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Diagnosis and pharmacological management of acute otitis media.

Acute otitis media (AOM) is an inflammation of the middle ear, accompanied by a rapid onset of signs and symptoms. These include pain, fever, irritability, anorexia, or vomiting (Berman, 1995). AOM occurs when there is effusion of fluid into the middle ear. Additionally, bacteria from the nasopharynx are drawn into the cavity, leading to the suppuration found in AOM.

AOM accounts for more than 30 million pediatric office visits per year. The condition occurs most frequently in the 6-month to 6-year population, with the greatest number (83%) occurring in children less than 3 years of age (Burns, Barbar, Brody, & Dunn 1996). There is a greater rate of occurrence in boys than girls. There are also racial differences in the incidence and prevalence of the disease. White children are more frequently affected than blacks, and the craniofacial structure of Native Americans and Eskimos is thought to be a contributing factor to their increased risk.

Other predisposing factors include exposure to secondary smoke, formula feeding, lower socioeconomic status, day care center attendance, and a sibling or parent history of severe recurrent otitis media (Hoekelman, Friedman, Nelson, & Siedel, 1992). Age at first episode is relevant to the prediction of future infections. The younger children are when they experience their first episode of AOM, the more likely they are to have future episodes (Klein, 1994).

Pathophysiology

The eustachian tube serves three major functions: ventilation, drainage, and protection. When a child is at rest, the nasopharyngeal end of the eustachian tube is closed. It is opened by the motions associated with swallowing, yawning, talking, and crying. When ventilation is normal, the pressure in the middle ear is comparable to atmospheric pressure. Normal pressure permits optimal mobility of the tympanic membrane and unobstructed conduction of sound (Hoekelman et al., 1992; Parsons & Waid, 1996).

The eustachian tube also serves as a drainage path for secretions. Secretions produced by goblet cells and mucus producing cells flow from the middle ear and eustachian tube to the nasopharynx (Parsons & Wald, 1996).

The eustachian tubes' structure serves a protective function. Its length provides distance between the bacteria-filled nasopharynx and the sterile middle ear cavity. The shorter, more horizontal and more flaccid eustachian tubes decrease the effectiveness of this protective defense. Children have been shown to have poorer ventilatory function of their eustachian tubes than adults. All of these factors predispose children to an increased risk of AOM (Maxson & Yamauchi, 1996).

When ventilation is impeded as a result of eustachian tube obstruction, negative pressure develops in the middle ear. Furthermore, this negative pressure generates continuous suction on the dysfunctional eustachian tube. This suction causes secretions to flow from the nasopharynx to the middle ear. Secretions replete with bacteria set up a perfect medium for bacterial proliferation, and hence acute otitis media (Maxson & Yamauchi, 1996; Parsons & Wald, 1996).

Clinical Findings

The child's history may vary in the type and intensity of symptoms. Ear pain, exhibited by irritability, or the inability to sleep, feeding difficulty, fever, diarrhea, vomiting, lethargy, or sudden hearing loss may be reported (Shapiro & Bluestone, 1995). Many parents report ear pulling, but this alone is not a reliable indicator of AOM.

AOM is closely linked with viral infections, especially respiratory syncytial virus, adenovirus, and influenza virus. Frequently, the young child who has suffered a recent upper respiratory tract infection lasting several days, presents to the primary care provider with symptoms of fever, irritability, and poor appetite. Otoscopic findings can confirm a diagnosis of AOM, even in the absence of symptoms.

Accurate diagnosis of AOM can only be made after confirmation of positive physical findings with pneumatic otoscopy. Pneumatic otoscopy permits the examiner to evaluate the appearance and mobility of the tympanic membrane (TM). The normal TM is translucent, and the short process and handle of the malleus are visible through the TM. The cone of light is visible, and the drum moves laterally and medially with the application of negative and positive pressure during pneumatic otoscopy.

Positive physical findings of full or bulging TM, absent or obscured bony landmarks, distorted or absent light reflex, decreased or absent mobility of TM, and bullae between layers of the TM are indicative of AOM. Erythema, or the presence of a fluid level, are not diagnostic of AOM in the absence of other findings (Berman, 1995). A tympanocentesis for culture and sensitivity of middle ear effusion is performed in rare cases. These include toxic patients, patients with complications such as mastoiditis, immune system compromise, or recurrent infections, and newborns (Berman, 1995; Graham & Uphold, 1994).

Causative Organisms and Antibiotic-Resistance

Knowledge of causative organisms is essential when selecting an antibiotic for treatment of AOM. The organisms most commonly identified in patients with AOM are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis (Shapiro & Bluestone, 1995; Eden et al., 1996).

Streptococcus pneumoniae accounts for 30% to 40% of cases. Next in frequency is Haemophilus influenzae with a rate of 21 to 23% and Moraxella catarrhalis causing approximately 12 to 14% of infections (Barnett & Klein, 1995; Shapiro & Bluestone, 1995; Eden et al., 1996). Pseudomonas aeruginosa, Beta streptococci, group A streptococci, and Staphylococcus aureus cause less than 3% of AOM. Viral causes are identified in between 8 to 25% of cultures occurring either alone or in combination with bacteria (Bluestone, Stephenson, & Martin, 1992).

Beta-lactamase producing strains of H. influenzae were first identified in the 1970s. The beta-lactamase enzyme produced by these organisms hydrolyzes amoxicillin and penicillin, causing resistance to these antibiotics (Barnett & Klein, 1995). An increase in the incidence of infections caused by these organisms since that time may be due to the overuse of newer broad spectrum beta-lactamase inhibitor antibiotics. Fifteen to 34% of the strains of H. influenzae and the majority of M. catarrhalis strains (82 to 90%) that cause AOM in the United States produce beta-lactamase (Barnett & Klein, 1995; Shapiro & Bluestone, 1995; Eden et al., 1996).

Approximately 20% of the S. pneumoniae strains now identified are also penicillin-resistant. This is due to an alteration in the penicillin-binding protein found on these organisms. These bacteria are becoming increasingly multi-drug resistant, exhibiting resistance to TMP/SMX, erythromycin, and cephalosporins. The addition of a beta-lactamase inhibitor to antibiotics is not effective against these bacteria, since resistance due to production of beta-lactamase enzyme is rare (15%) (Shapiro & Bluestone, 1995; McCracken, 1995).

Choosing Appropriate Antibiotic Therapy for Acute Otitis Media

The increasing incidence of amoxicillin-resistant organisms, and the introduction of many newer broadspectrum antibiotics make choosing pharmacologic treatment for AOM more complex and challenging. The first consideration is that acute otitis media is not life-threatening and rarely has serious complications. Initial treatment should be a wellknown therapy with very low risk. Amoxicillin, erythromycin-sulfasoxazol, and trimethaprim-sulfamethoxazole are first-line therapy for most children. Up to 80% of the most common pathogens remain susceptible to these antibiotics.

Compliance factors are important considerations when prescribing a drug in the pediatric population. More frequent dosing decreases treatment compliance. Eisen, Miller, Woodward, Spitznagel, and Przybeck (1990) reported that antibiotics prescribed for T1D dosing had compliance rates of 59%. BID dosing increased the chance of full compliance up to 74.9%. Once-a-day dosing can result in 83.6% compliance with therapy. By the second or third day of therapy, the child usually feels dramatically improved, decreasing the incentive for the parent to continue the full antibiotic course. It is important to note that full compliance with antibiotic therapy reduces the generation of antibiotic-resistant bacteria. If the efficacy of antibiotics is equal, prescribing decisions should take compliance into consideration (Schentag, 1995).

Two other important compliance factors for children are taste and side effects. Young children are less likely to tolerate medications with bitter or poor taste. Antibiotics with high incidence of gastrointestinal side effects, such as nausea and diarrhea, are much less likely to be taken for the full treatment course.

Cost also should be weighed when prescribing antibiotic therapy for AOM. AOM costs an estimated $3 to $4 billion annually in the United States for medical and surgical treatment. Therefore, managed care insurance companies are look carefully at providers' practices in choosing firstline, lower cost medications for uncomplicated otitis media.

Amoxicillin continues to be the first choice for antibiotic treatment of uncomplicated AOM in a non-allergic child. Advantages of amoxicillin are its low cost, palatability, safety, and efficacy. However, amoxicillin is ineffective against beta-lactamase-producing strains of Haemophilus influenza or Moraxella catarrhalis.

First line therapy for a child with an amoxicillin and penicillin allergy includes erythromycin-sulfasoxazole or trimethoprim-sulfamethoxazole. Both of these drugs provide good coverage against the three most common pathogens causing otitis media. Erythromycin-sulfasoxazole has the disadvantage of requiring QID dosing. Studies demonstrate that it can be given TID, but with increasing incidence of gastrointestinal side effects (Harrison, 1995). When prescribing erythromycin, multiple possibilities for drug interactions must be considered. In particular, use of erythromycin is contraindicated in a child taking propulsid (Cisapride[R]) or terfenedine (Seldane[R]), due to the rare occurrence of severe life-threatening cardiac arrhythmias. Erythromycin can also increase serum levels of theophylline, carbamazepine, and oral anticoagulants.

Trimethoprim-sulfamethoxazole (TMP/SMX) is inexpensive and has the advantage of BID dosing. This drug is usually well-tolerated by young children. However, this drug may cause Steven-Johnson Syndrome, a febrile, mucocutaneous syndrome that can be life-threatening (Harrison, 1995). Otitis media caused by organisms resistant to traditional antibiotic therapy requires treatment with an antibiotic effective against the beta-lactamase producing strains of Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. Alternatives to first line antibiotic therapy should be considered in the following situations (Eden et al., 1996; Pichichero, 1994; Rosenfeld, 1996):

1. Failure of the first line therapy after 48 to 72 hours

2. A persistent infection at 10 to 14 days

3. History of prior treatment failures for individual patient

4. Compliance features

5. A known high incidence of resistant organisms in the community

6. Conjunctivitis-otitis media syndrome suggesting H. influenzae.

The practitioner should consider the history of the particular child when prescribing therapy. This includes tolerance of the antibiotic as well as success rate of treatment. If amoxicillin fails to resolve acute AOM in a child twice during a respiratory season, a second-line antibiotic should be used for subsequent infections (Pichichero, 1994).

Second line antibiotic choices vary from practitioner to practitioner. A clinician must develop a manageable list of antibiotic choices and be familiar with the pharmacology of these drugs. Amoxicillin-clavulanate is highly effective against resistant organisms. The clavulanic acid increases the activity of the amoxicillin component by inactivating the beta-lactamase released by the bacterial cell. Amoxicillin-clavulanate has a high incidence of gastrointestinal side effects, especially diarrhea. These side effects can be minimized by instructing the parent to administer the medication with food. The newer formulation of this drug is designed for BID dosing. Decreased amounts of clavulanic acid and administration of doses 12 hours apart have significantly decreased gastrointestinal side effects.

Newer antimicrobial drugs have been developed in response to the increased incidence of antibiotic-resistant bacteria, including proportionally more penicillin-resistant Streptococcus pneumoniae in AOM. Cephalosporins provide a wide range of possibilities for treatment of otitis media. First generation cephalosporins are not useful in the treatment of otitis media, since they provide no coverage against gram-negative organisms.

Second generation cephalosporins that are used include cefuroxime axetil, cefprozil, and cefaclor. Cefaclor has good beta-lactamase inhibition against most bacteria. When used, it should be remembered that cefaclor can produce a serum sickness type reaction (Behrman & Kliegman, 1994). Cefprozil has a lower incidence of serum sickness, moderate cost, and requires only BID dosing. Cefuroxime axetil, with good beta-lactamase inhibition, is very effective against the three major causative organisms of AOM. It is not frequently prescribed, however, due to the poor taste of the suspension. Loracarbef is an alternative cephalosporin choice, but is less effective against H. influenzae and beta-lactamase producing organisms. Food decreases the absorption of Loracarbef, so it should be taken on an empty stomach. This may be particularly difficult with young children who tend to eat frequently.

Third generation cephalosporins available for AOM treatment include cefixime, cefpodoxine proxetil, and ceftriaxone. All three provide good coverage of the beta-lactamase producing strains of H. influenzae and M. catarrhalis. Cefpodoxine and ceftriaxone are also effective against S. pneumoniae, while cefixime is less effective against this organism. Cefixime has a long half-life with the advantage of once a day dosing and needs no refrigeration. Cefpodoxine is not frequently chosen for treatment of AOM due to poor taste. If prescribed to children being treated for gastroesophageal reflux, it must be remembered that absorption of cefpodoxine decreases with the use of antacids or H antagonists.

Ceftriaxone is available for intramuscular injection only. This is a good choice of treatment for a very ill child with vomiting or poor compliance with oral medication. It is administered in a single IM dose of 50 mg per kg. Disadvantages include pain at the injection site and the potential for induration or sterile abscesses. Overuse of ceftriaxone poses risk of increasing the multidrug resistance of S. pneumoniae. The newest cephalosporin, ceftibuten, has an extended half-life allowing once-a-day dosing. This antibiotic has exceptional beta-lactamase stability and is superior to other cephalosporins against the respiratory pathogens most commonly causing AOM (Nelson & McCracken, 1995).

All of the cephalosporins are relatively expensive compared to the traditional antibiotic choices of amoxicillin, TMP/SMX, and erythromycin/ sulfisoxazole. The most costly for 10day therapy include cefprozil, cefuroxime axetil, and cefpodoxine proxetil and cefixime (Mason, 1996; Pichichero, 1994). It must be remembered that children with penicillin allergy may have a 5% to !0% crosssensitivity to cephalosporins (Eden et al., 1996). Cephalosporin antibiotics should be prescribed with caution in these children.

Newer macrolide antibiotics that may be prescribed for AOM include clarithromycin and azithromycin. Clarithromycin is infrequently used due to the poor taste of the suspension. If used, it carries the same precautions regarding possible interaction with terfenedine and cisapride as erythromycin. Azithromycin, however, does not demonstrate these drug reactions.

Azithromycin has different pharmakokinetics and is found in high concentrations at local infection site (Nahata, 1995). Studies demonstrate prolonged action in tissue sites, making it unique in long term action. A five day course of azithromycin results in therapeutic levels of the drug persisting for six days after therapy, thus allowing a once a day, fiveday antibiotic course. Azithromycin studies indicate good coverage for the three major otitis media pathogens as well as good beta-lactamase inhibition (McLinn, 1995).

In conclusion, many factors are considered when selecting a course of antibiotic therapy. See Table 1 for a summary of antibiotic therapy profiles for otitis media.
Table 1. Antibiotic Therapy Profiles for Otitis Media
                                                          Beta-
DRUG                         S P      H I       M C       lactam
                                                          Inhibitor

AMOXICILLIN                  +        some      some      no
(Amoxil[R], Trimox[R])

AMOXICILLIN                  +        +         +         yes
CLAVULANATE
(Augmentin[R])

EES/Sulfasoxazole            +        +         +         yes
(Pediazole[R])

SMX/TMP                      +        +         +         some
(Bactrim[R], Septra[R])

CLARITHROMYCIN               +        some      +
(Biaxin[R])

AZITHROMYCIN                 +        +         +         yes
(Zithromax[R])

CEFACLOR (Ceclor[R])         +        some      +         yes

CEFPROZIL (Cefzil[R])        +        some      +         yes

CEFUROXIME AXETIL            +        +         +         yes
(Ceftin[R])

LORACABEF                    +        +         +         some
(Lorabid[R])

CEFIXIME (Suprax[R])         some     +         +         yes

CEFPODOXINE                  +        +         +         yes
PROXETIL (Vantin[R])

CEFTRIAXONE                  +        +         +         yes
(Rocephin[R[)

CEFTIBUTEN (Cedax[R])        +        +         +         yes

DRUG                       DOSAGE              ADVERSE
                                               REACTIONS

AMOXICILLIN                50 mg/kg/d          GI symptoms
(Amoxi[R], Trimox[R]       divided TID         Diarrhea
                           prophylaxis         Rashes - allergic
                           20 mg/kg hs

AMOXICILLIN                40 mg/kg/d          Diarrhea
CLAVULANATE                divided TID         Nausea/vomiting
(Augmentin[R])             45 mg/kg/d BID      Skin rashes

EES/Sulfasoxazole          50 mg/kg/d          GI subclinical
(Pediazole[R])             (EES)               elevation of LFTs
                           divided BID
                           to QID

SMX/TMP                    8 mg/kg TMP         Highest rate of
(Bactrim[R], Septra[R])    40 mg/kg/d          Steven-Johnson
                           SMX divided BID     Syndrome

CLARITHROMYCIN             15 mg/kg/d
(Biaxin[R])                divided
                           BID

AZITHROMYCIN               10 mg/kg/d          Gl effects
(Zithromax[R])             on day 1            Headache
                           5 mg/kg/d           Allergic
                                               reactions may
                           day 2 to 5          be prolonged

CEFACLOR (Ceclor[R])       40 mg/kg/d          GI symptoms
                           divided             Skin rashes
                           TID                 Serum sickness

CEFPROZIL (Cefzil[R])      30 mg/kg/d          Gl symptoms
                           divided             Skin rashes
                           BID                 Serum sickness

CEFUROXIME AXETIL          30 mg/kg/d          GI symptoms
(Ceftin[R])                divided             Rashes-urticaria
                           BID                 Serum sickness

LORACABEF                  30 mg/kg/d          GI symptoms
(Lorabid[R])               divided             Skin rashes-erythema
                           BID                 multiform

CEFIXIME (Suprax[R])       8 mg/kg/d           GI symptoms
                           Single dose         Skin rashes
                           Max: 400 mg         Steven Johnson
                                               Serum sickness

CEFPODOXINE                10 mg/kg/d          GI symptoms
PROXETIL (Vantin[R])       divided             Rashes
                           BID                 Increase in diarrhea

CEFTRIAXONE                50 rog/kg           GI symptoms
(Rocephin[R])              IM given            Skin rashes
                           in a single dose    Sterile abscesses
                                               Serum sickness

CEFTIBUTEN (Cedax[R])      9 mg/kg/d           GI symptoms
                           Single dose

DRUG                       COMPLIANCE          DRUG
                           ISSUES              INTERACTION

AMOXICILLIN                Needs
(Amoxi[R], Trimox[R]       refrigeration

AMOXICILLIN                Needs
CLAVULANATE                refrigeration
(Augmentin[R])             Take with food
                           6 hr between
                           doses

EES/Sulfasoxazole          QID dosing          Terfenidine
(Pediazole[R])             Poor taste          Theophylline
                                               Carbamazepine

SMX/TMP                    Poor taste          Decrease effect of
(Bactrim[R], Septra[R])    Least expensive     oral contraceptives
                                               Increase effect of
                                               oral
                                               hypoglycemics

CLARITHROMYCIN             No refrigeration    Terfenedine
(Biaxin[R])                Poor taste

AZITHROMYCIN               QD dosing for 5     May increase
(Zithromax[R])             days                theophylline levels
                           No
                           refrigeration
                           Give 1 hr ac
                           or 2 hr pc

CEFACLOR (Ceclor[R])       TID dosing
                           Needs
                           refrigeration
                           Good taste

CEFPROZIL (Cefzil[R])      Needs
                           refrigeration
                           Good taste
                           Moderate cost

CEFUROXIME AXETIL          Bitter taste
(Ceftin[R])                Better
                           absorbed with
                           food

LORACABEF                  Food
(Lorabid[R])               decreases
                           absorption -
                           Give 1 hr ac
                           or 2 hr pc

CEFIXIME (Suprax[R])       Single
                           dose q day
                           Good taste
                           No refrigeration

CEFPODOXINE                Bitter taste        Absorption
PROXETIL (Vantin[R])       Needs               decreased with
                           refrigeration       antacids and H2
                           Increased           antagonists
                           absorption
                           with food

CEFTRIAXONE                Pain at
(Rocephin[R])              injection site

CEFTIBUTEN (Cedax[R])


Abbreviations: SP= Streptococcus pneumoniae HI= Haemophilus infiuenzae MC= Moraxella catarrhalis

Sources: Physician's Desk Reference (1998); Mason (1996); Pichichero (1994); Eden, Fireman, & Stool (1996); Goldfarb (1995); Schentag, (1995).

Controversy Over Antibiotic Use

Much of the discussion above concerns the use of new antibiotics to combat antibiotic-resistant bacteria. In The Antibiotic Paradox (1992), Dr. Stuart Levy points out that it is precisely the success of antibiotic therapy that has created tremendous selective pressure in favor of bacteria that are antibioticresistant. Thus, overuse of antibiotics containing beta-lactamase inhibitors will help generate bacteria that are resistant by some other mechanism. The recommendation that practitioners start with first line antibiotics is critically important to stemming the tide of antibiotic-resistant pathogens. Similarly, discontinuing treatment prior to completion of the full course allows bacteria resistant to that antibiotic to become dominant.

Clinicians have become increasingly aware of the problems associated with the indiscriminate use of antibiotic therapy in everyday primary care practice. The American Society of Microbiology found that AOM is the most common reason for prescribing antibiotics in the United States. The organization attributes much of the antimicrobial resistance of H. influenzae and S. pneumoniae to the treatment of AOM (American Society for Microbiology, ! 995). Most pediatric primary care providers in this country continue to prescribe antibiotics for symptomatic cases of AOM. Overuse of antibiotics must be avoided, and practitioners should avoid diagnosis of AOM by telephone, or over diagnosis and treatment due to coercion by anxious, concerned parents Pichichero, 1994).

It is also important to remember that 70 to 90% of AOM may resolve spontaneously with no antibiotic treatment (Rosenfeld et al., 1994). Routine use of antibiotics has become more controversial in recent years. In the United Kingdom and many European and Scandinavian countries, uncomplicated AOM is treated with analgesics and supportive care. These countries report a high rate of spontaneous resolution and few complications.

A meta-analysis of antibiotic use in AOM concluded that antibiotics shorten the length of the acute illness. There was also increased symptomatic relief in studies that compared the use of antibiotics and a placebo for treatment of AOM. The analysis concluded that even though a small percentage of children benefited from antibiotic use, it was impossible to predict ahead of time which children they would be. The researchers endorsed a qualified approval for the use of antibiotics (Rosenfeld et al., 1994). Experts in the field of pediatrics and infectious disease have urged that greater caution be used in prescribing antibiotics for this common childhood illness.

Parent Education

Parents need information about the prevention and treatment of otitis media. All new mothers should be encouraged to breast feed their infants because of the immunologic benefits. Parents who choose to bottle feed must be aware of proper positioning during feeds. Positioning the child upright during feeds is best because lying the child flat can permit the entrance of liquid into the eustachian tube. Other preventive measures include avoidance of cigarette smoke and other children and adults who are sick (Eden et al., 1996).

Successful treatment of AOM is accomplished when parents are aware of their responsibilities in treatment. They need instructions on dosage, frequency, and completion of antibiotics. Parents should know that if symptoms do not subside within 23 days, or if they worsen, that the primary care provider must be called (Eden et al., 1996).

Pain associated with AOM usually resolves within 2-3 days from the start of antibiotic therapy. Parents can employ pain relief measures until the infection begins to resolve. Pain associated with AOM can be managed with pharmacologic and non-pharmacologic methods. Parents should be instructed to use warm compresses, distraction, and relaxation techniques to relieve associated ear pain (McCaffery & Beebe, 1989).

Analgesics with antipyretic effects such as acetaminophen (10-20 mg/kg every 4-6 hours) or ibuprofen (5-10 mg/kg every 6-8 hours), are effective oral medications for pain relief. Older children may benefit from analgesics containing codeine. Eardrops containing benzocaine and antipyrine (Auralgan) provide a local anesthetic effect, until the infection begins to resolve (Berman, 1996; McCaffery & Beebe, 1989).

Nurses can play an important role in providing parents with the information they need to help prevent AOM. Through prevention and early detection, serious complications and sequelae can be avoided. A practice protocol is presented in Table 2.

Table 2. Practice Protocol

Acute Otitis Media

Acute Otitis Media (suppurative otitis media, acute bacterial otitis media or purulent otitis media).

Definition

0titis media is one of the most common diagnoses made in primary care. Acute otitis media is defined as inflammation of the middle ear, and may be accompanied by other signs and symptoms.

Pathophysiology

Children are at risk because their eustachian tubes are shorter and straighter than adults. Acute otitis media frequently occurs following a viral upper respiratory infection. The child may develop fever, otalgia, irritability, anorexia, vomiting, or diarrhea. Complications include, but are not limited to hearing loss, perforation of the tympanic membrane, cholesteatoma, acute mastoiditis, meningitis, and epidural abscess.

Physical Examination

Diagnosis of acute otitis media is based upon the appearance of the tympanic membrane. Positive physical findings by pneumatic otoscopy include the following:

* full or bulging TM

* absent or obscured bony landmarks

* distorted light reflex decreased or absent mobility of TM by pneumatic otoscopy; bullae may form between layers of TM, often associated with mycoplasma pneumoniae

*** Erythema of TM is an inconsistent finding

Common Organisms

* Streptococcus pneumoniae

* Haemophilus influenzae (non-typable)

* Moraxella catarrhalis

Other (less commonly occurring):

* Group A Beta- Streptococcus

* Staphylococcus aureus

* Pseudomonas aeruginosa

* Haemophilus influenzae type B

Diagnostic Tests

* Usually none needed

* Tympanometry

* Consider ordering sinus films in clients with recurrent otitis media or otitis media with effusion

* Order CBC with differential and blood cultures in infants less than 3 months who appear toxic, have a high fever, or are immunocompromised

* Consider audiometry posttreatment

Treatment

Amoxicillin/Amoxil (40 mg/kg/day) in three divided doses for 10 days. Initial drug of choice because it is inexpensive and has few side effects. Two disadvantages are its ineffectiveness against B-lactamase producing pathogens, and its inability to be used in clients with penicillin allergies.

Initial therapy in the penicillin allergic child:

* Erythromycin ethylsuccinate sulfisoxazole acetyl/ Pediazole (50 mg/kg/day) in four divided doses for 10 days; or

* Trimethoprim sulfamethoxazole/Bactrim[R]/Septra[R] (8 mg/kg/day TMP, 40 mg/kg/day SMX) in two divided doses.

For B-lactamase producing organisms give one of the following:

* Cefprozil (Cefzil[R]) (30 mg/kg/day) in 2 divided doses for 10 days.

* Amoxicillin/clavulanate potassium (Augmentin[R]) (40 mg/kg/day) in three divided doses or (45 mg/kg/day) in two divided doses.

* Erythromycin-sulfisoxazole)/Pediazole not in infants < 2 months; 40-50 mg/kg/day in 4 divided doses.

* Bactrim/Septra not in infants < 2 months old; TMP 8 mg, SMX 40 mg/kg/day in 2 divided doses.

Complications

1. Tympanic membrane perforation; purulent drainage in the ear canal is visible. Healing of TM will occur spontaneously most of the time.

2. Mastoiditis: suppuration and osteomyelitis of mastoid air sacs. Area behind ear is red, swollen and tender. Auricle may protrude. Refer to ENT.

3. Meningitis: a child who does not have marked improvement in 24-48 hours and develops vomiting associated with fever; child will appear toxic.

4. Hearing loss; usually resolves.

5. Speech and language delay if chronic OM with failed tympanograms; especially during periods of language acquisition.

Patient Education

1. Follow-up if resolution of symptoms does not occur in 48-72 hours.

2. In routine cases follow-up visit should be scheduled after completion of antibiotic therapy.

Note: Adapted from Graham, M.V., & Uphold, C.R. (1994). Clinical guidelines in child health. Gainsville, FL: Barmarrae Books; and Burns, C., Barbar, N., Brody, M., & Dunn, A. (1996). Pediatric primary care: A handbook for nurse practitioners. Philadelphia: W.B. Saunders Company.

References

American Society for Microbiology. (1995). Report of the ASM task force on antibiotics. Washington, DC: American Society for Microbiology.

Barnett, E.D., & Klein, J.O. (1995). The problem of resistant bacteria for the management of acute otitis media. Pediatric Clinics of North America, 42(3), 509-516.

Behrman, R.E., & Kleigman, R.M. (1994). Essentials of pediatrics. Philadelphia: W.B. Saunders Company.

Benitz, W.E., & Tatro, D.S. (Eds.). (1995). The pediatric drug handbook. St. Louis: C.V. Mosby Company.

Berman, S. (1995). Current concepts: Otitis media in children. The New England Journal of Medicine, 332(23), 1560-1565.

Bluestone, C.D., Stephenson, J.S., & Martin, L.M. (1992). Ten-year review of otitis media pathogens. Pediatric Infectious Disease Journal, S11, 7-11.

Burns, C., Barbar, N., Brody, M., & Dunn, A. (1996). Pediatric Primary care: A handbook for nurse practitioners. Philadelphia: W.B. Saunders Company.

Eden, A.N., Fireman, P., & Stool, S. (1996). Managing acute otitis: A fresh look at a familiar problem. Contemporary Pediatrics, 13(3), 64-82.

Eisen, A.N., Miller, D.K., Woodward, R.S., Spitznagel, E., & Przybeck, T.R. (1990). The effect of prescribed daily dose frequency on patient medication compliance. Archives of Internal Medicine, 150, 1881-1883.

Goldfarb, J. (1995). New antimicrobial agents. The Pediatric Clinics of North America, 42(3), 717-735.

Graham, M.V., & Uphold, C.R. (1994). Clinical guidelines in child health. Gainsville, FL: Barmarrae Books.

Harrison, C.J. (1995). Perspectives on newer oral antimicrobials: What do they add? Pediatric Infectious Disease Journal, 14(5), 436-444.

Hoekelman, R., Friedman, S., Nelson, N., & Siedel, H. (1992). Primary pediatric care. St. Louis: Mosby Year Book, Inc.

Klein, J.O. (1994). Current issues in upper respiratory tract infections in infants and children: Rationale for antibiotic therapy. Pediatric Infectious Disease Journal, 13(1), S5-S8.

Levy, S.B. (1992). The antibiotic paradox: How miracle drugs are destroying the miracle. New York: Plenum Publishing Company.

Mason, W. (1996). The management of common infections in ambulatory children. Pediatric Annals, 25(11), 620-630.

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Nancy H. Montville, MSN, RN, C, is a Pediatric Nurse Practitioner, Watchung Pediatrics, Watchung, NJ.

Mary A. White, MSN, RN, C, is a Pediatric Nurse Practitioner, Watchung Pediatrics, Watchung, NJ.
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Author:Montville, Nancy H.; White, Mary A.
Publication:Pediatric Nursing
Date:Sep 1, 1998
Words:4825
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