Acute Otitis Media: Diagnosis & Treatment

• Upper and Lower Respiratory Tract Infections described.

Objectives

• Describe the etiology, pathophysiology, signs and symptoms, and treatment for each infection
• List the MOA, adverse effects, drug-drug interactions, contraindications, and expectations/ therapy for each medication

Otitis Media

• Guidelines from the American Academy of Pediatrics(AAP)

Etiology of Acute Otitis Media

• Streptococcus pneumoniae exhibits resistance via penicillin-binding proteins
• Haemophilus influenzae (non-typeable) and Moraxella catarrhalis can resist via β-lactamases

Pathophysiology of Acute Otitis Media

• Children are more susceptible due to shorter/more horizontal eustachian tubes
• Middle ear is blocked with fluid because of proliferation of bacteria coming from the nasopharynx
• Results in bulging and erythematous tympanic membrane

Diagnosis of Acute Otitis Media (AAP Guidelines)

• Middle ear effusion with moderate to severe bulging of tympanic membrane or new onset otorrhea not due to acute otitis externa
• Middle ear effusion with mild bulging of the tympanic membrane and onset of ear pain within the last 48 hours or intense erythema of the tympanic membrane

Clinical presentation of Acute Otitis Media

• Often follows viral upper respiratory tract infections
• Nonverbal children with ear pain might hold, rub, or tug their ear; infants might cry, be irritable, or have difficulty sleeping

Signs and Symptoms of Acute Otitis Media

• Bulging of the tympanic membrane
• Otorrhea
• Otalgia is considered moderate or severe if pain lasts at least 48 hours
• Fever is considered severe if temperature is 39°C [102.2°F] or higher

Treatment of Acute Otitis Media

• APAP or ibuprofen for pain

• Antibiotics are prescribed for:

  • 6 months - 12 years old + moderate to severe pain + 102.2°F
  • 6-23 months old + nonsevere bilateral acute otitis media

• Observation or antibiotics if:

  • 6-23 months old + nonsevere unilateral acute otitis media
  • 24 months to 12 years old + nonsevere acute otitis media

• First-line antibiotics for initial diagnosis:

  • Amoxicillin 80-90 mg/kg/day orally divided twice daily
  • Amoxicillin-clavulanate 90 mg/kg/day orally (amoxicillin) plus 6.4 mg/kg/day orally (clavulanate), divided twice daily. Use if certain criteria are present.

• Second-line antibiotics for initial diagnosis:

  • Cefdinir 14 mg/kg/day orally in 1-2 doses
  • Cefuroxime 30 mg/kg/day orally in two divided doses
  • Cefpodoxime 10 mg/kg/day orally in two divided doses for nonsevere penicillin allergy

• Ceftriaxone 50 mg/kg/day IM or IV for 3 days. Second line for nonsevere penicillin allergy

• First-line antibiotics for failure at 48-72 hours:

  • Amoxicillin-clavulanate 90 mg/kg/day orally of amoxicillin plus 6.4 mg/kg/day orally of clavulanate, divided twice daily

• Ceftriaxone 50 mg/kg/day IM or IV for 3 days

• Second-line antibiotic for failure at 48-72 hours:

  • Clindamycin 30-40 mg/kg/day orally in three divided doses plus a second or third-generation cephalosporin

• If a patient has received amoxicillin in the last 30 days, has concurrent purulent conjunctivitis, or has a history of recurrent infection unresponsive to amoxicillin, use a different antibiotic.

• Acute otitis media treatment includes therapy duration for 10 days, but may be shortened to 5-7 days for > six year olds in mild to moderate cases, by day 7, AOM will become otitis media with effusion, not always an indication for additional antibiotics.

• Addition of dexamethasone to a topical antibiotic ciprofloxacin (CiproDex) may decrease the length of time necessary for middle ear drainage when compared with a topical antibiotic alone

Recurrent AOM

• Defined as 3 episodes in six months or 4 episodes in one year.
• Consider tympanostomy tubes (T-tubes) to prevent AOM, reduces risk of hearing loss and language / learning disabilities

Prevention of Otitis Media

• Influenza, Haemophilus influenza, and pneumococcal vaccines

Side Note: What is a Formulary?

• List of drugs for use by prescriber, insurance, pharmacy or hospital Prescriber (You)
• PAs will collaborate with supervising physician to create a list of prescription drugs Insurance
• List of drugs covered by insurance
• Pharmacy benefits managers (PBMs) and prior authorization departments Pharmacy
• List of drugs stocked in pharmacy Hospital
• List of drugs approved for use
• Pharmacy & Therapeutics Committees

AOM Treatment Summary

• Diagnosis via Ear effusion w/ mod/severe bulging tympanic membrane or otorrhea, or ear effusion w/ mild bulging tympanic membrane & ear pain ( w/in 48 hours) or tympanic erythema
• Antibiotics for:
  • 6 months – 12 years old + moderate to severe pain (pain for 48 hours) + 102.2°F
  • 6-23 months old + nonsevere bilateral acute otitis media
• Observation or antibiotics for:
  • 6-23 months old + nonsevere unilateral acute otitis media
  • 24 months to 12 years old + nonsevere acute otitis media
• First line antibiotics:
  • Amoxil 80-90 mg/kg/day BID
  • Amox/clav. 90 mg/kg/day BID
• If a patient has received amoxicillin in the last 30 days, has concurrent purulent conjunctivitis, or has a history of recurrent infection unresponsive to amoxicillin, use a different antibiotic
• Cefdinir 14 mg/kg/day for Type II PCN allergy
• Therapy failure at 48 to 72 hours:
  • Amox/clav. 90 mg/kg/day BID
  • Clindamycin 30-40 mg/kg/day tid +/- Cefdinir 14mg/kg/day
• Age > 6 years old treat for 5 to 7 days if mild to moderate; treat for 10 days if severe
• Age 2 - 6 years old treat for 7 days if mild to moderate; treat for 10 days if severe
• Age < 2 years old treat for 10 days

Acute Bacterial Rhinosinusitis

• 2-10% of all upper respiratory infections are bacterial
• Most commonly caused by Streptococcus pneumoniae & Haemophilus influenzae (50 – 70% of cases), or Moraxella catarrhalis (8 – 16% of cases)
• Usually preceded by a viral respiratory tract infection that causes mucosal inflammation
• Mucosal secretions become trapped, local defenses are impaired, and bacteria from adjacent surfaces begin to proliferate

Clinical Presentation of Acute Bacterial Rhinosinusitis

• Onset with persistent signs or symptoms compatible with acute rhinosinusitis, lasting for ≥10 days without any evidence of clinical improvement
• Onset with severe signs or symptoms of high fever (Z39°C [102.2°F]) and purulent nasal discharge or facial pain lasting for at least 3 to 4 consecutive days at the beginning of illness
• Onset with worsening signs or symptoms characterized by new-onset fever, headache, or increase in nasal discharge following a typical viral URI that lasted 5 to 6 days and were initially improving ("double sickening")
• Purulent anterior nasal discharge, purulent or discolored posterior nasal discharge, nasal congestion or obstruction, facial congestion or fullness, facial pain or pressure, fever, headache, ear pain/pressure/fullness, halitosis, dental pain, cough, and fatigue

Treatment of Acute Bacterial Rhinosinusitis

• Nasal decongestants and antihistamines are not recommended
• Saline spray for nasal irrigation may be considered
• Intranasal corticosteroids are recommended only for patients with a history of allergic rhinitis
• Duration of therapy
• Adults for 5 – 7 days
• Children for 10 – 14 days

Antibiotic Regimens for Acute Bacterial Rhinosinusitis in Children

• Amoxicillin-clavulanate (45 mg/kg/day PO bid) is used for initial therapy
• For B-lactam allergy and Type I hypersensitivity use Levofloxacin (10-20 mg/kg/day PO every 12-24 h)
• For B-lactam allergy and Non-type I hypersensitivity use Clindamycin (30-40 mg/kg/day PO tid) plus cefixime (8 mg/kg/day PO bid) or cefpodoxime (10 mg/kg/day PO bid)
• For Risk for antibiotic resistance or failed initial therapy use Amoxicillin-clavulanate (90 mg/kg/day PO bid)
• For Severe infection requiring hospitalization use Clindamycin (30-40 mg/kg/day PO tid) plus cefixime (8 mg/kg/day PO bid) or cefpodoxime (10 mg/kg/day PO bid), Levofloxacin (10-20 mg/kg/day PO every 12-24 h), Ampicillin/sulbactam (200-400 mg/kg/day IV every 6 h), Ceftriaxone (50 mg/kg/day IV every 12 h), Cefotaxime (100-200 mg/kg/day IV every 6 h) or Levofloxacin (10-20 mg/kg/day IV every 12-24 h)
• For Resistance to clindamycin (~31%) is found frequently among Streptococcus pneumoniae serotype 19A isolates in different regions of the United States.

Antibiotic Regimens for Acute Bacterial Rhinosinusitis in Adults

• Amoxicillin-clavulanate (500 mg/125 mg PO tid, or 875 mg/125 mg PO bid) is used for initial therapy
• For B-lactan allergy use Doxycycline (100 mg PO bid or 200 mg PO qd)
• For Risk for antibiotic resistance or failed initial therapy use Amoxicillin-clavulanate (2000 mg/125 mg PO bid), Doxycycline (100 mg PO bid or 200 mg PO qd), Levofloxacin (500 mg PO qd), or Moxifloxacin (400 mg PO qd)
• For Severe infection requiring hospitalization use Ampicillin-sulbactam (1.5-3 g IV every 6 h), Levofloxacin (500 mg PO or IV qd), Moxifloxacin (400 mg PO or IV qd), Ceftriaxone (1-2 g IV every 12-24 h), or Cefotaxime (2 g IV every 4-6 h)
• High-dose amoxicillin-clavulanate is preferred in the following situations:
• geographic regions with high endemic rates (10% or greater) of invasive penicillin-nonsusceptible S. pneumoniae, (b) severe infection
• attendance at daycare
• age less than 2 or greater than 65 years
• recent hospitalization
• antibiotic use within the last month
• immunocompromised persons

ABR Treatment Summary

• Diagnosis is done for these cases:
  • S/Sx not improving after >= 10 days
  • Severe S/Sx (fever > = 102.2 F) for >= 3 days at start of infection
  • Worsening of S/Sx for >= 3 days starting at day 6-8 of initial infection
• First line antibiotic:
  • Amox/clav. 45 mg/kg/day BID or amox/clav. 875mg BID
  • Amox/clav. 90mg/kg/day BID or amox/clav. 2000mg BID
• Doxycycline 100mg BID for Adults Type I or Type II PCN allergy
• Second line antibiotic:
• Levofloxacin 10-20mg/kg/day for Pediatric Type I PCN allergy
• Clindamycin 30-40 mg/kg/day tid + cefixime 8mg/kg/day BID for Pediatric Type II PCN allergy
• Duration of therapy:
• Adults = 7 days
• Pediatrics = 10 days

Acute Pharyngitis

• Viruses cause majority of cases (39%)
• The bacteria Streptococcus pyogenes is another cause
• Mechanism is not well defined

Clinical Signs and Symptoms of Group A Streptococcal Pharyngitis

• A sore throat of sudden onset that is mostly self-limited
• Fever and constitutional symptoms resolving in about 3 to 5 days
• Clinical signs and symptoms are similar for viral causes and nonstreptococcal bacterial causes
• Pain on swallowing
• Fever
• Headache, nausea, vomiting, and abdominal pain (especially in children)
• Erythema/inflammation of the tonsils and pharynx with or without patchy exudates
• Enlarged, tender lymph nodes
• Red swollen uvula, petechiae on the soft palate, and a scarlatiniform rash

Signs Suggestive of Viral Origin for Pharyngitis

• Conjunctivitis
• Coryza
• Cough

Testing for Acute Pharyngitis

• Throat swab and culture
• Rapid antigen-detection test (RADT)

Treatment of Acute Pharyngitis

• Prevent transmission to close contacts; contagious period reduced to 1 day when antibiotics are started
• Prevent acute rheumatic fever and suppurative complications, such as peritonsillar abscess, cervical lymphadenitis, and mastoiditis
• Antipyretics, analgesics, and nonprescription lozenges and sprays containing menthol and topical anesthetics for temporary relief of pain

Antibiotic Regimens for Group A Streptococcal Pharyngitis

• For individuals without penicillin allergy

  • Penicillin V, oral for Children at 250 mg twice daily or 3 times daily, adolescents and adults at 250 mg 4 times daily or 500 mg twice daily for 10 d
  • Amoxicillin, oral at 50 mg/kg once daily (max = 1000 mg); alternate: 25 mg/kg (max = 500 mg) twice daily for 10 d
  • Benzathine penicillin G, intramuscular <27 kg at 600 000 U; ≥27 kg at 1 200 000 U for 1 dose

• For individuals with penicillin allergy

  • Cephalexin, oral at 20 mg/kg/dose twice daily (max = 500 mg/dose) for 10 d
  • Cefadroxil, oral at 30 mg/kg once daily (max = 1 g) for 10 d
  • Clindamycin, oral at 7 mg/kg/dose 3 times daily (max = 300 mg/dose) for 10 d
  • Azithromycin, oral at 12 mg/kg once daily (max = 500 mg) for 5 d
  • Clarithromycin, oral at 7.5 mg/kg/dose twice daily (max = 250 mg/dose) for 10 d

Treatment Regimens for Chronic Carriers of Group A Streptococci

• Clindamycin is given at 20-30 mg/kg/d in 3 doses (max = 300 mg/dose) orally for 10 d
• Penicillin V: 50 mg/kg/d in 4 doses x 10 d (max = 2000 mg/d) orally with rifampin: 20 mg/kg/d in 1 dose x last 4 d of treatment (max = 600 mg/d) for 10 d
• Amoxicillin-clavulanic acid is given at 40 mg amoxicillin/kg/d in 3 doses (max = 2000 mg amoxicillin/d) orally for 10 d
• Benzathine penicillin G (intramuscular) plus rifampin (oral)
  • Benzathine penicillin G is 600 000 U for <27 kg and 1 200 000 U for ≥27 kg intramuscular in one dose
  • Rifampin is 20 mg/kg/d in 2 doses (max = 600 mg/d) orally for 4 d

Secondary prophylaxis for Acute Pharyngitis:

• Documented histories of rheumatic fever
• Evidence of rheumatic heart disease
• Intramuscular benzathine penicillin G every 4 weeks
• Sulfadiazine can be givien when there's Penicillin allergy

AP Treatment Summary

• Diagnosis is made via Throat swab / rapid antigen-detection test
• Antibiotics as follows:
  • Amoxil
  • Pediatrics – 50 mg / kg / day; max 1,000 mg / day; can divide dose; preferred over PCN due to palatability
  • Adults – 1,000 mg Qday; can divide dose
  • Cephalexin – Type II PCN allergy
  • Pediatrics – 20mg/kg/dose BID
  • Adults – 500mg BID
  • Azithromycin – Type I PCN allergy
  • Pediatrics – 12mg/kg day x 5 days
  • Adults – 500mg qday x 5 days
  • Clindamycin – Type I PCN allergy or macrolide resistance
  • Pediatrics – 7mg/kg/dose TID
  • Adults – 300mg TID
• Duration of therapy should be 10 days, or 5 days if its azithromycin

Explore diagnosis, susceptibility factors in children, and antibiotic resistance mechanisms. This lesson also covers appropriate treatment strategies and risk factors associated with Acute Otitis Media. Learn about American Academy of Pediatrics (AAP) guidelines.