Transcript Acute Otitis Media

Acute Otitis Media
Continuity Clinic
Objectives
• Define otitis media (OM), acute otitis
media (AOM) and otitis media with
effusion (OME)
• Be familiar with the epidemiology of AOM
• List causative pathogens in children with
AOM and current bacteriologic resistance
patterns
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1999 7th International Symposium on Recent Advances in Otitis Media
Terms and Definitions
Otitis Media (OM)
Inflammation of the middle ear without reference to cause or pathogenesis.1
Middle Ear Effusion (MEE)
Liquid in the middle ear but not the etiology, pathogenesis, or duration (recent onset,
acute, subacute or chronic).1
 Serous: thin, watery liquid
 Mucoid: a thick, viscid mucus-like liquid
 Purulent: a pus-like liquid
 A combination of these
Otitis Media with Effusion (OME)
Inflammation of the middle ear with a collection of liquid in the middle ear space.
Signs and symptoms of acute infection absent.1
Serous, secretory or non-suppurative otitis media are terms that are no longer
recommended.
Acute Otitis Media (AOM)
Inflammation of the middle ear that is of rapid and short onset in association with
signs and symptoms indicating acute infection. The tympanic membrane is full or
bulging, opaque, and has limited mobility. Erythema is an inconsistent finding.1
One or more local or systemic signs are present: otalgia, otorrhea, fever, irritability,
anorexia, vomiting or diarrhea.
Otorrhea
Discharge from:1
 external auditory canal
 middle ear
 mastoid
 inner ear or intracranial cavity
Eustachian Tube Dysfunction
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Middle ear disorder that can have symptoms similar to otitis media, such as hearing
loss, otalgia, and tinnitus, but middle ear effusion is usually absent.1
Distinguishing AOM from OME
At least two of :
1. Abnormal color: white, yellow,
amber, blue
2. Opacification not due to scarring
3. Decreased or absent mobility
Yes
Or
Bubbles or air-fluid interfaces
behind the TM
Acute purulent otorrhea
not due to otitis externa
Yes
Middle Ear Effusion
(MEE)
No Acute
Inflammation
Acute
Inflammation
1. Distinct fullness or bulging of the TM
2. Substantial ear pain, including
unaccustomed tugging or rubbing of
the ear
3. Distinct erythema of the TM
Yes
Otitis Media with Effusion
(OME)
Acute Otitis Media
(AOM)
Hoberman A. Clinical Pediatr 2002;41:373-390 (reprinted with permission)
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Yes
Prevalence of Otitis Media
• 1993 - 1995 (NCHS),2 OM accounted for
 18% ambulatory visits (1-4 yr)
 14% visits during the 1st yr of life
• AOM episodes diagnosed2
 81% in pediatric practices
 13% in hospital ED
 6% in hospital outpatient departments
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Prevalence of Otitis Media
• Peak incidence of OM occurs during the first 2
years
• 60%-70% of children have >1 AOM before 1st
birthday4,5
• Early onset (<6 mo) associated with recurrent
AOM and chronic OME
• Recurrent AOM, >3 episodes/6 mo or >4
episodes/yr, ~ 20% of children
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Prevalence of Otitis Media
 AOM and OME, segments of a disease
continuum7
 Mean cumulative time with MEE (AOM or
OME)5

20.4% in 1st yr

16.6% in 2nd yr
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Risk Factors for OM
• Host factors




Age/Gender
Genetic predisposition
Cleft palate/Down syndrome
Allergy/Immunity
• Environmental factors






Daycare/Siblings
Bottle (versus breast) feeding
Pacifier use
Smoking
Low socioeconomic status
Season/Upper respiratory infections
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Host-Related Risk Factors
Age/Gender
 AOM most prevalent between 6 and 11 mo
 Shorter, horizontal lying eustachian tube
 Males, higher cumulative time with OME
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Environmental Risk Factors
Day Care Attendance
 Most important risk factor
 50-70% children 6-18 mo attending day care have
bilaterally persistent OME
 Number of children in day care, hours spent, age
at entry and siblings in daycare influence risk
 Day care increases risk of infection, use of
antibiotics, thus increasing selection of resistant
organisms
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Environmental Risk
Factors
Exposure to Household Cigarette Smoke
 Positive relationship between smokers in
household and OM during 1st but not 2nd year5
 Increased levels of cotinine in saliva correlated
with abnormal tympanograms and number of
smokers
 Association between early AOM onset and
cotinine in urine not found
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Pathophysiology of AOM
Otitis Media
Infection
Host Factors
Anatomic/Physiologic
Dysfunction
• Immature/impaired
immunology
• Familial predisposition
• Type of milk (breast
or formula)
• Gender
• Race
•
Eustachian tube
dysfunction
• Cleft Palate
Allergy
Environmental
Factors
Bluestone CD. Pediatr Infect Dis J. 1996:15:281-291 (reprinted with permission)
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Pathophysiology of AOM
• Eustachian tube (ET) functions include ventilation,
protection and clearance of secretions
• Impairment ET function MEE
• URI  inflammation of nasopharynyx (NP) and ET
• Inflammation  ET dysfunctionnegative middle
ear pressure
• Organisms colonizing NP aspirated into middle ear
resulting in AOM
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Microbiology: Antimicrobial
Resistance
Resistant (MICs 2 µg/mL)
Intermediate (MICs 0.12-1 µg/mL)
35
Resistance (%)
30
25
20
15
10
5
0
Year
1988-891 1990-911 1992-931 1994-952 1997-982 1999-002 2001-023
# Isolates
476
524
799
1527
1601
1531
1925
1.
2.
3.
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Doern GV. Am J Med. 1995; 99:3S-7S
Doern GV. ACC. 2001;45:1721
Doern GV. Unpublished data
Bacterial Resistance Against β-Lactam Abx
Peptidoglycan cell wall
β-lactamase
enzymes inactivate
β-lactam antibiotics
Plasma membrane
Altered PBPs
Cytoplasm
Clavulanic acid
irreversibly binds to
β-lactamase protecting
β-lactam antibiotics from
enzymatic cleavage
Antibiotic
β-lactamase
Clavulanic acid
Resistance increases
as altered PBPs
accumulate
Normal PBP
Altered PBP
Jacobs MR. Am J Manag Care. 1999;5(suppl 11):S651-S661
.
Bacterial Resistance Against
Macrolides
Bacteria alter macrolide binding site
(ermAM gene, MLSB phenotype)

Macrolide unable to block protein synthesis
Bacterial efflux pumps
(mefE gene, M phenotype)

Macrolide excreted from cell
Ribosomes
50
30
50
30
50
30
Cytoplasm
Jacobs MR. Am J Manag Care. 1999;5(suppl 11):S651-S661
Macrolide
Antibiotic Options
• 1st Line
– Amoxicillin : low versus high dose
– Augmentin
– PC allergy  Zithromax
• 2nd Line
– Cephalosporins
– Zithromax
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The Observation Option
Limited to healthy kids over the age of 6mos
May observe age group 6 months to 2 years if
AOM is uncertain and pt has nonsevere illness.
What defines a severe illness?
fever ≥ 39 C or 102.2 F, severe otalgia
Older than 2 years if nonsevere illness
Family has access to doctor, and family
member to close eye on patient
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A picture is worth a
thousand words…….
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Acute Otitis Media?
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Acute Otitis Media?
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What is your diagnosis?
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What is your diagnosis?
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Bonus Question -What is this?
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