otitis%20media%20-%20acute%20(pediatric)
OTITIS MEDIA - ACUTE (PEDIATRIC)
Otitis media is a general term used to describe inflammation of the middle ear which may be caused by an acute infection.
The symptoms are usually nonspecific and include otalgia (pulling of ear in an infant), irritability, otorrhea with or without fever.
Symptoms of upper respiratory tract infection may also be present

Principles of Therapy

  • Depending on the diagnostic certainty, patient’s age, illness severity & assurance of follow-up, selected patients may be treated w/ observation w/o antibiotic therapy
    • Placebo-controlled trials have shown that most patients improve w/o adverse consequences w/o antimicrobial therapy
  • An antibiotic prescription may be given to the guardian if patient’s symptoms worsen w/in 2-3 days or anytime during the observation period
Patients Who Should be Treated Initially w/ Antibiotics
  • ≥6 months old, w/ either unilateral or bilateral acute otitis media (AOM), presenting w/ severe illness
    • Severe illness is considered if otalgia is moderate to severe for >48 hours or fever ≥39°C
  • ≥6 months old, w/ AOM, w/ otorrhea
  • 6-24 months old, w/ bilateral AOM, presenting w/ mild otalgia for <48 hours & fever <39°C, no otorrhea
  • 6-24 months old, w/ unilateral AOM, & presenting w/ non-severe illness (mild otalgia for <48 hours & fever <39°C), no otorrhea
  • ≥2 years old, w/ unilateral or bilateral AOM, w/ non-severe illness (mild otalgia for <48 hours & fever <39°C)
  • Recurrent otitis media
Patient Who May be Observed Initially (Ensure follow-up)
  • 6-23 months old, w/ unilateral uncomplicated AOM & presenting w/ non-severe illness (mild otalgia for <48 hours & fever <39°C)
  • ≥2 years old, w/ unilateral or bilateral uncomplicated AOM, w/ confirmed diagnosis, & presenting w/ non-severe illness (no otorrhea)
Patients Who have been Previously Treated w/ Antibiotics
  • Childn previously treated w/ Amoxicillin w/in the last 30 days or diagnosed w/ concurrent purulent conjunctivitis or w/ a history of recurrent unresponsive to Amoxicillin, should be given antibiotics w/ beta-lactamase coverage
  • Shift to other antibiotics if child’s symptoms worsen or disease is unresponsive w/in 48-72 hours of treatment

Pharmacotherapy

Analgesics
  • Eg Paracetamol, Ibuprofen
  • Considered the mainstay of pain relief for acute otitis media (AOM)
  • Effective analgesia for mild-moderate pain

Topical agents

  • Eg Benzocaine, Lidocaine, Procaine
  • May provide temporary relief in patients >5 years
Antibiotics
Advanced Macrolides
  • Eg Azithromycin, Clarithromycin
  • These agents have decreased activity against drug-resistant S pneumoniae
    • Drug resistance to pneumococcus should be checked
  • May be given to patients w/ type I allergy to Penicillin & those refractory to advanced antibiotic therapy
Amoxicillin/High-dose Amoxicillin
  • Amoxicillin at sufficient doses is still considered the 1st-line agent for AOM
  • Recommended for pediatric patients w/o history of antibiotic intake within the last 30 days prior to administration of Amoxicillin
    • Child should be concurrent purulent conjunctivitis-free & w/o history of allergy to Penicillin
  • It is effective against most of the bacteria which cause AOM including susceptible & intermediate-resistant pneumococci
  • In areas where penicillin-resistant/nonsusceptible pneumococci are common, high-dose Amoxicillin should be given
Amoxicillin/Clavulanic acid (High dose)
  • High doses of Amoxicillin combined w/ Clavulanic acid are recommended for patients who fail standard Amoxicillin therapy or in those who present w/ severe or recurrent illness
  • This combination will provide coverage for beta-lactamase producing organisms (eg H influenzae & M catarrhalis) along w/ Penicillin-resistant/nonsusceptible S pneumoniae
Amoxicillin/Sulbactam
  • Effective against beta-lactamase producing bacterial strains (eg S pneumoniae, H influenzae & M catarrhalis)
  • Indicated for treatment of infections resistant to single therapy w/ beta-lactam or cephalosporins
Ceftriaxone [Intravenous (IV)/Intramuscular (IM)]
  • May be considered in patients unable to take oral medications
  • Treatment x 3 days is also recommended in patients who have failed Amoxicillin/clavulanic acid therapy & those w/ type I allergy to Penicillin
  • Has superior efficacy to S pneumoniae compared w/ alternative oral antibiotics
Cephalosporins (2nd & 3rd Generation)
  • Cefdinir, Cefixime, Cefpodoxime, Cefprozil & Cefuroxime are the preferred agents because of their effectiveness against drug resistant S pneumoniae, H influenzae & M catarrhalis
  • Cefdinir, Cefpodoxime & Cefuroxime are highly unlikely to develop cross-reactivity to Penicillin
  • These agents may be considered in patients w/ non-type 1 hypersensitivity reaction to Penicillin
Clindamycin
  • May be given to patients w/ type I allergy to Penicillin & those refractory to advanced antibiotic therapy
  • May be considered in a patient who has persistent AOM after previous complete antibiotic therapy & in whom tympanocentesis is not possible for Gram stain & culture
  • Clindamycin may be effective against Penicillin-resistant pneumococcal infection not responding to other treatment
  • Clindamycin is not active against H influenzae or M catarrhalis & should not be used if these organisms are suspected
Co-trimoxazole
  • Co-trimoxazole may be considered in patients w/ type 1 allergy to Penicillin
Macrolides
  • Eg Azithromycin, Clarithromycin, Erythromycin
  • May be considered in patients w/ type 1 allergy to Penicillin
  • Less efficacy against S pneumoniae & H influenzae compared to Penicillin
  • Depending on local resistance patterns, may be preferred over Co-trimoxazole
Duration of Antibiotic Therapy
  • Optimal duration of antimicrobial therapy in AOM patients is uncertain
Patient <2 years, severe illness or complicated presentation
  • Continue antibiotics x 10 days
Patient ≥2 years, mild-moderate illness & uncomplicated presentation
  • Continue antibiotics x 5 days

Non-Pharmacological Therapy

Pain Management
  • Application of warm or cold compress on the affected ear may help alleviate pain
  • Oil drops applied on the external auditory canal may also be helpful
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