines across specialties. They
highlight the need for increased dissemination of guideline content.
-- Kimberly Kahne, MD

The 2004 guideline was notable for recommending observation without

the use of antibiotics in select patients. Despite awareness and signifi-
cant publicity of these 2004 recommendations, evidence has shown
that clinicians are hesitant to change their practice.5 Management of
AOM with watchful waiting rather than prescription of antibiotics did
not increase after the 2004 guideline publication.6 A 2007 study re-
ported that up to 91% of ED patients received an antibiotic prescription
for AOM.7

EM Practice Guidelines Update 2014 2 www.ebmedicine.net May/June 2014

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Assessment Of The Guideline Methodology

T
o create this guideline, the AAP and AAFP partnered with the Table 1. Definition Of Evidence Quality Used In American Academy of
Agency for Healthcare Research and Quality and the Southern Pediatrics Recommendations
California Evidence-Based Practice Center. Using an evidence
report created by these agencies, a multidisciplinary writing commit-
tee used BRIDGE-Wiz (Building Recommendations in a Developers
Guideline Editor) software to aid in crafting action-oriented recommen-
dations and in determining the strength of the evidence. The relation-
ship between the strength of the evidence and the recommendation is
shown in Table 1.

The author of this issue of EM Practice Guidelines Update, Kimberly

Kahne, MD, as well as the Editor-in-Chief, Sigrid Hahn, MD, MPH,
graded these guidelines using the Appraisal of Guidelines for Re-
search and Education (AGREE) II instrument (available at
http://www.agreetrust.org/). This instrument is a checklist that allows
users to grade a guideline on 23 items in 6 domains, reflecting the
degree to which the guideline developers used unbiased, best-practice
methodology in developing the guideline and writing the recommenda-
tions. The results of the AGREE assessment are presented in Figure Figure 1. AGREE Criteria For Acute Otitis Media Guidelines
1, with a percentile calculated for each domain (maximumof 100%).
The score for relevance to emergency medicine is not part of the
AGREE instrument, but reflects the judgment of the author and editor
of this issue.

Kimberly Kahne, MD; and Sigrid Hahn, MD, MPH

Abbreviation: AGREE, Appraisal of Guidelines for Research and Education.

EM Practice Guidelines Update 2014 3 www.ebmedicine.net May/June 2014

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Selected Guideline Recommendations, With Discussion
T
he recommendations excerpted here are presented as they
appear in the original guidelines, including the strength of rec-
ommendation and the level of evidence. This review does not
include all recommendations provided in the original documents pub-
lished by the AAP and the AAFP. Instead, it includes those recommen-
dations most pertinent to emergency clinicians.
Diagnosis Of Acute Otitis Media
Key Action Statement 1A: Clinicians should diagnose AOM in
children who present with moderate to severe bulging of the TM
or new onset of otorrhea not due to acute otitis externa. (Evidence
Quality: Grade B. Strength: Recommendation)
Key Action Statement 1B: Clinicians should diagnose AOM in
children who present with mild bulging of the TM and recent (< 48
hours) onset of ear pain (holding, tugging, rubbing of the ear in a
nonverbal child) or intense erythema of the TM. (Evidence Quality:
Grade C, Strength: Recommendation)
Key Action Statement 1C: Clinicians should not diagnose AOM
in children who do not have middle ear effusion (based on pneu-
matic otoscopy and/or tympanometry). (Evidence Quality: Grade B,
Strength: Recommendation)
Editorial Comment: Kimberly Kahne, MD
The challenging feature of these diagnostic criteria for many clini-
cians will be that they rely upon pneumatic otoscopy, and the guideline
authors call this the standard" tool for diagnosis. Although they ac-
knowledge that many clinicians lack experience in removing cerumen
adequately or performing pneumatic otoscopy, an incomplete examina-
tion is no longer considered acceptable.
EM Practice Guidelines Update 2014 4
The guideline recommends the tools to help develop the appropriate
skills, including the following video:
http://www2.aap.org/sections/infectdis/video.cfm
These revised criteria were developed in reaction to criticisms of the
2004 definition, which lacked precision, and the fact that the guidelines
had a category of recommendations for patients with an uncertain
diagnosis, which many felt tacitly endorsed incomplete visualization
of the TM and poor otoscopic skills. The 2013 criteria were chosen to
achieve higher specificity while recognizing that the decreased sensi-
tivity may exclude less severe presentations of AOM.
Pain Management For Acute Otitis Media
Key Action Statement 2: The management of AOM should in-
clude an assessment of pain. If pain is present, the clinician should
recommend treatment to reduce pain. (Evidence Quality: Grade B,
Strength: Strong Recommendation)
Editorial Comment: Kimberly Kahne, MD
Although many episodes of AOM are associated with pain,9 clinicians
often view it as a secondary complaint that may not require direct at-
tention.10 Pain associated with AOM can be substantial and can last
longer in young children.11 Acetaminophen and ibuprofen are consid-
ered the mainstay of pain management for AOM.
www.ebmedicine.net May/June 2014
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Antibiotic Treatment Or Observation For Management For Acute Editorial Comment: Kimberly Kahne, MD
Otitis Media Since the 2004 guideline, substantial research has been published on
Key Action Statement 3A: Severe AOM The clinician should the initial management of AOM, including randomized controlled trials
prescribe antibiotic therapy for AOM (bilateral or unilateral) in chil- on antibiotic therapy versus placebo or no therapy.12-14 The evidence-
dren aged > 6 months with severe signs or symptoms (ie, moder- based recommendations are summarized in Table 2.
ate or severe otalgia or otalgia for at least 48 hours, or temperature
39C [102.2F] or higher). (Evidence Quality: Grade B, Strength: Table 2. Recommendations For Initial Management For
Strong Recommendation) Uncomplicated Acute Otitis Media
Key Action Statement 3B: Nonsevere bilateral AOM in young Age Otorrhea with Unilateral or Bilateral AOM* Unilateral AOM*
children The clinician should prescribe antibiotic therapy for AOM* bilateral AOM* without otor- without otor-
bilateral AOM in children aged < 24 months without severe signs with severe rhea rhea
or symptoms (ie, mild otalgia for < 48 hours, temperature < 39C symptoms

[102.2F]). (Evidence Quality: Grade B, Strength: Recommenda- 6 mo - Antibiotic Antibiotic Antibiotic therapy Antibiotic therapy
tion) 2y therapy therapy or additional
Key Action Statement 3C: Nonsevere unilateral AOM in young observation
children The clinician should either prescribe antibiotic therapy 2y Antibiotic Antibiotic Antibiotic thera- Antibiotic therapy
or offer observation with close follow-up based on joint decision- therapy therapy py or additional or additional
making with the parent(s)/caregiver for unilateral AOM in children observation observation
aged 6 months to 23 months without severe signs or symptoms (ie,
mild otalgia for < 48 hours, temperature < 39C [102.2F]). When
*Applies only to children with well-documented AOM with high certainty of diagnosis.
observation is used, a mechanism must be in place to ensure
A toxic-appearing child, persistent otalgia more than 48 h, temperature 39C (102.2F) in the
follow-up and begin antibiotic therapy if the child worsens or fails
past 48 h, or if there is uncertain access to follow-up after the visit.
to improve within 48 to 72 hours of onset of symptoms. (Evidence
This plan of initial management provides an opportunity for shared decision-making with the
Quality: Grade B, Strength: Recommendation)
childs family for those categories appropriate for additional observation. If observation is offered,
Key Action Statement 3D: Nonsevere AOM in older children
a mechanism must be in place to ensure follow-up and the initiation of antibiotics if the child wors-
The clinician should either prescribe antibiotic therapy or offer ob-
ens or fails to improve within 48 to 72 h of AOM onset.
servation with close follow-up based on joint decision-making with
Abbreviation: AOM, acute otitis media.
the parent(s)/caregiver for AOM (bilateral or unilateral) in children
Reproduced with permission from Pediatrics, Vol. 131, page e976, Copyright 2013 by the AAP.
aged 24 months without severe signs or symptoms (ie, mild otal-
gia for < 48 hours, temperature < 39C [102.2F]). When observa-
These recommendations contrast with the 2004 guideline, which rec-
tion is used, a mechanism must be in place to ensure follow-up
ommended antibiotic therapy for all children aged 6 months to 2 years
and begin antibiotic therapy if the child worsens or fails to improve
with a certain" diagnosis. Evidence has supported the safety of obser-
within 48 to 72 hours of onset of symptoms. (Evidence Quality:
vation or delayed antibiotic usage in young children and is an appropri-
Grade B, Strength: Recommendation)
ate management option when there is shared decision-making with the
parent.

EM Practice Guidelines Update 2014 5 www.ebmedicine.net May/June 2014

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Choice Of Antibiotics For Acute Otitis Media
Key Action Statement 4A: Clinicians should prescribe amoxicillin
for AOM when a decision to treat with antibiotics has been made
and the child has not received amoxicillin in the past 30 days or the
child does not have concurrent purulent conjunctivitis or the child
is not allergic to penicillin. (Evidence Quality: Grade B. Strength:
Recommendation)
Key Action Statement 4B: Clinicians should prescribe an anti-
biotic with additional beta-lactamase coverage for AOM when a
decision to treat with antibiotics has been made, and the child has
received amoxicillin in the last 30 days or has concurrent purulent
conjunctivitis, or has a history of recurrent AOM unresponsive to
amoxicillin. (Evidence Quality: Grade C. Strength: Recommenda-
tion)
Key Action Statement 4C: Clinicians should reassess the patient
if the caregiver reports that the childs symptoms have worsened
or failed to respond to the initial antibiotic treatment within 48 to
72 hours and determine whether a change in therapy is needed.
(Evidence Quality: Grade B. Strength: Recommendation)
EM Practice Guidelines Update 2014 6
Editorial Comment: Kimberly Kahne, MD
Once the decision has been made to start antibiotics, the emergency
clinician must choose an antibiotic that will have a high likelihood of
being effective against the most likely bacterial pathogen, taking into
account cost, taste, convenience, and adverse effects.
There have been no changes to the recommendation for first-line anti-
biotic choice since the 2004 guideline, despite new data on the effects
of 7-valent pneumococcal conjugate vaccine (PCV7, Prevnar) and
the awareness of an increase in multidrug-resistant strains of pneumo-
cocci. High-dose amoxicillin (80-90 mg/kg per day in 2 divided doses)
yields middle ear fluid levels that exceed the minimum inhibitory
concentrations of all intermediate (and many highly resistant) strains of
Streptococcus pneumoniae. The 3 most common bacterial pathogens
in AOM remain S pneumoniae, nontypeable Haemophilus influen-
zae, and Moraxella catarrhalis. Since the introduction of PCV7, there
has been a shift towards H influenzae and non-PCV7 serotypes of S
pneumoniae. The antibiotic susceptibility pattern for S pneumoniae is
expected to continue to evolve with the use of 7-valent pneumococcal
conjugate vaccine (PCV13, Prevnar 13).
Tables 3 and 4 (page 7) show a number of medications that are clini-
cally effective; however, amoxicillin remains first-line due to its effec-
tiveness in combination with low cost, safety, acceptable taste, and
narrow microbiologic spectrum. Patients who have taken amoxicillin in
the previous 30 days, patients with concurrent conjunctivitis, or pa-
tients for whom coverage for beta-lactamase-positive H influenza and
M catarrhalis is desired should be started on amoxicillin-clavulanate
(Augmentin) at a dose of 90 mg/kg/day of amoxicillin with 6.4 mg/kg/
day of clavulanate. Alternative antibiotics vary in their efficacy against
AOM pathogens.
For children aged < 2 years and children with severe symptoms, a
standard 10-day course is recommended. A 7-day course may be rec-
ommended for children aged 2 through 5 years with mild or moderate
AOM. For children aged 6 years with mild to moderate symptoms, a
5- to 7-day course is adequate.
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Table 3. Recommended Antibiotics For (Initial Or Delayed) Treatment Table 4. Recommended Antibiotics After 48-72 Hours Of Failure Of
Of Pediatric Acute Otitis Media Initial Antibiotic Treatment For Pediatric Acute Otitis Media
Recommended First-line Alternative Treatment Recommended First-line Alternative Treatment
Treatment (If Penicillin Allergy) Treatment
Amoxicillin (80-90 mg/kg/day Cefdinir (14 mg/kg/day in 1 Amoxicillin-clavulanate* (90 Ceftriaxone, 3 days
in 2 divided doses) or 2 doses) mg/kg/day of amoxicillin with Clindamycin (Cleocin),
or Cefuroxime (30 mg/kg/day in 6.4 mg/kg/day of clavulanate 30-40 mg/kg/day in 3 divided
Amoxicillin-clavulanate* (90 2 divided doses) in 2 divided doses) doses, with or without a third-
mg/kg/day of amoxicillin, with Cefpodoxime (10 mg/kg/day or generation cephalosporin
6.4 mg/kg/day of clavulanate in 2 divided doses) Ceftriaxone (50 mg IM or IV
[amoxicillin-to-clavulanate ra- Ceftriaxone (50 mg IM or IV for 3 days) Failure of second antibiotic
tio, 14:1] in 2 divided doses) per day for 1 or 3 days) Clindamycin (30-40
mg/kg/day in 3 divided doses)
plus third-generation cepha-
*May be considered in patients who have received amoxicillin in the previous 30 days or who losporin
have the otitis-conjunctivitis syndrome. Tympanocentesis

Cefdinir, cefuroxime (Ceftin, Zinacef), cefpodoxime, and ceftriaxone (Rocephin) are highly
unlikely to be associated with cross-reactivity with penicillin allergy, on the basis of their distinct
chemical structures.
Abbreviations: IM, intramuscular; IV, intravenous
Reproduced with permission from Pediatrics, Vol. 131, page e983, Copyright 2013 by the AAP.
Consult specialist
*May be considered in patients who have received amoxicillin in the previous 30 days or who
have the otitis-conjunctivitis syndrome.
Perform tympanocentesis/drainage if skilled in the procedure, or seek a consultation from an
otolaryngologist for tympanocentesis/drainage. If the tympanocentesis reveals
multidrug-resistant bacteria, seek an infectious disease specialist consultation.
Cefdinir, cefuroxime, cefpodoxime, and ceftriaxone are highly unlikely to be associated with
cross-reactivity with penicillin allergy on the basis of their distinct chemical structures.
Abbreviations: IM, intramuscular; IV, intravenous
Reproduced with permission from Pediatrics, Vol. 131, page e983, Copyright 2013 by the AAP.

EM Practice Guidelines Update 2014 7 www.ebmedicine.net May/June 2014

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References 10. Schecter NL. Management of pain associated with acute medical ill-
1. Grijalva CG, Nuorti JP, Griffin MR. Antibiotic prescription rates for ness. In: Schechter NL, Berde CB, Yaster M, eds. Pain in Infants, Chil-
acute respiratory tract infections in US ambulatory settings. JAMA. dren, and Adolescents. Baltimore: Williams & Wilkins; 1993:537-538.
2009;302(7):758-766. (Survey) (Textbook chapter)

2. McCaig LF, Besser RE, Hughes JM. Trends in antimicrobial prescrib-
ing rates for children and adolescent. JAMA. 2002;287(23):3096-
3102. (Survey)
3. Pitts SR, Niska RW, Xu J, et al. National hospital ambulatory medical
care survey: 2006 emergency department summary. Natl Health Stat
Report. 2008;7:1-38. (Survey)
4. American Academy of Pediatrics Subcommittee on Management of
Acute Otitis Media. Diagnosis and management of acute otitis media.
Pediatrics. 2004;113(5):1451-1465. (Clinical practice guidelines)
5. Vernacchio L, Vezina RM, Mitchell AA. Management of acute otitis
media by primary care physicians: trends since the release of the
2004 American Academy of Pediatrics/American Academy of Family
Physicians clinical practice guideline. Pediatrics. 2007;120(2):281-
287. (Survey)
6. Coco A, Vernacchio L, Horst M, et al. Management of acute otitis
media after publication of the 2004 AAP and AAFP clinical practice
guideline. Pediatrics. 2010;125(2):214-220. (Survey)
11. Rovers MM, Glasziou P, Appelman CL, et al. Predictors of pain and/
or fever at 3 to 7 days for children with acute otitis media not treated
initially with antibiotics: a meta-analysis of individual patient data. Pe-
diatrics. 2007;119(3):579-585. (Meta-analysis; 824 patients)
12. Hoberman A, Paradise JL, Rockette HE, et al. Treatment of acute
otitis media in children under 2 years of age. N Engl J Med.
2011;364(2):105-115. (Randomized trial; 291 patients)
13. Thtinen PA, Laine MK, Huovinen P, et al. A placebo-controlled
trial of antimicrobial treatment for acute otitis media. N Engl J Med.
2011;364(2):116-126. (Randomized double-blind trial; 319 patients)
14. Le Saux N, Gaboury I, Baird M, et al. A randomized, double-blind,
placebo-controlled noninferiority trial of amoxicillin for clinically di-
agnosed acute otitis media in children 6 months to 5 years of age.
CMAJ. 2005;172(3):335-341. (Randomized double-blind placebo-
controlled noninferiority trial; 512 patients)

7. Fischer T, Singer AJ, et al. National trends in emergency department

antibiotic prescribing for children with acute otitis media, 1996-2005.
Acad Emerg Med. 2007;14(12):1172-1175. (Retrospective database
study)

8. American Academy of Pediatrics Steering Committee on Quality Im-

provement and Management. Classifying recommendations for clinical
practice guidelines. Pediatrics. 2004;114(3)874-877. (Statement)

9. Hayden GF, Schwartz RH. Characteristics of earache among children

with acute otitis media. Am J Dis Child. 1985;139(7):721-723. (Pro-
spective; 335 cases)

EM Practice Guidelines Update 2014 8 www.ebmedicine.net May/June 2014

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CME Questions
To take the CME test, visit: www.ebmedicine.net/G0514 or scan the QR code below with a smartphone:

1. Which of the following patients meets criteria for the diagnosis of AOM?
a. A 3-year-old girl with otorrhea and evidence of acute otitis externa on examination
b. A 3-year-old girl with mild bulging of the TM and complaints of ear pain for the past 24 hours
c. A 3-year-old girl with moderate erythema of the TM and complaints of ear pain for the past 24 hours
d. A 3-year-old girl with upper respiratory infection symptoms and complaints of right-sided otalgia

2. Which of the following patients meets criteria for the diagnosis of AOM?
a. A 6-month-old boy with mild bulging of the TM and ear-pulling for 2 weeks
b. A 6-month-old boy with mild bulging of the TM
c. A 6-year-old boy with severe bulging of the TM
d. None of the above

3. Which antibiotic should be initiated in a 15-month-old girl diagnosed with uncomplicated bilateral AOM?
a. Amoxicillin 45 mg/kg/day divided into 2 doses
b. Amoxicillin 80-90 mg/kg/day divided into 2 doses
c. Ceftriaxone 50 mg/kg intramuscular injection x 1
d. Clindamycin 30-40 mg/kg/day in divided into 3 doses

4. In which patient is observation an inappropriate form of management?

a. A 3-year-old with unilateral AOM and severe otalgia for 48 hours
b. A 10-month-old with unilateral AOM and fever to 38.5C for 48 hours
c. A 10-month-old with bilateral AOM and fever to 38.5C for 48 hours
d. A and B
e. A and C

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To contact the Editor-In-Chief, email Sigrid Hahn, MD, MPH at:
editorial@ebmedicine.net
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EM Practice Guidelines Update 2014 10
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Date of Original Release: May 1, 2014. Date of most recent review: April 15, 2014. Termination date: May
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