4/10/2014. Prof.Dr.Mohamed Bassiouny Professor of Otolaryngology Alexandria University.

Transcription

1 Prof.Dr.Mohamed Bassiouny Professor of Otolaryngology Alexandria University. 1

2 Aim When? What? For how long? Antibiotic Hamada, 5 month old baby referred to your office C/O ; Irritability, fever, vomiting and diarrhoea since 2 days. 2

3 The condition started since 2 days following URT infection. The family seeked medical advice. The family Dr assured the family,and gave only antipyretic. The condition worsened. 3

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5 Omar 22 months. Pain in both ears since one day. 5

6 Youssef 4 years old. Pain in left ear since 2 days. 6

7 MOHAMED BASSIOUNY, M. D. Professor of Otolaryngology Faculty of Medicine Alexandria University 7

8 Definition: Acute Suppurative Inflammation of the Muco-periosteal Lining of the Middle Ear Cleft. Middle Ear Cleft = Eustachian tube + Tympanic Cavity + Mastoid Antrum + Mastoid Air Cells 8

9 Epidemiology Incidence of infection All children by 6 months of age: 48% All children by 1 year of age: 79% All children by 2 years of age: 91% The peak incidence of AOM is from ages 3-18 months. Average of 1.5 Acute Otitis Media episodes per year Despite the recent advances in antibacterial agents, the incidence of acute otitis media is on the rise. Acute otitis media Inflammation in the nasopharynx extends to the medial end of the Eustachian tube, creating stasis and inflammation, which, in turn, alter the pressure within the middle ear. Stasis also permits pathogenic bacteria to colonize the normally sterile middle ear space by direct extension from the nasopharynx. 9

10 Pathogenesis (1) Allergy URT infection Mechanical or functional obstruction of Eust. Tube Adenoid Negative middle ear pressure Inhibits the drainage Impaired mucociliary transport M.E.Effusion. ANTI-INFECTIVES FOR INTERNAL USE ONLY Pathogenesis (2) Reflux from nasophryngeal secretion Aspiration from high negative M.E. pressure Insufflation during crying or sneezing Contamination of effusion from nasopharyngeal secretion ANTI-INFECTIVES FOR INTERNAL USE ONLY 10

11 Pathogenesis (3) 1- Infant &young children have a shorter eustachian tube.. More susceptible to reflux of nasopharyngeal secretion into middle-ear space 2-Young children Increase frequency of viral upper RTIs. Odema of eustachian tube mucosa.. Increase of eustachian tube dysfunction 3- Reactive enlargement of lymphoid tissue ( Adenoids ) at eustachian tube orifice.. Mechanically block tube function 4- Passive exposure to cigarette smoke. Level of cotinine ( metabolite of nicotine ). Adverse effect on ciliary motion and mucociliary clearance ANTI-INFECTIVES FOR INTERNAL USE ONLY Causative pathogens in AOM ( as recovered from MEE) Pathogen % S. pneumoniae H. Influenza M. Catarrhalis 3-20 Viruses: respiratory syncytial virus, rhinovirus, coronavirus, parainfluenza, adenovirus, and enterovirus,

12 Diagnostic approach The history of AOM varies with age, but a number of constant features manifest during the otitis-prone years. Irritability or feeding difficulties may be the only indication of a septic focus in the neonate. Older children begin to demonstrate a consistent presence of fever (with or without a coexistent URTI) and otalgia or earache. In older children and adults, hearing loss becomes a constant feature of AOM & OME, with reports of ear stuffiness noted even before the detection of middle ear fluid. 12

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15 How to differentiate between congestion due to crying and otitis media? Otoscopic Diagnosis 15

16 Pneumatic Otoscopy and Tympanometry Pneumatic otoscopy is the primary diagnostic tool for diagnosing the presence of middle ear effusion (MEE) and AOM. Unless the eardrum is bulging (AOM), has air fluid levels, or is obviously a normal TM, the only way to be certain of the presence of MEE on physical exam is by noting the movement of the TM. A grey, erythematous, dull, or yellow TM may not reflect the presence of middle ear fluid. Tympanometry can be used to confirm the diagnosis of MEE. It should only be used to confirm a clinical diagnosis. NOW FOR SOME EXAMPLES Treatment SHOULD ANTIBIOTICS BE USED TO TREAT AOM? The answer is still controversial Spontaneous recovery in 81% of cases Antimicrobial therapy enhanced the primary control by 13.7% 16

17 In the preantibiotic era, complications of AOM such as mastoiditis were far more common than they are today; This difference may be due to the current routine use of antibiotics. It is not possible to determine which cases require antimicrobial therapy and which will resolve spontaneously. AOM in light of the recent guidelines of AAP. Prof. Dr. Mohamed Bassiouny, Professor of Otolaryngology. University of Alexandria 17

18 Scope of the guidelines: These guidelines provide recommendations for the management of uncomplicated acute otitis media in otherwise healthy children from 6 months through 12 years of age without tympanostomy tubes, anatomic abnormalities such as cleft palate or Down syndrome, immune deficiencies, or cochlear implants. Children with OME without AOM are also excluded. 18

19 Burden of the disease: Since the publication of the previous guidelines AOM management has witnessed many changes: Clinician visits for OM decreased from 950 per 1000 children in to 634 per 1000 children in There has been a proportional decrease in antibiotic prescriptions for OM from 760 per 1000 in to 484 per 1000 in The percentage of OM visits resulting in antibiotic prescriptions remained relatively stable (80% in ; 76% in ). Contributing factors to decrease in visits for OM include: Financial issues relating to insurance, such as copayments, that may limit doctor visits, public education campaigns regarding the viral nature of most infectious diseases, use of the PCV7 pneumococcal vaccine, and increased use of the influenza vaccine. Clinicians may also be more attentive to differentiating AOM from OM with effusion (OME), resulting in fewer visits coded for AOM and fewer antibiotic prescriptions written. Burden of the disease: Since the publication of the previous guidelines AOM management has witnessed many changes: clinician visits for OM decreased from 950 per 1000 children in to 634 Despite per 1000 children in all There this has been a proportional decrease in antibiotic prescriptions for OM from 760 per 1000 in to 484 per 1000 in The percentage of OM visits resulting in antibiotic prescriptions remained relatively stable (80% in ; 76% in ). Contributing factors to decrease in visits for OM include: including financial issues OM relating remains to insurance, the such most as copayments, common that may condition limit doctor visits, for public education campaigns regarding the viral nature of most infectious diseases, which useantibacterial of the PCV7 pneumococcal agents vaccine, are andprescribed increased use of the for influenza vaccine. Clinicians may also be more attentive to differentiating AOM children in the United States. from OM with effusion (OME), resulting in fewer visits coded for AOM and fewer antibiotic prescriptions written. 19

20 Regional perspective: Acute otitis media (AOM) is one of the most frequent diagnoses and reasons for prescribing antibiotics in children. 1 A recent data analysis conducted in Italy showed that Otitis Media represents a considerable burden for the healthcare system. 2 Another national survey conducted in Turkey showed that the medical and economic burden of AOM to the health economics in Turkey is considerable. 1 As such, the diagnosis and management of AOM has a significant impact on the health of children, cost of providing care, and overall use of antibacterial agents. Dinleyici EC et al., Results of a national study on the awareness of and attitudes toward acute otitis media (AOM) among clinicians and the estimated direct healthcare costs in Turkey (TR-AOM Study).Int J Pediatr Otorhinolaryngol Feb 21. doi:pii: S (13) /j.ijporl Marchisio P et al., Burden of acute otitis media in primary care pediatrics in Italy: a secondary data analysis from the Pedianet database. BMC Pediatr Nov 29;12(1):185. Key Action Statement 1A Clinicians should diagnose acute otitis media (AOM) in children who present with moderate to severe bulging of the tympanic membrane (TM) or new onset of otorrhea not due to acute otitis externa. Evidence Quality: Grade B. Strength: Recommendation.. 20

21 Rating The Evidence Grade A-At least one randomized well conducted study. Grade B-Well conducted study but not randomized. Grade C-Expert committee reports or opinions. Key Action Statement 1B Clinicians should diagnose AOM in children who present with mild bulging of the TM and recent (less than 48 hours) onset of ear pain (holding, tugging, rubbing of the ear in a nonverbal child) or intense erythema of the TM. Evidence Quality: Grade C. Strength: Recommendation. 21

22 Key Action Statement 1C: Clinicians should not diagnose AOM in children who do not have middle ear effusion (MEE) (based on pneumatic otoscopy and/or tympanometry). Evidence Quality: Grade B. Strength: Recommendation. Key Action Statement 2: The management of AOM should include an assessment of pain. If pain is present, the clinician should recommend treatment to reduce pain. Evidence Quality: Grade B. Strength: Strong Recommendation. 22

23 Key Action Statement 3A Severe AOM: The clinician should prescribe antibiotic therapy for AOM (bilateral or unilateral) in children 6 months and older with severe signs or symptoms (ie, moderate or severe otalgia or otalgia for at least 48 hours or temperature 39 C [102.2 F] or higher).. Evidence Quality: Grade B. Strength: Strong Recommendation Key Action Statement 3B Nonsevere bilateral AOM in young children: The clinician should prescribe antibiotic therapy for bilateral AOM in children 6 months through 23 months of age without severe signs or symptoms (ie, mild otalgia for less than 48 hours and temperature less than 39 C [102.2 F]). Evidence Quality: Grade B. Strength: Strong Recommendation 23

24 Key Action Statement 3C: Nonsevere unilateral AOM in young children: The clinician should either prescribe antibiotic therapy or offer observation with close follow-up based on joint decision making with the parent(s)/caregiver for unilateral AOM in children 6 months to 23 months of age without severe signs or symptoms (ie, mild otalgia for less than 48 hours and temperature less than 39 C [102.2 F]). When observation is used, a mechanism must be in place to ensure follow-up and begin antibiotic therapy if the child worsens or fails to improve within 48 to 72 hours of onset of symptoms. Evidence Quality: Grade B. Strength: Recommendation. Key Action Statement 3D: Nonsevere AOM in older children: The clinician should either prescribe antibiotic therapy or offer observation with close follow-up based on joint decision-making with the parent(s)/ caregiver for AOM (bilateral or unilateral) in children 24 months or older without severe signs or symptoms (ie, mild otalgia for less than 48 hours and temperature less than 39 C [102.2 F]). When observation is used, a mechanism must be in place to ensure follow-up and begin antibiotic therapy if the child worsens or fails to improve within 48 to 72 hours of onset of symptoms. Evidence Quality: Grade B. Strength: Recommendation. 24

25 Key Action Statement 4A Clinicians should prescribe amoxicillin for AOM when a decision to treat with antibiotics has been made and the child has not received amoxicillin in the past 30 days or the child does not have concurrent purulent conjunctivitis or the child is not allergic to penicillin. Evidence Quality: Grade B. Strength: Strong Recommendation Key Action Statement 4B Clinicians should prescribe an antibiotic with additional β- lactamase coverage for AOM when a decision to treat with antibiotics has been made, and the child has received amoxicillin in the last 30 days or has concurrent purulent conjunctivitis, or has a history of recurrent AOM unresponsive to amoxicillin. Evidence Quality: Grade C. Strength: Recommendation 25

26 Key Action Statement 4C: Clinicians should reassess the patient if the caregiver reports that the child s symptoms have worsened or failed to respond to the initial antibiotic treatment within 48 to 72 hours and determine whether a change in therapy is needed. Evidence Quality: Grade B. Strength: Recommendation. Recommended Antibiotics for (Initial or Delayed) Treatment and for Patients Who Have Failed Initial Antibiotic Treatment Initial Immediate or Delayed Antibiotic Treatment Recommended First-line Treatment Amoxicillin (80 90 mg/ kg per day in 2 divided doses) or Amoxicillin-clavulanate a (90 mg/kg per day of amoxicillin, with 6.4 mg/kg per day of clavulanate in 2 divided doses) Alternative Treatment (if Penicillin Allergy) Adapted from Lieberthal AS, Carroll AE, Chonmaitree T et al. Pediatrics 2013;131(3):e Antibiotic Treatment After hours of Failure of Initial Antibiotic Treatment Recommended First-line Treatment Cefdinir (14 mg/kg per day in Amoxicillin-clavulanate a 1 or 2 doses) c (90 mg/kg per day of amoxicillin, with 6.4 mg/kg per day of clavulanate in 2 divided doses) Alternative Treatment Ceftriaxone c, 3 days Clindamycin (30 40 mg/kg per day in 3 divided doses), with or without third-generation cephalosporin Cefuroxime (30 mg/kg per or Failure of second antibiotic day in 2 divided doses) c Cefpodoxime (10 mg/kg per day in 2 divided doses) c Ceftriaxone (50 mg IM or IV per day for 1 or 3 days) c Ceftriaxone (50 mg IM or IV for 3 days) c Clindamycin (30 40 mg/kg per day in 3 divided doses) plus third-generation cephalosporin Tympanocentesis b Consult specialist b IM, intramuscular; IV, intravenous; a May be considered in patients who have received amoxicillin in the previous 30 days or who have the otitis-conjunctivitis syndrome; b Perform tympanocentesis/drainage if skilled in the procedure, or seek a consultation from an otolaryngologist for tympanocentesis/drainage. If the tympanocentesis reveals multidrug-resistant bacteria, seek an infectious disease specialist consultation; c Cefdinir, cefuroxime, cefpodoxime, and ceftriaxone are highly unlikely to be associated with cross-reactivity with penicillin allergy on the basis of their distinct chemical structures. 26

27 Antibiotics therapy: 2004 Duration of Therapy: The optimal duration of therapy for patients with AOM is uncertain however recommendations are: Children younger than 2 years and children with severe symptoms 10 day course Children 2 to 5 years of age with mild or moderate AOM 7day course Children 6 years and older with mild to moderate symptoms 5-7 day course 27

28 Key Action Statement 5A: Clinicians should not prescribe prophylactic antibiotics to reduce the frequency of episodes of AOM in children with recurrent AOM. Evidence Quality: Grade B. Strength: Recommendation. Key Action Statement 5B: Clinicians may offer tympanostomy tubes for recurrent AOM (3 episodes in 6 months or 4 episodes in 1 year with 1 episode in the preceding 6 months). Evidence Quality: Grade B. Strength: Option. 28

29 Key Action Statement 6A: Clinicians should recommend pneumococcal conjugate vaccine to all children according to the schedule of the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention, American Academy of Pediatrics (AAP), and American Academy of Family Physicians (AAFP). Evidence Quality: Grade B. Strength: Strong Recommendation. Key Action Statement 6B: Clinicians should recommend annual influenza vaccine to all children according to the schedule of the Advisory Committee on Immunization Practices, AAP, and AAFP. Evidence Quality: Grade B. Strength: Recommendation.. 29

30 Key Action Statement 6C: Clinicians should encourage exclusive breastfeeding for at least 6 months. Evidence Quality: Grade B. Strength: Recommendation... Key Action Statement 6D: Clinicians should encourage avoidance of tobacco smoke exposure. Evidence Quality: Grade C. Strength: Recommendation 30

31 3- Passive smoking - Exposure to smoke can result in changes in the mucosa of the URT, including decreased activity of cilia, increase secretion of mucus, and hyperplasia of goblet cells - A biochemical marker (Cotinine), documents exposure to tobacco smoke when measured in saliva,serum,or urine - High concentrations of cotinine in infants and children have been associated with increase incidence of AOM and prolonged time with middle ear effusion ANTI-INFECTIVES FOR INTERNAL USE ONLY Etzel,et al,1992. II- Environmental R.Fs. 1- Day care An increased incidence of RTIs occurs in children attending group day care compared with children in small-group or home day care Wald,et al,1988. ANTI-INFECTIVES FOR INTERNAL USE ONLY 31

32 2- Breast feeding - Children who are breast-fed have fewer episodes of O.M. than do infants who are bottle-fed - Breast-feeding for 3 months or more was associated with decreased incidence of A.O.M. in the 1st. Year of life - A constituent of breast milk appears to be the important protective factor rather than feeding position ANTI-INFECTIVES Jerome O.Klein,1998 FOR INTERNAL USE ONLY 4- Season Winter, and early spring during which the peak incidence of RTIs ANTI-INFECTIVES FOR INTERNAL USE ONLY Jerome O.Klein,

33 5- Poverty Take home messages: Prophylactic antibiotics should not be prescribed to reduce recurrences. Instead, these children may be offered the option of tympanostomy tubes. Amoxicillin remains the first-line agent; drugs that have additional beta-lactamase coverage are selected for kids who have already had it in the prior month or who are allergic to penicillin Pneumococcal conjugate vaccine and annual flu shots are recommended for all children 33

34 Take home messages: The 2004 guidelines used a three-part definition for acute otitis media: acute onset of symptoms, acute middle ear inflammation, and middle ear effusion. The 2013 update also requires middle ear effusion for diagnosis, but it now has to be based on tympanometry or pneumatic otoscopy. Additional diagnostic criteria include: moderate to severe bulging of the tympanic membrane or new onset of discharge not due to an infected ear canal, and mild bulging of the ear drum and onset of ear pain within 48 hours, which could be indicated by holding, tugging, rubbing of the ear for nonverbal children, or intense redness of the tympanic membrane. Antibiotics should be given for severe cases of bilateral or unilateral acute otitis media for children >6 months based on ear pain that is moderate or severe, lasts for at least 48 hours, or is accompanied by a temperature of >102.2 F. In less severe cases, watchful waiting could be offered instead of antibiotics unless both ears are affected in kids aged 6 23 months. Antibiotics should be given to older children with non severe AOM if their condition worsens or fails to improve within 48 to 72 hours of observation. Recurrent acute otitis media is defined as three episodes in six months or four episodes in the prior year with one in the past six months. Clinical decision making Several distinctive features of the drug under consideration, include: Antibacterial spectrum (Broad Spectrum) PK/PD (MIC, Tissue concentration & Eradication) Patient Satisfaction (e.g. Number of daily doses, Duration of therapy & Early relief of Symptoms) Tolerability Palatability Reasonable Cost (cost-effective) Clinicians also consider therapeutic efficacy based on clinical trials and the recommendations of respectful organizations

35 Clinical algorithm by the Clinical Advisory Committee on Treatment of Recurrent and Persistent AOM (2006) NO risk factors Amoxicillin 45 mg/kg (maximum 1.5 g/d) Or Amoxicillin 90 mg/kg (maximum 3 g/d) High risk for Penicillin-resistant S pneumoniae Amoxicillin 90 mg/kg or Amoxicillin/ clavulanate 90 mg/kg or Cefpodoxime or Cefprozil or Cefuroxime High risk for β-lactamasepositive H influenza, or M catarrhalis or Amoxicillin/clavulanate 45 mg/kg or Cefpodoxime or Cefprozil or Cefuroxime High risk for β-lactamasepositive H influenza, or M catarrhalis Amoxicillin 90 mg/kg or Amoxicillin/ clavulanate 90 mg/kg or Cefpodoxime or Cefprozil or Cefuroxime Failure Ceftriaxone or alternative oral agent with similar activity Failure Tympanocentesis Pichichero ME, Casey JR. Acute otitis media: Making sense of recent guidelines on antimicrobial treatment, J Fam Pract Apr;56(4): Consider a second line antibiotic in when: the clinician has a high suspicion for concurrent conjunctivitisotitis media syndrome, commonly caused by a beta-lactamase producing organism, For children with allergies to penicillin, or other reasons to consider alternative antibiotics Second choice antibiotics: Amoxicillin/clavulanate Cefdinir Cefprozil Cefuroxime Ceftriaxone Azithromycin Clarithromycin 35

36 Recommendatios You must be able to see clearly the drum. Beware of the red TM reflex. Use pneumatic otoscope Good antibiotherapy. A 10-day antibiotic course is the minimum. Return Visit is more important than the first one. When dealing with Meningitis, watch out for Otitis Media. When dealing with Meningitis, watch out for Otitis Media. IN uncomplicated otitis media you should prescribe antibiotic in ; infants less than 6 months, bilateral otitis media and in severe cases. 36

37 Antibiotic recommendations: It is important to note that alternative antibiotics vary in their efficacy against AOM pathogens. For example, recent US data on in vitro susceptibility of S. pneumoniae to cefdinir and cefuroxime are 70% to 80%, compared with 84% to 92% amoxicillin Efficacy. In vitro efficacy of cefdinir and cefuroxime against H. influenzae is approximately 98%, compared with 58% efficacy of amoxicillin and nearly 100% efficacy of amoxicillin/clavulanate. Macrolides, such as erythromycin and azithromycin, have limited efficacy against both H influenzae and S pneumoniae. Clindamycin lacks efficacy against H influenzae. Clindamycin alone (30 40 mg/kg per day in 3 divided doses) may be used for suspected penicillin-resistant S. pneumoniae; however, the drug will likely not be effective for the multidrug-resistant serotypes. Although a single injection of ceftriaxone is approved by the US FDA for the treatment of AOM, results of a double tympanocentesis study (before and 3 days after single dose ceftriaxone) by Leibovitz et al175 suggest that more than 1 ceftriaxone dose may be required to prevent recurrence of the middle ear infection within 5 to 7 days after the initial dose 37

38 Bacterial susceptibility to Antibiotics : Current data from different studies with non-aom sources and geographic locations that may not be comparable show that 58% to 82% of H. influenzae isolates are susceptible to regular and high-dose amoxicillin. Nationwide data suggest that 100% of M. catarrhalis derived from the upper respiratory tract are β-lactamase positive but remain susceptible to amoxicillin clavulanate. Bacterial susceptibility to Antibiotics : Susceptible pathogens Adequate MEF concentrations > MIC Selection of antibiotic to treat AOM is based on the suspected type of bacteria and antibiotic susceptibility pattern, although clinical pharmacology and clinical and microbiologic results and predicted compliance with the drug are also taken into account. Current US data from a number of centers indicates that approximately 83% and 87% of isolates of S. pneumoniae from all age groups are susceptible to regular (40 mg/kg/day) and high-dose amoxicillin (80 90 mg/kg/day divided twice daily), respectively. High-dose amoxicillin will yield middle ear fluid levels that exceed the minimum inhibitory concentration (MIC) of all S. pneumoniae serotypes that are intermediately resistant to penicillin (penicillin MICs, μg/ml), and many but not all highly resistant serotypes (penicillin MICs, 2 μg/ml) for a longer period of the dosing interval and has been shown to improve bacteriologic and clinical efficacy compared with the regular dose. Hoberman et al reported superior efficacy of high-dose amoxicillin/ clavulanate in eradication of S. pneumoniae (96%) from the middle ear at days 4 to 6 of therapy compared with azithromycin. 38

39 Rationale for Antibiotic therapy: The rationale for antibiotic therapy in children with AOM is based on a high prevalence of bacteria in the accompanying MEE. Bacterial and viral cultures of middle ear fluid collected by tympanocentesis from children with AOM showed 55% with bacteria only and 15% with bacteria and viruses. Microbiology: The 3 most common bacterial pathogens in AOM are: S. pneumoniae Nont ypeable Haemophilus influenzae Moraxella catarrhalis. Streptococcus pyogenes (group A β-hemolytic streptococci) accounts for less than 5% of AOM cases. Recommendation 3A Observation without use of antibacterial agents in a child with uncomplicated AOM is an option for selected children based on diagnostic certainty, age, illness severity, and assurance of follow-up. The observation option for AOM refers to deferring antibacterial treatment of selected children for 48 to 72 hours and limiting management to symptomatic relief. The decision to observe or treat is based on the child s age, diagnostic certainty, and illness severity. To observe a child without initial antibacterial therapy, it is important that the parent/caregiver has a ready means of communicating with the clinician. There also must be a system in place that permits reevaluation of the child. If necessary, the parent/caregiver also must be able to obtain medication conveniently. 39

40 Clinical decision making Several distinctive features of the drug under consideration, include: Antibacterial spectrum (Broad Spectrum) PK/PD (MIC, Tissue concentration & Eradication) Patient Satisfaction (e.g. Number of daily doses, Duration of therapy & Early relief of Symptoms) Tolerability Palatability Reasonable Cost (cost-effective) Clinicians also consider therapeutic efficacy based on clinical trials and the recommendations of respectful organizations. 79 Clinical algorithm by the Clinical Advisory Committee on Treatment of Recurrent and Persistent AOM (2006) Antibiotic treatment with amoxicillin, TMP/SMX, or macrolides within prior month (TMP/SMX) =trimethoprim/ sulfamethoxazole NO Risk factor analysis Yes NOT RECOMMENDED Amoxicillin, TMP-SMX, Erythromycin, sulfisoxazole, azithromycin, clarithromycin NO risk factors Amoxicillin 45 mg/kg (maximum 1.5 g/d) Or Amoxicillin 90 mg/kg (maximum 3 g/d) High risk for Penicillin-resistant S pneumoniae Amoxicillin 90 mg/kg or Amoxicillin/ clavulanate 90 mg/kg or Cefpodoxime or Cefprozil or Cefuroxime High risk for β-lactamasepositive H influenza, or M catarrhalis Or Amoxicillin/clavulanate 45 mg/kg or Cefpodoxime or Cefprozil or Cefuroxime High risk for β-lactamasepositive H influenza, or M catarrhalis Amoxicillin 90 mg/kg or Amoxicillin/ clavulanate 90 mg/kg or Cefpodoxime or Cefprozil or Cefuroxime 40

41 Clinical algorithm by the Clinical Advisory Committee on Treatment of Recurrent and Persistent AOM (2006) NO risk factors Amoxicillin 45 mg/kg (maximum 1.5 g/d) Or Amoxicillin 90 mg/kg (maximum 3 g/d) High risk for Penicillin-resistant S pneumoniae Amoxicillin 90 mg/kg or Amoxicillin/ clavulanate 90 mg/kg or Cefpodoxime or Cefprozil or Cefuroxime High risk for β-lactamasepositive H influenza, or M catarrhalis or Amoxicillin/clavulanate 45 mg/kg or Cefpodoxime or Cefprozil or Cefuroxime High risk for β-lactamasepositive H influenza, or M catarrhalis Amoxicillin 90 mg/kg or Amoxicillin/ clavulanate 90 mg/kg or Cefpodoxime or Cefprozil or Cefuroxime Failure Ceftriaxone or alternative oral agent with similar activity Failure Tympanocentesis Pichichero ME, Casey JR. Acute otitis media: Making sense of recent guidelines on antimicrobial treatment, J Fam Pract Apr;56(4): Consider a second line antibiotic in when: the clinician has a high suspicion for concurrent conjunctivitisotitis media syndrome, commonly caused by a beta-lactamase producing organism, For children with allergies to penicillin, or other reasons to consider alternative antibiotics Second choice antibiotics: Amoxicillin/clavulanate Cefdinir Cefprozil Cefuroxime Ceftriaxone Azithromycin Clarithromycin 41

42 Recommendation 3A If a decision is made to treat with an antibacterial agent, the clinician should prescribe amoxicillin for most children. (This recommendation is based on randomized, clinical trials with limitations and a preponderance of benefit over risk.) When amoxicillin is used, the dose should be 80 to 90 mg/kg per day. (This option is based on extrapolation from microbiologic studies and expert opinion, with a preponderance of benefit over risk.) In patients who have severe illness (moderate to severe otalgia or fever of 39 C or higher42) and in those for whom additional coverage for lactamase positive Haemophilus nfluenzae and Moraxella catarrhalis is desired, therapy should be initiated with high-dose amoxicillin-clavulanate (90 mg/kg per day of amoxicillin component, with 6.4 mg/kg per day of clavulanate in 2 divided doses). This dose has sufficient potassium clavulanate to inhibit all -lactamase producing H influenzae and M catarrhalis Is there any significance for the age? 42

43 It is recommended that treatment with a 10-day course of antibiotics be given to children less than 2 years of age with AOM Amoxicillin, in the dose range of mg/kg/day is effective in the treatment of a first episode of AOM or for a recurrence more than 1 month since recovery from a prior episode of AOM Recommendation 4 If the patient fails to respond to the initial management option within 48 to 72 hours, the clinician must reassess the patient to confirm AOM and exclude other causes of illness. If AOM is confirmed in the patient initially managed with observation, the clinician should begin antibacterial therapy. If the patient was initially managed with an antibacterial agent, the clinician should change the antibacterial agent. 43

44 Recommendation 5 Clinicians should encourage the prevention of AOM through reduction of risk factors. Number of factors associated with early or recurrent AOM which are not amenable to change: for example, genetic predisposition, premature birth, male gender, Native American/Inuit ethnicity, family history of recurrent otitis media, presence of siblings in the household, and low socioeconomic status. Factors which are amenable to change: During infancy and early childhood, reducing the incidence of respiratory tract infections by altering child care center attendance patterns can reduce the incidence of recurrent AOM significantly. The implementation of breastfeeding for at least the first 6 months also seems to be helpful against the development of early episodes of AOM. Avoiding supine bottle feeding ( bottle propping ),reducing or eliminating pacifier use in the second 6 months of life, eliminating exposure to passive tobacco smoke have been postulated to reduce the incidence of AOM in infancy; (however, the utility of these interventions is unclear.) Immunoprophylaxis with killed121 and live-attenuated intranasal122 influenza vaccines has demonstrated more than 30% efficacy in prevention of AOM during the respiratory illness season. (Most of the children in these studies were older than 2 years.) Atypical presentation of AOM? 44

45 Atypical otitis media Otitis media in infancy. Acute necrotizing otitis media. Tuberculous otitis media. Mycobacterial otitis media 45

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48 Recommendatios You must be able to see clearly the drum. Beware of the red TM reflex. Use pneumatic otoscope Good antibiotherapy. A 10-day antibiotic course is the minimum. Return Visit is more important than the first one. When dealing with Meningitis, watch out for Otitis Media. When dealing with Meningitis, watch out for Otitis Media. IN uncomplicated otitis media you should prescribe antibiotic in ; infants less than 6 months, bilateral otitis media and in severe cases. 48

49 49