Transcript Discussion Recurrent Acute Otitis Media

Acute Otitis Media
Dr. Hamid Rahimi
Pediatric Infectious Disease Specialist
Acute Otitis Media
The most common infection for which antibacterial agents
are prescribed for children in the US
1/3 of office visits to pediatricians
Peak incidence 6 – 12 months old
≈ 2/3 of children experience at least one episode by 1 year old
Acute Otitis Media - Definitions
AOM is an inflammation of the middle ear associated with a collection of
fluid in the middle ear space (effusion) or a discharge (otorrhea)
Recurrent otitis
>3 episodes of AOM within 6 months that middle ear is normal, without
effusions, between episodes
Most children with recurrent acute otitis media are otherwise healthy
Otitis prone
Six or more acute otitis media episodes in the first 6 years of life
12% of children in the general population
Persistent Middle-Ear Effusion
When an episode of otitis media results in persistence of middle-ear fluid
for 3 months, & TM remains immobile
More common in white children & < 2 yo
AOM vs. COM
Chronic otitis media
Called chronic serous otitis in the past, this pattern is usually defined as
a middle-ear effusion that has been present for at least 3 months.
Some sort of eustachian tube dysfunction is the principal predisposing
factor.
Persistent structural changes, such as a persistent eardrum perforation,
imply past otitis but not necessarily chronic infection.
Acute otitis media is commonly defined as…
1. Presence of a middle ear effusion (MEE)
2. TM inflammation
3. Presenting with a rapid onset of symptoms such as fever, irritability, or
earache
Diagnosis
Etiologic diagnosis
Clinical diagnosis
Case one
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History
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One year old boy brought with cough, runny nose, and
fever.
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He is also tugging at his ear and appears to be very fussy.
Physical Exam
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T= 38 0C Ax.
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Upper respiratory tract sign & symptom
Normal TM
Gray
Pink
Describe TM appearance
What’s your advice?
1. Tell mother that he has a viral upper respiratory infection or
cold that will not benefit from treatment with antibiotics at this
time as he does not have an ear infection.
2. Tell mother that he has an ear infection that requires treatment
with antibiotics.
3. Explain to mother that he has a red ear drum. The redness is
probably caused by his cold but may also be the beginning of an
ear infection. You will need to examine him again in 2 days to
determine if he has an ear infection and needs antibiotics.
4. Explain to mother that you aren't sure whether Robert is
developing an ear infection. Since he has a fever you would
prefer to treat him with antibiotics. Something might be
brewing.
Clinical diagnosis
A diagnosis of AOM can be established if acute purulent
otorrhea is present and otitis externa has been excluded.
Presence of a middle ear effusion & acute signs of middle
ear inflammation in presence of acute onset of signs &
symptoms
History
Children with AOM usually present with …
History of rapid onset of otalgia (or pulling of the ear in an
infant), irritability, poor feeding in an infant or toddler, otorrhea,
and/or fever
Except otorrhea other findings are nonspecific i.e.
Fever, earache, and excessive crying present in children …
90%
72%
with AOM
without AOM
Laboratory tests
Routine laboratory studies, including complete
blood count and ESR, are not useful in the
evaluation of otitis media.
Otoscopy
The key to distinguishing AOM from OME is the
performance of pneumatic otoscopy using
appropriate tools and an adequate light source
Use of visual otoscopy alone is discouraged
Pneumatic otoscope - equipment
Technique
Systematic assessment of the TM by the use of the
COMPLETES mnemonic
Color
Other conditions
Mobility Position
Lighting
Entire surface
Translucency
External auditory canal and auricle
Seal
Normal tympanic membrane
Middle-Ear Effusion
MEE is commonly confirmed …
Directly by…
Tympanocentesis
Presence of fluid in the external auditory canal
Indirectly by…
Pneumatic otoscopy
Tympanometry
Acoustic reflectometry
Signs of presence of MEE
Signs of presence of MEE
Fluid level
Bobbles
Signs of presence of MEE
Perforation
Cobble stoning
Normal TM
Translucent
Signs of presence of MEE
Semi-opaque
Opaque
Normal TM
Gray
Pink
Signs of presence of MEE
Pale yellow
White
Signs of presence of MEE
Pneumatic otoscopy
Reduced or absent mobility of the tympanic membrane is
additional evidence of fluid in the middle ear
Tympanometry or acoustic reflectometry
Can be helpful in establishing a diagnosis when the presence of
middle-ear fluid is difficult to determine
Tympanometry
OME vs. AOM
Major challenge
Otitis Media with Effusion
Vs.
Acute Otitis Media
Signs & symptoms of middle-ear inflammation
Signs or symptoms of middle-ear inflammation indicated
by …
a.
Non – otoscopic findings
a. Distinct otalgia (discomfort clearly referable to the ear[s] that
results in interference with or precludes normal activity or
sleep)
b. However, these symptoms must be accompanied by abnormal
otoscopic findings
b.
Otoscopic findings
Acute inflammation – otoscopic findings
Signs of acute inflammation are necessary to differentiate AOM from
OME.
Distinct fullness or bulging
The best and most reproducible sign of acute inflammation
Marked redness of the tympanic membrane
Marked redness of the tympanic membrane without bulging is an unusual finding
in AOM.
Normal TM
Neutral
Signs of presence of MEE
Distinct fullness
Bulging
Normal TM
Gray
Pink
Signs of middle-ear inflammation
Injection
Marked redness
Usefulness of findings
Adjusted LR
95% CI
Bulging tympanic membrane
51
36-73
Cloudy tympanic membrane
34
28-42
Distinctly impaired tympanic membrane mobility
31
26-37
Distinctly red tympanic membrane
(hemorrhagic, strongly, or moderately red)
8.4
6.7-1
Findings
Predictive value of combinations of otoscopic findings
in children with acute ear symptoms
Normal TM
Neutral
Signs of presence of MEE
Distinct fullness
Bulging
Established acute otitis media
Differential diagnosis - 2
Other conditions
Redness of tympanic membrane
AOM
Crying
Upper respiratory infection with congestion and inflammation of the mucosa lining the
entire respiratory tract
Trauma and/or cerumen removal
Decreased or absent mobility of tympanic membrane
AOM and OME
Tympanosclerosis
A high negative pressure within the middle ear cavity
Ear pain
Otitis externa
Ear trauma
Throat infections
Foreign body
Temporomandibular joint syndrome
Uncertainty in diagnosis of AOM
The diagnosis of AOM, particularly in infants and
young children, is often made with a degree of
uncertainty.
Common factors …
Inability to sufficiently clear the external auditory canal of
cerumen
Narrow ear canal
Inability to maintain an adequate seal for successful
pneumatic otoscopy or tympanometry
An uncertain diagnosis of AOM is caused most often
by inability to confirm the presence of MEE.
Management
Case two
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A 1.5 year old boy, is brought into your office
because of cough, runny nose, and fever.
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Physical Exam
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T= 39 0C Ax.
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Upper respiratory tract sign & symptom
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The finding of pneumatic otoscopy are shown in next
slide…
Describe TM appearance & mobility
How would you manage this illness
episode?
1. Tell mother that his son has a viral upper respiratory
infection or cold that will not benefit from treatment with
antibiotics at this time as he does not have an ear infection.
2. Tell mother that his son has an ear infection that requires
treatment with antibiotics.
3. Tell mother that his son has an ear infection but doesn't need
treatment with antibiotics.
Clinical Course
The systemic and local signs and symptoms of AOM usually resolve in 24
to 72 hours with appropriate antimicrobial therapy, and somewhat more
slowly in children who are not treated.
However, middle ear effusion persisted for weeks to months after the onset
of AOM …
Among children who were successfully treated…
70% resolution of effusion within two weeks
90% up to 3 months
Symptomatic therapy - 1
Pain remedies
PO analgesics
Ibuprofen and acetaminophen
The efficacy of a topical agent
Auralgan (combination of antipyrine, benzocaine, and
glycerin)
The topical herbal extract Otikon Otic solution
Remedies such as distraction, external application of heat or
cold, and oil instilled into the external auditory canal have been
proposed, but there are no controlled trials that directly address
the effectiveness of these remedies
Symptomatic therapy - 2
Decongestants and antihistamines
Alone or in combination were associated with…
Increased medication side effects
Did not improve healing or prevent surgery or other
complications in AOM
Not approved by AAP for < 2 year old
In addition, treatment with antihistamines may prolong the
duration of middle ear effusion
Comparative AOM Outcomes for
Observation vs Antibacterial Agent
AOM Outcome
Antibacteral Rx
Observation
P Value
Relief at 24 hours
60%
59%
NS
Relief at 2-3 days
91%
87%
NS
Relief at 4-7 days
79%
71%
NS
Clinical Resolution
82%
72%
NS
Mastoiditis/Complication
0.59%
0.17%
NS
Persistent MEE 4-6 wks
45%
48%
NS
Persistent MEE 3 mo.
21%
26%
NS
Diarrhea/Vomiting
16%
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-
Skin Rash/Allergy
2%
-
-
Number Need to Treat (NNT)
NNT for antibiotic therapy in AOM
7 to 8 children with AOM would have to be treated with
antibiotics to prevent one case of clinical failure by 1 week.
One review estimated the need to treat 17 children in order for 1
child to have improved pain at 2 days.
In addition, antibiotics were associated with almost twice the rate
of vomiting, diarrhea, and rashes.
Watch & See protocol
Observation without use of antibacterial agents in
a child with uncomplicated AOM is an option for
selected children
In this protocol …
Deferring antibacterial treatment of selected children for
48 -72 hrs & limiting management to symptomatic relief
Observation option is based on …
Diagnostic certainty
Age
Illness severity
Assurance of follow-up
Criteria for initial antibacterial-agent treatment or
observation in children with AOM
Age
<6 mo
Certain Diagnosis
Antibacterial therapy
6mo – 2 yr Antibacterial therapy
>2 yr
Antibacterial therapy if
severe illness
Observation option if
non-severe illness
Uncertain Diagnosis
Antibacterial therapy
Antibacterial therapy if
severe illness
Observation option if
non-severe illness
Observation option
Definitions
Non-severe illness is …
Mild otalgia
&
fever <39°C in the past 24 hours
Severe illness is
Moderate to severe otalgia
OR
fever  39°C
A certain diagnosis of AOM meets all 3 criteria …
1) Rapid onset
2) Signs of MEE
3) Signs and symptoms of middle-ear inflammation.
Criteria for initial antibacterial-agent treatment or
observation in children with AOM
Age
<6 mo
6 mo – 2 yr
>2 yr
Certain Diagnosis
Uncertain Diagnosis
Antibacterial therapy
Antibacterial therapy
Antibacterial therapy
Antibacterial therapy if
severe illness
Observation option if
non-severe illness
Antibacterial therapy if
severe illness
Observation option if
non-severe illness
Observation option
Observation
Observation is only appropriate when …
Follow-up can be ensured and antibiotic therapy initiated
if symptoms persist or worsen
Specific follow-up system i.e.
Reliable parent / caregiver
Convenient obtaining medications if necessary
Observation
Antibiotics should be prescribed when the patient does not
improve with observation for 48 to 72 hours
Adequate follow-up may include …
1 - A parent-initiated visit or phone contact if symptoms worsen or do
not improve at 48 -72 hrs
2 - A scheduled follow-up appointment in 48 -72 hrs
3 - Giving parents an antibiotic prescription that can be filled if
illness does not improve in this time frame.
Which antibiotic ???
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Amoxicillin
Ammoxicillin + Clavulanate
Azithromycin
Cefixime
Cefuroxime
Ceftriaxone
Clarithromycin
Clindamycin
Erythromycin
Cotrimoxazole
Erythromycin + Cotrimoxazole
Penicillin V / G
Penicillin Procain 800.000 / 400.000
Penicillin 6:3:3 / 1.200.000
Gentamicin / Amikacin
Cephalexin
Cloxacillin
Metronidazole
Microbiology of AOM
Frequency
Major Mechanism of
Resistance
What we can do?
S. pneumoniae
+++
penicillin-resistant (PBP2a)
High Dose PCN
H. influenzae
++
beta-lactamase
35-50%
M. catarrhalis
++
Bacterial Species
beta-lactamase
55-100%
beta-lactamase
Inhibitors
(clavulanate)
Antibacterial therapy
If a decision is made to treat with an antibacterial agent,
the clinician should prescribe amoxicillin for most
children.
When amoxicillin is used, the dose should be
80 - 90 mg/kg/day
Predicted treatment failure rates based on PD breakpoints for
expected pathogens in low- or high-risk AOM
AOM high risk for amoxicillin-resistant organism
In patients who have severe illness
&
AOM high risk for amoxicillin-resistant organism
Children who were received antibiotics in the previous 30 days
Children with concurrent purulent conjunctivitis (otitis-conjunctivitis
syndrome)
Children receiving amoxicillin for chemoprophylaxis of recurrent AOM
(or urinary tract infection)
High-dose amoxicillin-clavulanate
(90 mg/kg per day of amoxicillin & 6.4 mg/kg / day of clavulanate )
In allergy to amoxicillin
If allergic reaction was not a type I hypersensitivity reaction (urticaria
or anaphylaxis)
Cefuroxime (30 mg/kg per day in 2 divided doses)
If type I reactions
Azithromycin (10 mg/kg / day on day 1 followed by 5 mg/kg / day for 4
days as a single daily dose)
Clarithromycin (15 mg/kg per day in 2 divided doses)
Other possibilities include
Erythromycin-sulfisoxazole (50 mg/kg per day of erythromycin) or
sulfamethoxazole-trimethoprim (6 - 10 mg/kg per day of trimethoprim).
In daily clinical practice…
Month of year ( mehr vs. farvardin)
Previous antibacterial treatment
When return
In daily clinical practice…
q8h
Amoxicillin (2/3)
125
250
Co-Amoxiclav. (1/3)
156(125+31)
312(250+62)
Bid
Faramox (1/2)
200
400
Farmentin (1/2)
228(200+28)
456(400+56)
In daily clinical practice…
Previous antibacterial treatment
Amoxicillin 45 mg/kg
Amoxicillin - Clavul. 90mg/kg
Azithromycin
Cefixime
Cotri-Erythro
Cefuroxime
Azithromycin
Cefixime
Cotri-Erythro
Cefuroxime
Amoxicillin - Clavul. 30mg/kg
Amoxicillin - Clavul. 90mg/kg
Amoxicillin 90mg/kg
Duration of therapy
For children ≥ 6 years of age with mild to
moderate disease 5 -7 days is appropriate
For younger children and for children with severe
disease, a standard 10-day course is recommended
Acute Otitis Media
Management - Tympanocentesis
Indications for a tympanocentesis or myringotomy are…
1. AOM in an infant <6 wks with a past NICUadmission
2. AOM in a patient with compromised host resistance
3. Unresponsive AOM despite courses of 2-4 different antibiotics
4. Acute mastoiditis or suppurative labyrinthitis
5. Severe pain
Algorithm to distinguish AOM from OME
Malpractice
Administering PCN 6:3:3 in treatment
Decongestants may decreased blood flow to the respiratory
mucosa, which may impair delivery of antibiotics
Antihistamines may prolong the duration of middle ear
effusion
Prevention
Continue exclusive breastfeeding as long as
possible
NO "bottle-propping" or taking a bottle to bed
Smoke-free environment
IF high-risk for recurrent acute otitis media
Prolonged courses of antimicrobial prophylaxis
Amoxicillin (20 to 30 mg/kg/day) or sulfisoxazole (50 mg/kg/day)
given once daily at bedtime for 3 to 6 months or longer
Pneumococcal vaccine & influenza vaccine
marginally benefit
Pneumococcal vaccine reduce all otitis media by 6%.
Case 3
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You are seeing a 18 month old infant at your office. His
mother is concerned about his frequent ear infections.
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You note in his chart that he has had 4 ear infections; 3 of
which occurred in the past 6 months. Two of the 4
infections were unresponsive and required multiple
antibiotic courses. According to mother, the baby is now
asymptomatic; eating and sleeping well.
Which risk factor you consider??
1. Altered eustacian tube function
2. Frequent colds
3. Immune system
4. Smoking
5. Hay fever and allergies
Management of
Recurrent Acute Otitis Media
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A child has recurrent acute otitis media (RAOM) when 3 new episodes
of AOM have occurred in 6 months or 4 episodes within 12 months.
Approximately 20% of children younger than two years of age have
RAOM.
Follow patients with RAOM monthly with pneumatic otoscopy, as
AOM episodes are often asymptomatic.
Consider obtaining audiologic and speech evaluations in these cases
when there are concerns about language development, and when
appropriate begin a home language intervention program.
Antibiotic prophylaxis
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Studies suggest that the benefits, if any, are quite marginal.
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While antibiotic prophylaxis reduced the AOM rate by 44%, the mean rate difference was only
about one and a third less episodes per patient year for patients receiving antibiotics compared
to controls.
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Consider antibiotic prophylaxis for certain time limited situations such as the
time period between deciding to place ventilating tubes and the day surgery
will be performed, or when surgery is being considered in late winter or spring
and 1 or 2 months of prophylaxis may get the child out of the high risk season
and avoid the surgery.
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Therapeutic options include either continuous antibiotic prophylaxis or
intermittent prophylaxis for colds especially during winter respiratory viral
infection months.
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Antibiotics used for prophylaxis include amoxicillin and sulfisoxazole (Gantrisin). Amoxicillin
appears to be more effective in the current environment.The efficacy of these antibiotics is best
documented with dosing twice/day, but daily doses may be effective. Consider referring patients
for ventilating tubes after a first breakthrough episode of AOM on prophylaxis.
Immunoprophylaxis
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Another approach to preventing recurrent AOM episodes is active
immunization. Use of the conjugate pneumococcal vaccine, Prevenar,
appears to reduce the overall frequency of AOM by 6-7% .
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However, immunized children with RAOM experience more benefit; such as a 23%
reduction in AOM episodes after the 12 month dose and a 20 % reduction in the
need for ventilating tubes .
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Immunize children older than 2 years who experience RAOM with 23
valent polysaccaride pneumococcal vaccine (Pneumovax) .
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Immunize children older than 6 months who have had an AOM episode
in the first 6 months of life or have RAOM with influenza vaccine when
supplies are available. Clinically significant reductions in AOM
episodes have been well documented .
Ventilating Tubes with or without
Adenoidectomy
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Ventilating tubes are indicated when a child has experienced 5 or more
new AOM episodes within 12 months.
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The decision to insert ventilating tubes for recurrent AOM should not be based on
parental recall.
In selected patients, especially those with associated otitis media with
effusion, performing an adenoidectomy as well as inserting tubes may
reduce the likelihood of ventilating tube reinsertions and additional
otitis media related hospitalizations.