Pediatric Infectious Diseases - Acute Otitis Media

Question 1

Risk factors for AOM

Answer 1

-Smoke exposure
-Formula feeding
-Immunization status
-Atopy
-Daycare attendance
-Male gender
-Family history
-Onset of first episode before 6-12 months of age (earlier means higher risk)
-Whites
-Lower socioeconomic status
-Congenital anomalies
-Immune deficiency

Question 2

What is otitis media with effusion (OME)?

Answer 2

-Middle ear fluid is sterile; no signs of acute infection
-Antibiotics not indicated and not beneficial

Question 3

What is acute otitis media (AOM)?

Answer 3

-Bacterial infection likely
-Antibiotics indicated if symptomatic

Question 4

Most common organisms in AOM

Answer 4

-Strep pneumoniae
-Heamophilus influenzae
-Moraxella catarrhalis

Question 5

Which vaccine is recommended for all babies

Answer 5

Pneumococcal vaccine

Question 6

Clinical manifestations of AOM

Answer 6

-Otalgia (ear pain)
-Holding or tugging at ear
-Fever
-Irritability
-Poor feeding/anorexia
-Disrupted sleep
-Malaise
-Otorrhea (ear discharge)
-Sometimes asymptomatic

Question 7

How do you diagnose AOM?

Answer 7

Look at the tympanic membrane

Question 8

What does a normal tympanic membrane look like?

Answer 8

-Slightly concave
-Pearly gray in color
-Transluscent
-Moves in response to pressure

Question 9

What does a tympanic membrane look like in AOM?

Answer 9

-Bulging
-Cloudy or purulent effusion
-Immobile

Question 10

What must be present to diagnose AOM?

Answer 10

-Acute onset
-Middle ear effusion
-Symptoms of middle ear inflammation

Question 11

In what cases would you not treat AOM

Answer 11

-Non-severe, unilateral and between 6 months to 2 years old
-Non-severe older than 2 years old regardless of bilateral vs unilateral

Question 12

What do you do when observing?

Answer 12

-Defer antibiotics for 48-72 hours
-Watch for resolution of symptoms
-Provide symptomatic relief

Question 13

What do you do if observation fails?

Answer 13

-Communicate with physician
-Begin antimicrobial therapy
-Continue symptomatic therapy

Question 14

What is a Safety-Net Antibiotic Prescription (SNAP)

Answer 14

Allows parents 1-2 days for infection to resolve and if it does not then they can fill the prescription

Question 15

How are bacterial resistances overcome in the treatment of AOM?

Answer 15

-Strep pneumoniae penicillin resistance is overcome by using high dose amoxicillin (first line)
-Haemophilus influenzae and moraxella catarrhalis are overcome by using a beta-lactamase inhibitor like Augmentin (second line)

Question 16

What is the first-line drug of choice for AOM?

Answer 16

High dose amoxicillin

Question 17

Dose of first-line treatment of AOM

Answer 17

80-90 mg/kg/day divided Q12H for 5-10 days

Question 18

Advantages of amoxicillin in AOM

Answer 18

-In the middle ear high dose amox concentrations exceed MIC in S. pneumoniae resistant to penicillin
-Safe, effective, inexpensive
-Half-life of 4-6 hours in middle ear (1 hour in serum)

Question 19

When would we not use high dose amoxicillin in AOM?

Answer 19

-Known resistance
-Treatment failure
-Amoxicillin in last 30 days
-Allergy
-Concurrent conjunctivitis

Question 20

What is second-line treatment for AOM?

Answer 20

-Augmentin
-Cefpodoxime (may be first if allergic to amoxicillin)

Question 21

What is the Augmentin dose for AOM?

Answer 21

90 mg/kg/day of amox component divided Q12H

Question 22

Advantages of Augmentin in AOM

Answer 22

Additional coverage for beta-lactamase producing organisms

Question 23

Disadvantages of Augmentin in AOM

Answer 23

-May be more expensive
-Diarrhea associated with clavulanate (dose clavulanate at 10 mg/kg/day or less)

Question 24

Which form of Augmentin must be picked?

Answer 24

ES version so that way clavulanate can stay under 10 mg/kg/day

Question 25

Cefpodoxime dose

Answer 25

10 mg/kg/day divided Q12H

Question 26

When is ceftriaxone used in AOM?

Answer 26

-Third line -Only used in severe cases where oral treatment is not an option or oral treatment fails

Question 27

Ceftriaxone dosing for AOM

Answer 27

-50 mg/kg daily IM -One dose initial therapy -Three doses if treatment failure

Question 28

What are the alternative agents for AOM?

Answer 28

-Clindamycin -Levofloxacin -Macrolides (erythromycin and azithromycin) -Bactrim

Question 29

When would you use alternative therapy in AOM?

Answer 29

-Repeated treatment failure (get a culture) -If cephalosporin anaphylaxis

Question 30

Dosing for clindamycin

Answer 30

30-40 mg/kg/day divided TID

Question 31

In what cases would you need to treat AOM for 10 days?

Answer 31

-Severe or recurrent AOM -TM perforation -Less than 2 years

Question 32

What duration of therapy would you use for patients with AOM older than 2 years old or not severely ill?

Answer 32

5-7 days

Question 33

What adjunctive therapy could you give to children with AOM?

Answer 33

-APAP PO -Ibuprofen PO -Lidocaine otic drops

Question 34

APAP PO dosing for AOM

Answer 34

10-15 mg/kg/dose Q4-6H

Question 35

Ibuprofen PO dosing for AOM

Answer 35

5-10 mg/kg/dose Q6-8H

Question 36

When should you not use lidocaine otic drops?

Answer 36

-In ruptured TM or tubes -Children less than 2 years old

Question 37

What medications are not routinely recommended for patients with AOM?

Answer 37

-Decongestants/antihistamines (may be useful in URI, caution in under 4 years old) -Dexamethasone (Not routine) -Otikon otic solution (Need more data) -Sweet oil (can cause bacterial growth)

Question 38

When should you follow-up with young infants with severe episodes or any children with continuing pain?

Answer 38

Within days

Question 39

When should you follow-up with infants or young children with history of frequent recurrences?

Answer 39

2 weeks

Question 40

When should you follow-up with children who have sporadic episodes of AOM?

Answer 40

One month

Question 41

When should you follow-up with older children?

Answer 41

No follow-up needed

Question 42

How do you prevent AOM?

Answer 42

-Routine vaccination (pneumococcal and influenza) -Reduction of preventable risk factors -Prophylaxis -Tympanostomy tubes

Question 43

What are tympanostomy tubes?

Answer 43

Small ventilation tubes inserted through TM to provide drainage of eustachian tubes

Question 44

When are tympanostomy tubes indicated?

Answer 44

-3 or more episodes in less than 6 month olds -4 or more episodes in less than 12 month olds

Question 45

What is chronic suppurative otitis media?

Answer 45

Perforated TM with persistent drainage lasting more than 6 weeks

Question 46

What is the most common isolate in CSOM?

Answer 46

MRSA

Question 47

How do you treat CSOM?

Answer 47

Ofloxacin or cipro ear drops for 2 weeks

Question 48

What can cause acute otitis externa?

Answer 48

Trauma or trapped moisture

Question 49

What organisms can be present in AOE?

Answer 49

-Pseudomonas -S. aureus -Consider fungal if no improvement

Question 50

How do you treat AOE?

Answer 50

(treat with ear drops first) -Polymyxin B, neomycin, and hydrocortisone -Ofloxacin -Cipro with hydrocortisone