1 / 44

Acute Otitis Media

Acute Otitis Media. Dr. Ghaleb Zughayar Consultant Pediatrician and Neonatologist. . Objectives Otitis Media. Demonstrate an understanding of pathophysiology List the common pathogens Demonstrate knowledge of both the advantages and disadvantages of antibiotic therapy

aulii
Download Presentation

Acute Otitis Media

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Acute Otitis Media Dr. Ghaleb Zughayar Consultant Pediatrician and Neonatologist.

  2. ObjectivesOtitis Media • Demonstrate an understanding of pathophysiology • List the common pathogens • Demonstrate knowledge of both the advantages and disadvantages of antibiotic therapy • Demonstrate application of an appropriate treatment plan

  3. Definition • Acute Otitis Media (AOM) • “acute onset of symptoms, evidence of a middle ear effusion, and signs or symptoms of middle ear inflammation.” • Otitis Media with effusion (OME) • “Presence of MEE without signs or symptoms of infection, previously named: secretory, serous, or glue ear. ” Rudolph's Pediatrics - 21st ed 2002

  4. Definition (continuous) • Difficult to treat AOM (20%) • Recurrent AOM: three or more episodes in the previous six months or four or more in the preceding twelve months. • Treatment failure AOM: a lack of improvement in sign and symptoms within 48-72 hours of AB treatment .

  5. Definition (continuous). • Chronic Otitis media with effusion: OME that persists beyond three months. • CSOM: purulent otorrhea that persists for more than six weeks despite appropriate treatment for AOM.

  6. Epidemiology • 31 million visits to physicians annually in U.S. • Most common diagnosis for an AB prescription in children. • Diagnosed > 5 million times a year. • 3-5 billion $/year in U.S. • 50,000 deaths / year worldwide. N Engl J Med 2002 347:1169-1174

  7. Pathophysiology • Eustachian tube obstruction • Length: shorter in children • Angle: 10o children vs. 45o adult • Decreased immunocompetence • Follows upper respiratory infection (URI) • Peak incidence 2 - 4 days N Eng J Med 2002 347: 169-1174; Pediatr Infect Dis J 1996 15:281-291

  8. Risk factors ● Age <2 years ● Atopy ● Bottle propping ● Chronic sinusitis ● Ciliary dysfunction ● Cleft palate and craniofacial anomalies ● Child care attendance ● Down syndrome and other genetic conditions ● First episode of AOM when younger than 6 months of age ● Immunocompromising conditions Pediatr Infect Dis J 1999 18:1-9

  9. Specific Otalgia Otorrhea Dizziness Hearing loss Non-specific Fever (50%) Vomiting/diarrhea Anorexia Irritability Diagnosis: Clinical Manifestations

  10. Diagnosis: Clinical Findings • Otoscopic findings • Bulging TM • Yellow, white, or bright red color • Opacification of eardrum • Impaired visibility of ossicular landmarks • Squamous exudate Rudolph’s Pediatrics - 21st ed 2002

  11. Bacterial Streptococcus pneumoniae Haemophilus influenzae Moraxella catarrhalis Viral RSV Influenzae A & B Parainfluenzae 1,2, & 3 Rhinovirus Adenovirus Enterovirus Coronavirus Pathogens

  12. Potential Complications • Hearing loss • Acute mastoiditis Rare: • Meningitis • Subdural/extradural abscess

  13. Allergies AOM history Spectrum of activity Local resistance pattern Recent antibiotic treatment Age Duration Compliance Adverse drug events Cost Treatment Considerations

  14. Treatment Considerations • Drug resistant S. pneumoniae (DRSP)incidence increasing • Patients at high risk for DRSP • Attending day care • < 2 years old • Antibiotic therapy in preceding 3 months

  15. Penicillin Resistance of S. pneumoniaeU.S. 1979-2000

  16. DRSP at Children’s Hospital Boston

  17. Why Focus on Pneumococcus? • Most common initial bacterial pathogen • Most common isolate after failed therapy • Least likely bacterial pathogen to self resolve • Most likely to cause severe otitis media • Most likely to cause suppurative complications of otitis (mastoiditis) Pediatr Infect Dis J 1998 17: 1084-1089

  18. Treatment Options • AOM spontaneously resolves 40 - 60% • Symptomatic therapy • Applied heat, analgesics, antipyretics & topical anesthetic • Adjunctive therapy • Decongestants, antihistamines, & corticosteroids • Who to treat with antibiotics? • < 2 yo • AOM s/sx  3 days • Ill-appearing patients • Patients at an increased risk of DRSP N Engl J Med 2002 347: 1169-1174

  19. Judicious Antibiotic Use • Proper diagnosis of AOM or OME before committing to antibiotic therapy • Diagnosis of AOM requires evidence of local inflammation & systemic symptoms • Erythema alone is not sufficient • Thickened, bulging and opaque TM • Pain • OME does not need immediate antibiotic therapy • Commonly seen with acute URI • Little or no benefit of antibiotic therapy • Persistent effusion expected for 2-3 months following therapy for AOM, but if persists > 3 months consider re-treatment

  20. Amoxicillin: 1st Line Rationale Pediatric Infect Dis J 1999; 18:1-9 Pediatric Infect Dis J 1998; 17:1058-1059

  21. How Effective is HD (90 mg/kg/d) Amoxicillin* Against Pneumococcus? Dagan et al. Poster 107, ICAAC 2000 *Study done w/ amox/clav but clav has no activity against pneumococcus

  22. Treatment Failure • No improvement in ear pain, fever, or tympanic membrane otorrhea, bulging or redness after 3 days of antibiotic therapy • 2nd Line Therapy • DRSP • Beta-lactamase producing H.influenza and M. cattarhalis Pediatr Infect Dis J 1999 18:1-9

  23. Prevention • Heptavalent pneumococcal conjugate vaccine (n=37,868) • Reduction of otitis office visits • Reduction of antibiotic prescriptions • Influenza vaccine • Goal: decrease number of URI • Breast feeding • Prophylaxis • 3 episodes in 6 months or 4 episodes in 1 yr • <6 months with >1 episode • Cause of resistance in the community Pediatr Infect Dis J 2003 22:10-16; Pediatr Infect Dis J 1998 17:1084-1089

  24. Dutch Guidelines for AOM

  25. In Summary . . . • Antibiotic resistance is here • High rates of antibiotic use in children has contributed to resistance rates • Vast majority of antibiotic use in children is for AOM • Minimizing unnecessary antibiotic prescribing can slow the rate of resistance • First line treatment of AOM is amoxicillin 90 mg/kg/day divided TID !!

  26. Treatment

  27. DRSPBeta-lactam Activity & Levels Dowell SF et al. Pediatr Infect Dis J 1999 Apr; 18 (4): 341

  28. Class Penicillin Considerations Most effective PO agent vs. DRSP Does NOT cover beta-lactamase producing H. flu or M.cat Tastes excellent Dosing SD: 40 mg/kg/day TID HD: 90 mg/kg/day TID (max 3 g/day) Adverse Events Rash Diarrhea Nausea/vomiting Contraindications Hypersensitivity to penicillins Dosage Forms Capsule Chewable Tab Tablet Suspension Amoxicillin

  29. Augmentin®Selection after HD Amoxicillin Failure • Addition of clavulanate • No additional coverage for pneumococcus compared to amoxicillin • Augmentin ES® = 90 mg/kg/d of amoxicillin which is equivalent, NOT superior to HD amoxicillin for DRSP • Excellent coverage for beta lactamase positive H. flu and M. cat

  30. Class Penicillin Considerations Equal DRSP coverage to amoxicillin Covers beta-lactamase producing H. flu & M.cat Food may enhance absorption, as well as decreases GI upset Tastes good Dosing HD 80 - 90 mg/kg/day TID (except XR)(max 3g/day amox) Adverse Events Nausea/vomiting Diarrhea Rash Contraindications Hypersensitivity to penicillins Dosage forms Suspension & chewable tablets 125/31.25/5 mL, 200/28.5/5 mL, 250/62.5/5 mL, 400/57/5 mL Susp ES  600 mg/42.9/5 mL Tablet  250 mg, 500 mg, 875 mg (125 mg clavulanate) Tablet XR  1000 mg/62.5 mg Amoxicillin/clavulanate(Augmentin®; Augmentin ES®; Augmentin XR®)

  31. Oral Cephalosporins:Selection after HD Amoxicillin Failure All ORAL cephalosporins are LESS ACTIVE against DRSP than amoxicillin • No benefit for DRSP after failing high dose amoxicillin • Adds improved H. flu and M. cat coverage • Stable against beta-lactamase activity

  32. Class Cephalosporin (2nd generation) Considerations Decreased efficacy against DRSP Efficacious against beta-lactamase producing H.flu & M.cat Requires food for absorption Tastes bad Dosing 30 mg/kg/day BID (max 1000 mg/day) Adverse Events Nausea/vomiting Diarrhea Rash Contraindications Hypersensitivity to cephalosporins Dosage forms Suspension Tablets Cefuroxime axetil

  33. Class Cephalosporin (3rd generation) Considerations Decreased efficacy against DRSP Efficacious against beta-lactamase producing H.flu & M.cat Tolerable taste-banana/strawberry Dosing 14 mg/kg/day QD - BID (max 600 mg/day) Adverse Events Nausea/vomiting Diarrhea Rash Contraindications Hypersensitivity to cephalosporins Dosage forms Suspension Tablets Cefdinir

  34. Ceftriaxone 3rd Generation Cephalosporin • Option when PO therapy fails • High middle ear fluid levels • Slightly better activity than amoxicillin • No comparison trial vs. HD amoxicillin for DRSP therapy • Requires 3 IM doses • 1 dose only has ~50% eradication of intermediate resistant strains of pneumococcus • 95% eradication of resistant strains • Little data on fully resistant DRSP (PCN MIC>2) Lebowitz E et al Pediatr Infect Dis 1998;17:1126

  35. Class Cephalosporin (3rd generation) Considerations Good coverage against DRSP and beta- lactamase producing M. cat & H. flu Dosing 50 mg/kg QD for 3 days IM (max 1 gram) Adverse Events Nausea/vomiting Diarrhea Rash Contraindications Hypersensitivity to cephalosporins Dosage forms IM / IV Ceftriaxone

  36. Non Beta-lactam Antibiotics Activity Against DRSP % Isolates Susceptible Pen-S Pen-I Pen-R Clindamycin 98% 90% 85% Erythromycin 96% 80% 51% Bactrim 94% 60% 20% Dowell SF et al. Pediatr Infect Dis J 1999

  37. Clindamycin (Cleocin®)If HD Amoxicillin Failure • Excellent pneumococcal coverage • Active against 80-85% of DRSP strains • NO H. flu or M. cat coverage at all • Requires co-therapy with agent active against H flu (Bactrim, cefixime, etc.) • Palatability issue for suspension

  38. Class Lincosamide Considerations NO coverage-H. flu or M. cat 15% cross resistance with DRSP Consider in combo tx for penicillin allergic patients Tastes awful Dosing 10 - 30 mg/kg/day TID (max 1800 mg/day) Adverse Events Nausea/vomiting Diarrhea Rash Increased LFT’s Contraindications Hypersensitivity to clindamycin Dosage forms Suspension Capsules Clindamycin: Cleocin®

  39. MacrolidesIf HD Amoxicillin Failure Erythromycin – Azithromycin- Clarithromycin • 80% of penicillin intermediate and 50% of resistant strains remain fully susceptible to macrolides • H. influenza coverage generally less susceptible than with beta-lactams • All have good M. cattarhallis coverage

  40. Class Macrolide Considerations DRSP ~ 50% cross resistance Decreased H. flu coverage Tastes okay - aftertaste Dosing 10 mg/kg x1 dose then 5 mg/kg QD for 4 days (max 500mg/250 mg) 10 mg/kg QD for 3 days (max 500 mg) 30 mg/kg x 1 (max 1500 mg) Adverse Events Nausea/vomiting Diarrhea Abdominal pain Rash Contraindications Hypersensitivity to macrolides Dosage forms Injection Suspension Tablet Azithromycin

  41. Trimethoprim/Sulfamethoxazole(Bactrim®) • 20% of DRSP strains remain fully susceptible to Bactrim and significantly lower level of activity than with macrolides or clindamycin • H. influenza and M. cattarhallis coverage • Dosing: 6-12 mg/kg/day BID

  42. Is it Rational to Treat AOM with Antibiotics to Prevent Mastoiditis? • Dutch strategy vs. US practice (100,000 children/year): • 2 additional mastoiditis cases in Netherlands • 7,800 more antibiotic prescriptions in US • 1,600 fewer adverse drug effects in Netherlands • # needed to treat = 3,900 to prevent 1 episode mastoiditis • Estimated antibiotic $ to prevent 1 episode = $117,000 (assumption $30/Rx) • 800 ADRs to prevent 1 episode mastoiditis • Additional cost to manage ADE? PIDJ 2001;20:140-4

More Related