CAREFUL
ANTIBIOTIC
USE
ININ
OTITIS
CAREFUL
ANTIBIOTIC
USE
OTITISMEDIA
MEDIA
• Otitis media with effusion does NOT require antibiotic treatment
• Acute otitis media does not always require antibiotic treatment
Confirm middle
ear effusion
No effusion
NOT
OME
Or
AOM
Yes, effusion present
Signs/Symptoms of ear pain, fever, or irritability & bulging yellow/red tympanic membrane?
Yes
No No
Acute Otitis Media (AOM)
DIAGNOSIS
•
History of acute onset of signs and symptoms
WITH
•
The presence of middle ear effusion (indicated by
bulging of the TM or limited absent TM mobility,
otorrhea, or air-fluid level)
WITH
Signs or symptoms of middle-ear
inflammation (indicated by distinct
erythema of the TM or distinct otalgia)
•
Children less than 6 months old:
TREATMENT
• Treat with antibiotics even when Dx is uncertain.
Children aged 6 months to 2 year:
• Treat with antibiotics only if severe illness and/or
when Dx is confirmed, if Dx is uncertain and/or nonsevere then simply observe without A/B treatment)
Children aged 2 year and above:
• Treat with antibiotics only if severe illness. if Dx is
uncertain or illness is non-severe then simply observe
without treatment
• Most cases of AOM resolve with symptomatic
treatment alone and do not require antibiotics.
Managem
ent should
include
assessme
nt of pain
¬ if pain is present, clinician should recommend treatment to reduce
pain.
resolution of OME.
PREVENTION
.
• handwashing
• breastfeeding
• avoidance of environmental tobacco smoke
• avoidance of feeding in a supine, flat
position
.
Presence
effusion
Otitis of
Media
with(including
Effusionimmobility
(OME)
of the tympanic membrane)
• Presence of effusion (including
immobility WITHOUT
of the tympanic
Signs membrane)
or symptoms of acute infection.
Nonspecific signs and
symptoms (rhinitis,
WITHOUT
cough, diarrhea) are often present.
• Signs or symptoms of acute
infection. Nonspecific signs
and symptoms
(rhinitis, cough,
TREATMENT
diarrhea) are often present.
Antibiotic treatment has not been
demonstrated to be effective in long-term
•
Antibiotic treatment has not
been demonstrated to be
effective in long-term resolution
of OME.
•
A single course of treatment
for 10-14 days may be used
when a parent or caregiver
expresses a strong aversion to
impending surgery.
Avoiding
unnecessary
treatment of just
OME would save up
to 6-8 million courses
of antibiotics each
year & help prevent
resistance
*Management should include assessment of pain—if present, clinician should recommend treatment to reduce pain
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CONFIDENTIAL
Treatment for Acute Otitis Media
ISSUES
•
1st line agents
Amoxicillin
•
Standard dose
80-90 mg/kg/day PO per day
in div doses
•
Allergy to Penicillin and/or Beta-lactams
Azithromycin
Clarithromycin
10 mg/kg PO 1st day then
5mg/kg PO daily
for 4 days
15 mg/kg/PO div bid for 5
days
•
Allergy/anaphylaxis w/ beta-lactam (hypersensitivity
Type I reaction)*cross-sensitivity possibility still exists in a few patients
Cefuroxime axetil
Cefprozil
30 mg/kg day PO div bid for
5 days
30 mg/kg day PO div bid for
5 days
2nd-Line Agents
This guideline perhaps may not apply to the
following types of patients:
Failure of Amoxicillin
Amoxicillin-clavulanate
Cefuroxime axetil
Cefprozil
90 mg/kg/day PO div bid
(based on
amoxicillin)/(use amoxicillin
or clavulanate 7:1
formulation)
30 mg/kg/day PO div bid for
10 days
30 mg/kg/day PO div bid for
10 days
•
infants less than 6 weeks old
•
premature infants who are hospitalized
•
children with craniofacial abnormalities
such as cleft palate
•
Clarithromycin
•
•
children who are immunocompromised or
have severe underlying systemic disease
•
children with complications of AOM (e.g.,
sepsis, mastoiditis)
•
Also excluded are children with a clinical
recurrence of AOM within 30 days or AOM
Beta-lactam Allergy
Azithromycin
Antibiotic prophylaxis is no longer
recommended for recurrent AOM
A single course of treatment for 10-14
days may be used when a parent or
caregiver expresses a
strong aversion to impending surgery.
Treat symptomatically for 48–72
hours from symptom onset if
pain/fever is manageable with
systemic analgesics, provided followup can be ensured and provided
symptoms don’t worsen earlier. After
this timeframe 48–72 hours,
antibiotics may be considered for
AOM
Additionally, in patients with sinus
infection, acute bacterial
rhinosinusitis should be diagnosed
and treated with antibiotics only if no
improvement after 10 days or
symptoms worsen after five to seven
days.
10 mg/kg PO 1st day then
5mg/kg
or daily for 4 days
15 mg/kg/PO div bid for 10
days
Use a 10-day therapy as standard for children aged 5 years and younger.
Use of 5- to 7-day course is appropriate in children aged 6 years and older
with mild to moderate disease
with underlying chronic OME.
•
The recommendations in this guideline do
not indicate an exclusive course of
treatment. Variations, taking into account
individual circumstances, may be
appropriate.
References:
1.
CDC website: Pediatric treatment guidelines for upper respiratory tract infections; Otitis Media: Pediatrics Physician Information (Sheet) http://www.cdc.gov/drugresistance/community/healthcare_provider.htm
2.
CLINICAL PRACTICE GUIDELINES: American Academy of Pediatrics and American Academy of Family Physicians, Subcommittee on Management of Acute Otitis Media. Diagnosis and management of
acute otitis media. Pediatrics 2004;113(5):1451-65.
3.
Canadian Clinical Practice Guidelines 2007 from the Alberta Medical Association
4.
Dowell SF, Marcy SM, Phillips WR, Gerber MA, Schwartz B. Otitis media-Principles of judicious use of antimicrobial agents. Pediatrics 1998;101(1 Suppl Pt 2):165-71.
5.
Stool SE, Berg AO, Berman S, et al. Otitis media with effusion in young children. Clinical practice guideline. AHCPR Publication no 94-0622 1994.
6.
American Academy of Family Physicians, American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Pediatrics Subcommittee on Otitis Media with Effusion. Otitis media with effusion.
Pediatrics 2004;113(5):1412-29.
7.
Wong DM, Blumberg DA, Lowe LG. Guidelines for the use of antibiotics in acute upper respiratory tract infections. Am Fam Physician. 2006 Sep 15;74(6):956-66.
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