PNP: Acute Otitis Media
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A diagnosis of AOM requires?
- 1) a history of acute onset of signsand symptoms,
- 2) the presence of MEE, and
- 3) signs andsymptoms of middle-ear inflammation
Elements of the definition of AOM are all of the following:
- 1. Recent, usually abrupt, onset of signs and symptoms of middle-ear inflammation and MEE
- 2. The presence of MEE that is indicated by any of the following:
- a. Bulging of the tympanic membrane
- b. Limited or absent mobility of the tympanic membrane
- c. Air-fluid level behind the tympanic membrane
- d. Otorrhea
- 3. Signs or symptoms of middle-ear inflammation as indicated by either
- a. Distinct erythema of the tympanic membrane or
- b. Distinct otalgia (discomfort clearly referable to the ear[s]that results in interference with or precludes normal activity or sleep)
What is the highest predictive value for the presence of MEE? ...for AOM?
Fullness or bulging of thetympanic membrane is often present and has the highest predictive value for the presence of MEE.When combined with color and mobility, bulging is also the best predictor of AOM.
If one is having trouble determining the diagnosis of AOM and AOE, what can one use to help determine the diagnosis?
Acoustic reflectometry can be helpful, because it requires no seal of the canal and can determine the presence of middle-ear fluid through only a small opening in the cerumen.
Pain management must be addressed in children with otalgia. What may be offered for pain relief?
Tylenol or Motrin
What is the recommendations for children 6 months to 2 years of age with nonsevere illness at presentation and an uncertain diagnosis and to children 2 years of age and older without severe symptoms at presentation or with an uncertain diagnosis?
- Waiting 48 - 72 hours with a means of rechecking the ears for follow-up and being able to obtain the medication if necessary.
- The association of age younger than 2 years with increased risk of failure of watchful waiting and the concern for serious infection among children younger than 6 months influence the decision for immediate antibacterial therapy.
What is severe illness classified?
Nonsevere illness is mild otalgia and fever 39°C in the past 24 hours. Severe illness is moderate to severe otalgia or fever 39°C.
What is the drug of choice for AOM?
When amoxicillin is used, the dose should be 80 to 90mg/kg per day.
What is the drug of choice for patients who have severe illness (moderate to severe otalgia or fever of 39°C or higher) and in those for whom additional coverage for -lactamase–positive Haemophilus influenzae and Moraxella catarrhalisis desired?
Therapy should be initiated with high-dose amoxicillin-clavulanate (90 mg/kg perday of amoxicillin component, with 6.4 mg/kg perday of clavulanate in 2 divided doses).
What is the common pathogens in AOM?
Streptococcus pneumoniae,nontypeable H influenzae, and M catarrhalis
What is the common virual pathogen found with AOM?
respiratory syncytial virus, rhinovirus, coronavirus, parainfluenza, adenovirus, and enterovirus,
What has caused a decrease in AOM?
heptavalent pneumococcal vaccine
Risk factors for the presence of bacterial species likely to be resistant to amoxicillin include:
- attendance at childcare,
- recent receipt (less than 30 days) of antibacterial treatment,
- and age younger than 2 years
If the patient is allergic to amoxicillin and the allergic reaction was not a type I hypersensitivity reaction (urticaria or anaphylaxis) what Abx can be used?
- cefdinir (14mg/kg per day in 1 or 2 doses),
- cefpodoxime (10mg/kg per day, once daily),
- or cefuroxime (30mg/kg per day in 2 divided doses) can be used.
What Abx can be used for a Type 1 reaction (Uticaria or anaphylaxis)?
- azithromycin (10 mg/day on day 1 followed by 5 mg/kg per day for 4 days as a single daily dose)
- or clarithromycin (15 mg/kg per day in 2 divided doses) kg per
- erythromycin-sulfisoxazole(50 mg/kg per day of erythromycin)
- or sulfamethoxazole-trimethoprim (6–10 mg/kg per day of trimethoprim)
- Penicillin-allergic patient Txed for (S pneumoniae that is PCN
- resistant) is clindamycin at 30to 40 mg/kg per day in 3 divided doses.
- In the patient who is vomiting or cannot otherwise tolerate oral medication, a single dose of parenteral ceftriaxone (50 mg/kg) has been shown to be effective for the initial treatment of AOM.
How long does one Tx with an Abx?
- For children <5y/o = 10 days
- For chidren >6y/o = 5 - 7 days
If child fails to respond in 48 - 72 hours, what should the clinician do?
- If on Abx therapy - change the Abx
- If not on Abx therapy - start Abx therapy
A patient who fails amoxicillin-potassium clavulanateshould be treated with
A 3-day course of parenteral ceftriaxone (Ceftriaxone 50 mg/kg per day, given for 3 consecutive days either intravenously or intramuscularly) because of its superior efficacy against S pneumoniae, compared with alternative oral antibacterials.
Why should assurance that OME resolves be particularly important for children with cognitive or developmental delays?
they may be impacted adversely by transient hearing loss associated with MEE.
A number of factors are shown to be associated with increased AOM. What are these factors?
- genetic predisposition,
- premature birth,
- male gender,
- Native American/Inuit ethnicity,
- family historyof recurrent otitis media,
- presence of siblings in the household,
- and low socioeconomic status.
How might one decrease the incidence of this population in getting AOM?
- Alternating the stay of day care centers (staying away from those with upper respiratory infections)
- Breast feeding for at least the first 6 months
- Avoiding propping up the bottle when bottle feeding
- Reducing or eliminating a pacifier the 2nd 6mo of life
- Eliminating exposure to passive tobacco smoke
- Immunoprophylaxis with killed and live-attenuated intranasal influenza vaccines has demonstrated more than 30% efficacy in prevention of AOM during the respiratory illness season.
- Pneumococcalconjugate vaccines have proven effective in preventing vaccine-serotype pneumococcal otitis media
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