|


 

Shafkat Anwar, M.D.

Pediatric Resident Level 3
Children¶s National Medical Center
  

ð Definition of AOM
ð Pain Management
ð Initial Observation vs. Antibacterial treatment
ð Antibiotic Choice
ð Preventative Measures



ð Acute otitis media (AOM) is the most common
infection for which antibacterial agents are
prescribed for children in the United States.

ð Office visits for OM (was) 16 million in 2000

ð 802 antibacterial prescriptions per 1000 visits for

a total of more than 13 million prescriptions in
2000.

ð An individual course of antibacterial therapy can

range in cost from $10 to more than $100 3-5
 
ð Diagnosis and management of uncomplicated AOM.
Based on the AAP Policy Statement: Diagnosis and
Management of Acute Otitis Media7

ð Ages 2 months to 12 years

ð No signs/symptoms of systemic illness unrelated to

the middle ear

ð Otherwise healthy child without underlying conditions

that may alter the natural course of AOM
‰
ð Pathogenic bacteria isolated in ~ 65Î75% of
cases

ð ühree pathogens predominate:

Streptococcus pneumoniae (40%)
nontypable Haemophilus influenzae (25Î30%)
÷oraxella catarrhalis (10Î15%)

ð Respiratory viruses may also be found, either

alone or, more commonly, in association with
pathogenic bacteria 6
! 



ð üo diagnose AO÷ the clinician should:

† confirm a history of acute onset

† identify signs of middle ear effusion
† evaluate for the presence of signs and
symptoms of middle-ear inflammation


ð Recent, usually abrupt and rapid onset of signs and
symptoms of middle-ear inflammation and MEE

ð Symptoms include:
Otalgia, or pulling of the ear in an infant
Irritability in an infant or toddler
Otorrhea, and/or fever

ð ühese findings, other than otorrhea, are nonspecific and

frequently overlap those of an uncomplicated viral URI

ð üherefore, clinical history alone is poorly predictive of the

presence of AOM, especially in younger children
| ‰
‰

ühe presence of MEE is indicated by any of the following:

a. Bulging of the tympanic membrane

(highest predictive value for the presence of MEE)

b. Limited or absent mobility of the tympanic membrane

c. Air-fluid level behind the tympanic membrane

d. Otorrhea
| ‰



Signs or symptoms of middle-ear inflammation is indicated by:

a. Distinct erythema of the tympanic membrane or

b. Distinct otalgia: discomfort clearly referable to the ear[s]

that results in interference with«normal activity or sleep
 üRANSLAüION:
You have to dig out the earwax!
You have to perform pneumatic otoscopy!!

 

 

Ossicles

üM intact, no
effusion/erythema, no
fluid level, no bulge

Light Reflex
7
 V
  


  

! "#

AAP: Redness of the tympanic membrane caused by inflammation

may be present and must be distinguished from the pink
erythematous flush evoked by crying or high fever, which is
usually less intense and remits as the child quiets down.
! 
$



ühe management of AOM should include an

assessment of pain. If pain is present, the
clinician should recommend treatment to
reduce pain.
! 
%|  & 


Observation without use of antibacterial agents in

a child with uncomplicated AOM is an option for
selected children based on:

ð diagnostic certainty
ð age
ð illness severity
ð assurance of follow-up
  && 


Age Certain Uncertain

Diagnosis Diagnosis
< 6 mo Ab¶ic tx Ab¶ic tx

6 mo ± 2 y Ab¶ic tx Ab¶ic tx if severe illness

or observation if
nonsevere illness

>2y Ab¶ic tx if severe Observation

illness or
observation if
nonsevere illness
  
 

ð ühe likelihood of recovery without antibacterial therapy differs
depending on the severity of signs and symptoms at initial
examination.

ð «current evidence does not suggest a clinically important

increased risk of mastoiditis in children when AOM is
managed only with initial symptomatic treatment without
antibacterial agents.

 '(
)
ð Vhen considering (observation), the clinician should verify
the presence of an adult who will reliably observe the child,
recognize signs of serious illness, and be able to provide
prompt access to medical care if improvement does not
occur.

ð If there is worsening of illness or if there is no improvement in

48 to 72 hours while a child is under observation, institution
of antibacterial therapy should be considered.
! 
%| * 
ð ëf a decision is made to treat with an
antibacterial agent, the clinician should
Amoxicillin
prescribe ÚÚÚÚÚÚÚÚÚÚÚ for most children.

ð Vhen amoxicillin is used, the dose should be

80 to 90 mg/kg per day
____________________.
|+  &|

ð In patients who have severe illness (moderate to severe
otalgia or fever > 39°C) and in those for whom additional
coverage for ß-lactamase-positive Haemophilus influenzae
and ÷oraxella catarrhalis is desired, therapy should be
initiated with high-dose amoxicillin-clavulanate.

ð Approximately 50% of isolates of H flu and 100% of ÷

catarrhalis from the upper respiratory tract are likely to be ß-
lactamase (+). ~ 15% to 50% (average: 30%) of upper
respiratory tract isolates of S pneumoniae are also not
susceptible to PCN.
!
!
 

ð attendance at child care

ð recent receipt (less than 30 days) of antibacterial

treatment

ð age younger than 2 years

 |
 |+ 
ð If the patient is allergic to amoxicillin and the allergic reaction
was not a type I hypersensitivity reaction (urticaria or
anaphylaxis), cefdinir, cefpodoxime, or cefuroxime can be
used.

ð In cases of type I reactions, azithromycin or clarithromycin

can be used.

ð Ceftriaxone X 3 consecutive days either IV or IM, can be used

in children with vomiting or situations that preclude
administration of PO antibiotics.





ð §or younger children and for children with severe disease, a

standard 10-day course is recommended.

ð §or children 6 years of age and older with mild to moderate

disease, a 5- to 7-day course is appropriate.
! 
,| '


ð If the patient fails to respond to the initial
management option within 48-72 hours, reassess
the patient to confirm AOM and exclude other
causes of illness.

ð If AOM is confirmed in the patient was initially

managed with observation, begin antibacterial
therapy.

ð If the patient was initially managed with an

antibacterial agent, change the antibacterial
agent.
| '


ð A patient who fails amoxicillin-potassium clavulanate should
be treated with a 3-day course of parenteral ceftriaxone.

ð If AOM persists, tympanocentesis should be recommended

to make a bacteriologic diagnosis.

ð If tympanocentesis is not available, a course of clindamycin

may be considered.
! 
-
 
ð linicians should encourage the prevention of
AO÷ through reduction of risk factors
† Administering the influenza vaccine
† reducing the incidence of respiratory tract
infections by altering child care center
attendance
† implementation of breastfeeding for at least the
first 6 months, avoiding supine bottle feeding
† reducing or eliminating pacifier use in the second
6 months of life
† eliminating exposure to passive tobacco smoke
! 
.*
+

ð o recommendations for complementary and

alternative medicine (A÷ for treatment of AO÷
are made based on limited and controversial
data.




ð Diagnose AOM
ð Manage the pain
ð Decide on observation vs. antibacterial
treatment
ð Choose an antibiotic
ð Monitor and follow up
ð Encourage preventative measures
V*

u
 
      
 ! "#" Pediatr Infect Dis J.
u$$%&u'()*+Î)*,
- .! "  !! (/"0
1! %" 
. !2-33+4 5 %%+u
' 11 "(
"1 u$)+Î$3 Adv Data.
u$$-&-u%(uÎu,
% . 6 7"#6 
4 " (-333
 Adv Data. -33-&'-,(uÎ'-
+ .!8 9: /!  ;"44!
""" JAMA. -33-&-,)('3$*Î'u3-
* 9 " 
;<4" u)" . !2
-33%1" 5 -u',
) 8" 
14" "5
6  -33*84&-+=->(u3u)

, 14!" .

?" " u''
 +  -33%