Otitis Media

Definition of Acute OM

A diagnosis of AOM requires:

  • Recent, usually abrupt, onset of signs and symptoms of middle-ear inflammation and MEE
  • The presence of MEE that is indicated by any of the following:
  • Bulging of the tympanic membrane
  • Limited or absent mobility of the tympanic membrane
  • Air-fluid level behind the tympanic membrane
  • Otorrhea
  • Signs or symptoms of middle-ear inflammation as indicated by either
  • Distinct erythema of the tympanic membrane or
  • distinct otalgia (discomfort clearly referable to the ear[s] that results in interference with or precludes normal activity or sleep)
  • Random Points

    Otalgia

    Watchful Waiting

    About 80% of otherwise healthy kids with acute otitis media get better without antibiotics. The American Academy of Pediatrics and American Academy of Family Physicians now recommend "watchful waiting" for some kids.

    Placebo-controlled trials of AOM over the past 30 years have shown consistently that most children do well, without adverse sequelae, even without antibacterial therapy. By 24 hours, 61% of children have decreased symptoms whether they receive placebo or antibacterial agents. By 7 days, approximately 75% of children have resolution of symptoms. Watchful waiting and mastoiditis; 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. Clinicians should remain aware that antibacterial-agent treatment might mask mastoiditis signs and symptoms, producing a subtle presentation that can delay diagnosis. The potential of antibacterial therapy at the initial visit to shorten symptoms by 1 day in 5% to 14% of children can be compared with the avoidance of common antibacterial side effects in 5% to 10% of children, infrequent serious side effects, and the adverse effects of antibacterial resistance. 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.

      (From PEDIATRICS Vol. 113 No. 5 May 2004, pp. 1451-1465)

    Therapy

    Common Pathogens:

    The results favoring standard 10-day therapy have been most significant in children younger than 2 years and suggestive of increased efficacy in those 2 to 5 years of age. Thus, for younger children and for children with severe disease, a standard 10-day course is recommended. For children 6 years of age and older with mild to moderate disease, a 5- to 7-day course is appropriate. Stepwise pattern (if one fails, try the next): 

    1. watchful waiting
    2. amoxicillin 80-90 mg/kg/da
    3. amox-clavulanate: 90 mg/kg/d amox (start here for temp >39 or severe otalgia)b (consider OMNICEF (cefdinir))
    4. A patient who fails amoxicillin-potassium clavulanate should be treated with a 3-day course of parenteral ceftriaxone because of its superior efficacy against S pneumoniae, compared with alternative oral antibacterials
    5. If AOM persists, tympanocentesis should be recommended to make a bacteriologic diagnosis.
    6. If tympanocentesis is not available, a course of clindamycin may be considered for the rare case of penicillin-resistant pneumococcal infection not responding to the previous regimens. If the patient still does not improve, tympanocentesis with Gram-stain, culture, and antibacterial-agent sensitivity studies of the fluid is essential to guide additional therapy
    7. Special cases

    a.The justification to use amoxicillin as first-line therapy in most patients with AOM relates to its general effectiveness when used in sufficient doses against susceptible and intermediate resistant pneumococci as well as its safety, low cost, acceptable taste, and narrow microbiologic spectrum. Only S pneumoniae that are highly resistant to penicillin will not respond to conventional doses of amoxicillin. Accordingly, approximately 80% of children with AOM will respond to treatment with high-dose amoxicillin, including many caused by resistant pneumococci. The higher dose will yield middle-ear fluid levels that exceed the minimum inhibitory concentration of all S pneumoniae that are intermediate in resistance to penicillin and many, but not all, highly resistant S pneumoniae. Risk factors for the presence of bacterial species likely to be resistant to amoxicillin include attendance at child care, recent receipt (less than 30 days) of antibacterial treatment, and age younger than 2 years.

    b. This dose has sufficient potassium clavulanate to inhibit all ▀-lactamase-producing H influenzae and M catarrhalis. Note: per Sept 2004 Pediatric news, 3rd gen cephalosporins cefdinir (better tasting, once/day) and cefpodoxime (bad tasting) are highly effective against H. flu and other B-lactamase producing organisms, and have less gastrointestinal upset.

    c. Sept 2004 Pediatric news: because of PCV7 vaccination, there is an upward trend of H. flu infection in response to the decrease in strep. Standard doses of azithro has marginal B-lactamase coverage, but recent data suggest that a double dose of azithromycin 20/kg/d x 3d, is as effective as augmentin in kids < 2yo and under w/ persistent or recurrent AOM.  (Antimicrob. Agents Chemother. 47[10]:3179-86, 2003).

    Persistent Middle Ear Effusion

    Persistent MEE after resolution of acute symptoms is common and should not be viewed as a need for active therapy. OME must be differentiated clinically from AOM and requires additional monitoring but not antibacterial therapy. Assurance that OME resolves is particularly important for children with cognitive or developmental delays that may be impacted adversely by transient hearing loss associated with MEE.

    Prevention

    Source:
    CLINICAL PRACTICE GUIDELINE
    Diagnosis and Management of Acute Otitis
    Media
    Subcommittee on Management of Acute Otitis Media
    PEDIATRICS Vol. 113 No. 5 May 2004, pp. 1451-1465

    Antibiotic Resistance

    References:
    Baquero F, Loza E. Antibiotic resistance of microorganisms involved in
    ear, nose and throat infections. Pediatr Infect Dis J. 1994;13(suppl
    1):S9-S14
    Dowell SF, Butler JC, Giebink GS, et al. Acute otitis media:
    management and surveillance in an era of pneumococcal
    resistanceŚreport from the Drug-resistant Streptococcus pneumoniae
    Therapeutic Working Group. Pediatr Infect Dis J. 1999;18:1-9
    Dowell SF, Marcy SM, Phillips WR, Gerber MA, Schwartz B. Otitis
    mediaŚprinciples of judicious use of antimicrobial agents. Pediatrics.
    1998;101(suppl):S165-S171
    Rosenfeld RM, Vertrees JE, Carr J, et al. Clinical efficacy of
    antimicrobial drugs for acute otitis media: metaanalysis of 5400
    children from thirty-three randomized trials. J Pediatr.
    1994;124:355-367