Otitis media peds

SELECT INTERVENTION IN AT-RISK CHILDREN with otitis media with effusion

Tympanostomy if chronic bilateral OME (3 mo or longer) with documented hearing difficulty and recurrent AOM with unilateral or bilateral middle ear effusion. Adenoidectomy can be considered in children ≥4 years with recurrent OME.

WATCHFUL WAITING, CONSISTING OF ANALGESIA WITHOUT ANTIMICROBIAL THERAPY, IS AN ACCEPTABLE TREATMENT OPTION IN AOM

Low risk for adverse outcome without antimicrobial therapy • High rate of spontaneous AOM resolution without antimicrobial therapy or worsening of symptoms • Watchful waiting is only appropriate for the child ≥6 months with non- severe illness based on joint decision making with parents/caregivers for unilateral AOM • If watchful waiting is used, the follow-up must be ensured with ability to start antibiotic therapy within 48-72 hr if symptoms do not improve or worsen

Nonsevere illness:

Mild otalgia for <48 hr Or Fever <39°C (<102.2°F) in the past 24 hr

DIAGNOSIS OF AOM IN CHILDREN

Moderate or severe bulging of tympanic membrane (TM) OR new onset of otorrhea not related to otitis externa (OE) with otalgia • Mild bulging of TM AND recent (≤48 hr) onset of ear pain (in nonverbal child—tugging, holding, rubbing) OR intense TM erythema with otalgi

Severe illness:

Moderate to severe otalgia Or Otalgia for >48 hr Or Fever ≥39°C (≥102.2°F)

Presentation can also include

bulging of TM and recent (≤48 hours) onset of ear pain (seen as tugging, holding, rubbing in a nonverbal child) or intense TM erythema with otalgia. Distinct otalgia with discomfort clearly referable to the ear results in interference with or precludes normal activity or sleep.

Which of the following must be present for the diagnosis of AOM? More than one can apply.

bulging of the tympanic membrane (TM) otalgia

The components of AOM include objective findings such as a

bulging, erythematous tympanic membrane (TM) with limited or absent mobility on insufflation, or otorrhea unrelated to otitis externa.

Streptococcus pneumoniae (49%), Haemophilus influenzae (29%), Moraxella catarrhalis (28%), and various respiratory tract viruses

contribute to the infectious and inflammatory processes of the middle ear.

A potential complication resulting from prolonged OME includes:

delay in language development.

Which of the following is usually absent in otitis media with effusion (OME)?

fever

Which of the following criteria should be met for a child to be treated for AOM with observation and analgesia but no antimicrobial therapy? (Choose all that apply.)

age greater than 6 months nonsevere illness

. Passive cigarette smoke exposure, feeding in a supine position, and pacifier use beyond age 10 months

likely also predispose a child to AOM secondary to eustachian tube dysfunction or eustachian tube obstruction.

Amoxicillin

remains the first-line antimicrobial for AOM treatment for the majority of children who do not have penicillin (PCN) allergy.

Eustachian tube obstruction caused by an upper respiratory viral illness

remains the most common predisposing factor for developing AOM.

Otitis media with effusion (OME) typically clears by afterAOM.

8 weeks

A 3-year-old boy with AOM continues to have otalgia and fever (≥39°C [≥102.2°F]) after 3 days of amoxicillin 80 mg/kg/day with an appropriate dose of clavulanate (Augmentin®) therapy. Which of the following is recommended?

Administer intramuscular ceftriaxone.

FIRST-LINE TREATMENT

Amoxicillin (80-90 mg/kg/day in 2 divided doses) OR Amoxicillin-clavulanate (90 mg/kg/day of amoxicillin, with 6.4 mg/kg/day of clavulanate in 2 divided doses)

ANTIBIOTIC TREATMENT AFTER 48-72 HR OF FAILURE OF INITIAL ANTIBIOTIC TREATMENT

Amoxicillin-clavulanate (90 mg/kg/day of amoxicillin, with 6.4 mg/kg/day of clavulanate in 2 divided doses) OR Ceftriaxone (50 mg IM/IV for 3 days)

MANAGEMENT OF AOM SHOULD INCLUDE ASSESSMENT OF PAIN AND, IF PRESENT, CLINICIAN SHOULD RECOMMEND TREATMENT FOR PAIN MANAGEMENT

Analgesics: Acetaminophen or ibuprofen is recommended Topical anesthetic agent can provide short-term (approximately 30 min) pain relief

FIRST-LINE TREATMENT with PCN allergy

Cefdinir (14 mg/kg/day in 1 or 2 doses) OR Cefuroxime (30 mg/kg/day in 2 divided doses) OR Cefpodoxime (10 mg/kg/day in 2 divided doses) OR Ceftriaxone (50 mg IM or IV/day for 1 or 3 days)

ANTIBIOTIC TREATMENT AFTER 48-72 HR OF FAILURE OF INITIAL ANTIBIOTIC TREATMENT with PCN allergy

Ceftriaxone ×3 days (as above) OR Clindamycin (30-40 mg/kg/day in 3 divided doses) with or without a third generation cephalosporin Tympanocentesis Referral to specialist

Otitis Media With Effusion (OME)

Fluid in middle ear without signs or symptoms of ear infection

Causative Organisms in Acute Bacterial Otitis Media (AOM)

H. influenzae, M. catarrhalis, S. pneumoniae.

FIRST-LINE INTERVENTION with Otitis media with effusion

Watchful waiting in most 75%-90% resolve within 3 mo without specific treatment

Which of the following is the most prudent first-line treatment choice for an otherwise well toddler with acute otitis media (AOM) who requires antimicrobial therapy?

amoxicillin

The incidence of AOM in children has decreased in the past decade in part because of:

an increase in select vaccination use.

.Characteristics of S. pneumoniae include:

antimicrobial resistance because of altered protein binding sites.

Management of AOM should include

assessment of pain and, if present, the clinician should recommend treatment for pain management. Acetaminophen or ibuprofen can be used as analgesics.

Almost all cases of AOM are found to be caused either by

bacteria and viruses together (66%), bacteria alone (27%), or virus alone (4%).

Which of the following does not represent a risk factor for recurrent AOM in younger children?

beta-lactam allergy

Which of the following represents the best choice of clinical agents for a child with AOM who has had a history of penicillin allergy who requires antimicrobial therapy

cefdinir

In the treatment of acute otitis media in the child, which of the following antimicrobial agents affords the most effective activity against Streptococcus pneumoniae?

cefuroxime

Most AOM is caused by:

certain gram-positive and gram-negative bacteria and select respiratory viruses.

Although AOM remains the most common childhood condi- tion for which antibiotics are prescribed, the incidence of AOM and the resulting antimicrobial prescriptions have

decreased over the past decade as a result of many factors, including increased rates of pneumococcal and influenza vaccination.

conditions that cause eustachian tube dysfunction or eustachian tube obstruction, such as allergic rhinitis, upper respiratory infec- tion, and craniofacial abnormalities,

encourage status of secretions and allow aspiration of pharyngeal flora into the middle ear, resulting in AOM.

The main risk factor for AOM in infants is:

eustachian tube dysfunction.

Because children in day-care settings typically have more upper respiratory infections, attendance at group child care is also a

for nasopharyngeal carriage of bacteria implicated in AOM.

Otitis media with effusion (OME)

formerly known as serous otitis media, is defined as the presence of fluid in the middle ear in the absence of signs or symptoms of acute in- fection. With OME, 80% of children clear the middle ear by 8 weeks. If OME persists beyond 8 weeks, the presence of communication problems and other symptoms dictates the need for further evaluation and treatment

Characteristics of Moraxella catarrhalis include:

high rate of beta-lactamase production.

Observation as initial treatment is only appropriate

if child is >6 months, has nonsevere illness, and infection is unilateral. Observation should include assurance of follow-up, and appropriate analgesia should be provided

Acute Otitis Media (AOM)

is among the most frequent diagnoses noted in office visits in children younger than age 15 years.

. Characteristics of H. influenzae include

organism most commonly isolated from mucoid middle ear effusion.

The eustachian tubes

provide drainage of middle ear secretions and protection of the middle ear from pharyngeal secretions and bacterial contaminants.

Treatment of otitis media with effusion usually includes:

symptomatic therapy

In a child older than 3 months, otalgia, fever, and other symptoms

that persist beyond 48 to 72 hours of therapy can indicate treatment failure, and repeat evaluation is in order and a change in therapy is recommended.

Which of the following signs indicates possible AOM diagnosis in a preverbal child?

tugging on the ear

A treatment option for persistent OME is:

tympanostomy

An additional intervention to reduce AOM risk includes

universal childhood pneumococcal and influenza immunization.

Current guidelines recommend that clinicians should only offer tym- panostomy to children

with chronic bilateral OME (3 months or longer) with documented hearing difficulty and to those with recurrent AOM who have unilateral or bilateral middle. ear effusion (MEE).

Bottle feeding is a risk factor for AOM,

with rates significantly lower among infants who were breastfed for the first 6 to 12 months of life;