Acute Otitis Media by mikeholy


									             Acute Otitis Media

Continuity Clinic
  • Define otitis media (OM), acute otitis
    media (AOM) and otitis media with
    effusion (OME)

  • Be familiar with the epidemiology of AOM

  • List causative pathogens in children with
    AOM and current bacteriologic resistance
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                                        1999 7th International Symposium on Recent Advances in Otitis Media

                                    Terms and Definitions
 Otitis Media (OM)                  Inflammation of the middle ear without reference to cause or pathogenesis.1

 Middle Ear Effusion (MEE)          Liquid in the middle ear but not the etiology, pathogenesis, or duration (recent onset,
                                    acute, subacute or chronic).1
                                     Serous: thin, watery liquid
                                     Mucoid: a thick, viscid mucus-like liquid
                                     Purulent: a pus-like liquid
                                     A combination of these

 Otitis Media with Effusion (OME)   Inflammation of the middle ear with a collection of liquid in the middle ear space.
                                    Signs and symptoms of acute infection absent.1
                                    Serous, secretory or non-suppurative otitis media are terms that are no longer

 Acute Otitis Media (AOM)           Inflammation of the middle ear that is of rapid and short onset in association with
                                    signs and symptoms indicating acute infection. The tympanic membrane is full or
                                    bulging, opaque, and has limited mobility. Erythema is an inconsistent finding.1
                                    One or more local or systemic signs are present: otalgia, otorrhea, fever, irritability,
                                    anorexia, vomiting or diarrhea.

 Otorrhea                           Discharge from:1
                                     external auditory canal
                                     middle ear
                                     mastoid
                                     inner ear or intracranial cavity

Continuity ClinicMiddle ear disorder that can have symptoms similarusually absent. such as hearing
 Eustachian Tube Dysfunction
                             loss, otalgia, and tinnitus, but middle ear effusion is
                                                                                     to otitis media,
                    Distinguishing AOM from OME
       At least two of :
       1. Abnormal color: white, yellow,
                                                           Bubbles or air-fluid interfaces               Acute purulent otorrhea
                             amber, blue           Or
                                                                  behind the TM                          not due to otitis externa
       2. Opacification not due to scarring
       3. Decreased or absent mobility

                                    Yes                        Yes

                                   Middle Ear Effusion

                               No Acute                        Acute
                             Inflammation                  Inflammation

                                                        1. Distinct fullness or bulging of the TM
                                                        2. Substantial ear pain, including
                                                           unaccustomed tugging or rubbing of
                                                           the ear
                                                        3. Distinct erythema of the TM


        Otitis Media with Effusion                                 Acute Otitis Media
                  (OME)                                                 (AOM)

                              Hoberman A. Clinical Pediatr 2002;41:373-390 (reprinted with permission)

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       Prevalence of Otitis Media
   • 1993 - 1995 (NCHS),2 OM accounted for
       18% ambulatory visits (1-4 yr)
       14% visits during the 1st yr of life

   • AOM episodes diagnosed2
       81% in pediatric practices
       13% in hospital ED
       6% in hospital outpatient departments

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         Prevalence of Otitis Media
    • Peak incidence of OM occurs during the first 2

    • 60%-70% of children have >1 AOM before 1st

    • Early onset (<6 mo) associated with recurrent
      AOM and chronic OME

    • Recurrent AOM, >3 episodes/6 mo or >4
      episodes/yr, ~ 20% of children

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          Prevalence of Otitis Media
    AOM and OME, segments of a disease

    Mean cumulative time with MEE (AOM or
         20.4% in 1st yr
         16.6% in 2nd yr

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            Risk Factors for OM
    • Host factors
          Age/Gender
          Genetic predisposition
          Cleft palate/Down syndrome
          Allergy/Immunity
    • Environmental factors
          Daycare/Siblings
          Bottle (versus breast) feeding
          Pacifier use
          Smoking
          Low socioeconomic status
          Season/Upper respiratory infections
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       Host-Related Risk Factors

         AOM most prevalent between 6 and 11 mo

         Shorter, horizontal lying eustachian tube

         Males, higher cumulative time with OME

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        Environmental Risk Factors

 Day Care Attendance
     Most important risk factor
     50-70% children 6-18 mo attending day care have
      bilaterally persistent OME
     Number of children in day care, hours spent, age
      at entry and siblings in daycare influence risk
     Day care increases risk of infection, use of
      antibiotics, thus increasing selection of resistant
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          Environmental Risk
 Exposure to Household Cigarette Smoke
     Positive relationship between smokers in
      household and OM during 1st but not 2nd year5
     Increased levels of cotinine in saliva correlated
      with abnormal tympanograms and number of
     Association between early AOM onset and
      cotinine in urine not found

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           Pathophysiology of AOM
                                                                                                               Otitis Media

    Host Factors
     • Immature/impaired                                                                                   Dysfunction
                                                                                                           • Eustachian tube
     • Familial predisposition
     • Type of milk (breast                                                                                • Cleft Palate
        or formula)
      • Gender
      • Race

                                  Allergy                                           Environmental

                         Bluestone CD. Pediatr Infect Dis J. 1996:15:281-291 (reprinted with permission)

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         Pathophysiology of AOM
  • Eustachian tube (ET) functions include ventilation,
    protection and clearance of secretions
  • Impairment ET function MEE
  • URI  inflammation of nasopharynyx (NP) and ET
  • Inflammation  ET dysfunctionnegative middle
    ear pressure
  • Organisms colonizing NP aspirated into middle ear
    resulting in AOM

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                  Microbiology: Antimicrobial
                                     Resistant (MICs 2 µg/mL)

                                     Intermediate (MICs 0.12-1 µg/mL)

     Resistance (%)






   Year       1988-891 1990-911 1992-931 1994-952 1997-982 1999-002 2001-023
   # Isolates   476      524      799      1527     1601     1531     1925
                           1.   Doern GV. Am J Med. 1995; 99:3S-7S
                           2.   Doern GV. ACC. 2001;45:1721
                           3.   Doern GV. Unpublished data

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Bacterial Resistance Against β-Lactam Abx

  β-lactamase                                                                     Peptidoglycan cell wall
  enzymes inactivate
  β-lactam antibiotics                                                                Plasma membrane

                                                      Altered PBPs

                                                                                           Resistance increases
                                                                                           as altered PBPs
Clavulanic acid                                                                            accumulate
irreversibly binds to
β-lactamase protecting
                                     Antibiotic                        Normal PBP
β-lactam antibiotics from            β-lactamase                       Altered PBP
enzymatic cleavage                   Clavulanic acid
                         Jacobs MR. Am J Manag Care. 1999;5(suppl 11):S651-S661   .
      Bacterial Resistance Against
  Bacteria alter macrolide binding site                               Bacterial efflux pumps
    (ermAM gene, MLSB phenotype)                                    (mefE gene, M phenotype)
                                                                                
Macrolide unable to block protein synthesis                         Macrolide excreted from cell

                               50       50       50
                               30       30       30


                        Jacobs MR. Am J Manag Care. 1999;5(suppl 11):S651-S661
               Antibiotic Options
  • 1st Line
     – Amoxicillin : low versus high dose
     – Augmentin
     – PC allergy  Zithromax
  • 2nd Line
     – Cephalosporins
     – Zithromax

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         The Observation Option
         Limited to healthy kids over the age of 6mos

         May observe age group 6 months to 2 years if
         AOM is uncertain and pt has nonsevere illness.

             What defines a severe illness?

                    fever ≥ 39 C or 102.2 F, severe otalgia

         Older than 2 years if nonsevere illness

         Family has access to doctor, and family
         member to close eye on patient

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            A picture is worth a
           thousand words…….

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            Acute Otitis Media?

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            Acute Otitis Media?

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         What is your diagnosis?

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         What is your diagnosis?

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   Bonus Question -What is this?

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