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Antibiotics for Acute Otitis Media


Antibiotics for Acute Otitis Media in Children - Antibiotics for AOM - Antibiotics Acute Otitis Media Children - Acute Otitis Media Antibiotic Treatment - Acute Otitis Media Antibiotic Therapy

Otitis media is the most common outpatient diagnosis with a bacterial etiology made in pediatric practice. The incidence is 10-20 %for each year of life up to 6 years of age and then decreases dramatically to less than 1 % by the age of 12. By definition, these patients require antimicrobial therapy and therefore, this diagnosis accounts for the greatest proportion of antimicrobial prescriptions written.

After respiratory infections, inflammation of the middle ear is the most prevalent disease of childhood. The other areas of the temporal bone which can be contiguous with the middle ear, including the mastoid, petrousus apex and perilabyrinthine air cells, may also be involved. Otitis media can be further divided into acute otitis media (AOM) without effusion, otitis media with effusion (OME), chronic suppurative otitis media (COM) with or without cholesteatoma, and atelectasis of the tympanic membrane, middle ear or mastoid. Acute otitis media is usually suppurative or purulent, but serous effusions may also have an acute onset.

Signs and Symptoms of Acute Otitis Media

  • Often there is a history of a preceding URI. There may be fever, irritability, ear pulling,, vomiting, diarrhea, and pain on swallowing.
  • The older child will complain of ear pain and the younger child may awake at night with some discomfort.
  • Otorrhea: spontaneous rupture of the tympanic membrane
  • Decreased hearing
  • Vertigo, nystagmus, tinnitus, and facial paralysis are unusual presenting symptoms.
  • Eye drainage: infections secondary to non-typable H. influenza are often associated with conjunctivitis
Acute otitis media is the inflammation of the area behind the tympanic membrane (TM, eardrum). The middle ear contains air and is placed behind the eardrum. When the eardrum vibrates, tiny bones within the middle ear transmit the sound signals to the inner ear. In the inner ear, nerves are stimulated in order to relay the sound signals to the brain. The eustachian tube, which connects the middle ear to the nose, normally ventilates and equalizes pressure of the middle ear. When child’s ears “pop” while yawning or swallowing, the eustachian tube adjusts the air pressure in the middle ear.

Acute otitis media is an infection that produces pus, fluid, and inflammation in the middle ear. Older children often complain about ear pain, ear fullness, or hearing loss. Irritability, fussiness or difficulty in sleeping, feeding or hearing may be seen in infants. Fever may be present in a child of any age.

These symptoms are frequently associated with signs of upper respiratory infection, such as a runny or stuffy nose or a cough. Severe ear infections may cause TM rupture. If TM rupture occurs the pus then starts to drain through out of the middle ear and into the ear canal. The hole in the eardrum from the rupture usually heals after medical treatment.

Although the incubation period is variable, otitis media is usually develops 4 to 7 days after upper respiratory tract infection

Diagnosis of Acute Otitis Media

The tympanic membrane can not be adequately seen while partially occluded by cerumen. Cerumen removal by curette is essential and should be regularly used. If the wax is dry or deep in the auditory canal then cerumenolytics and/or warm water irrigation may be necessary.

Pneumatic otoscopy has been advocated as an important adjunct to assist in diagnostic accuracy of AOM yet most physicians find it inconvenient or remain unconvinced. Four characteristics of the TM should be evaluated and described in every examination (position, mobility, colour, degree of translucency). The normal TM is in the neutral position (neither retracted nor bulging), pearly gray, translucent and responds briskly to positive and negative pressure, indicating an air filled space. The abnormal TM may be retracted or bulging, and immobile or poorly mobile to positive and/or negative air pressure. The colour of the eardrum is of minor importance although patients with AOM more often have a red TM. The key differentiating features of AOM compared to OME on physical exam relate to TM position. In AOM the TM almost always is bulging and in OME it is usually retracted or, occasionally, it is in neutral position. The TM is thickened in both AOM and OME, thereby reducing visibility through it. Sometimes a yellow or grayish middle ear effusion can be seen behind the TM in either condition.

Tympanometry and acoustic reflectometry each have attributes which make them of value in providing information about the possible presence of a middle ear effusion. The sensitivity, specificity, positive predictive value and negative predictive value of the two instruments has been assessed in comparison with pneumatic otoscopy, audiometry and tympanocentesis findings. As a result both of them have some limitations. Acoustic reflectometry has the advantage of not requiring a seal within the canal which improves its usefulness in the crying child because a reading can be obtained when a child stops crying to take a breath. Tympanometry provides additional information about actual pressures within the middle ear space.

Myringotomy is not necessary rountinely for the patient with intense pain and imminent rupture of the membarane it provides dramatic relief. (14-17). Selective use of tympanosynthesis may improve diagnostic accuracy because it validates or refutes the physicians’ impression after visual examination. Certainly proper restraint of the patient and excellent visualisation of the TM are essential; mild sedation may also be helpful in some cases. Tympanosynthesis should be performed and it is beneficial.

Treatment of Acute Otitis Media

Antimicrobial therapy is one of the cornerstones in the management of AOM but some studies have suggested that its routine use is not indicated. As the most cases of AOM resolve spontaneously, antimicrobial therapy is not always necessary. Nonetheless, complications such as mastoiditis may be developed, so that; routine use of antibiotics were recommended. It is probably not possible to determine a priori which cases of AOM will result in suppurative complications, it is likewise not possible to determine which cases require antimicrobial therapy and which will resolve spontaneously. Therefore, it appears prudent to consider all cases of AOM candidates for antimicrobial therapy in order to minimize the likelihood of complications. Some authors recommend watchful waiting for 48 to 72 hours before initiating antibiotic therapy. This approach may be feasible in children over two years of age if good follow-up can be assured; therefore, decisions about whether to withhold antibiotics therapy initially must be made on a patient-by-patient basis.

The most frequent etiological bacterial agents are S. pneumoniae, H. influenzae, M.catarrhalis, group A streptococcus and S. aureus. Viruses continue to cause a substantial minority of cases, and antibiotic therapy would not be expected to affect the outcome. With the increasing prevalence of beta-lactamase- producing (penicillin-resistant) strains of H influenzae and M catarrhalis, alarms have been sounded about the wisdom of routinely using aminopenicillins (such as amoxicillin) as the standard first-line antimicrobial for uncomplicated AOM. Despite theoretical concerns about the diminishing usefulness of amoxicillin, it continues to be as effective as any other oral antimicrobial agent for childhood AOM. Most comparative trials of antimicrobial therapy in AOM have failed to demonstrate a difference in effectiveness between amoxicillin and any other agent. Their use may be associated with relatively high rates of side effects and may increase the pressure for selection of multiple antibiotic-resistant strains of bacteria (Table 2). Therefore, because of its excellent track record’ (for infections due to penicillin-susceptible and- resistant bacteria), low cost, safety and acceptability to patients, amoxicillin remains the drug of choice for uncomplicated AOM.

Antibiotics in Acute Otitis Media
There is still some debate whether antibiotics influence the short term outcome of acute otitis media.

Choice of antibiotic
Amoxicillin is the recommended first-line antibiotic for acute otitis media (AOM) where antibiotics are indicated. Five days treatment at the following doses is sufficient for uncomplicated ear infections in children:

  • under 2 years, 125mg three times daily
  • 2-10 years, 250 mg three times daily
  • over 10 years, 500 mg three times daily

Erythromycin is an alternative for penicillinallergic patients, although it is less effective against Haemophilus influenzae, which is the cause of AOM in around 25% of people

  • azithromycin and clarithromycin are alternatives that are effective against all the main pathogens that cause AOM
  • Some studies suggest that antibiotics are associated with a reduction of middle ear effusions, particularly when they are unilateral, three months post treatment.

    Antibiotics used in AOM do not affect:

  • the recurrence rate of otitis media
  • the referral rate for ENT problems
  • prevalance of middle ear effusions at one month
  • Pain and crying drops off markedly, whether or not the child is treated with antibiotic from the begining of the second day.

    Short course antibiotics for healthy children with uncomplicated acute otitis media (Review)
    Acute otitis media (AOM), or middle ear infection, is a common childhood illness, with more than half of all children having at least one infection by the time they are seven. Although otitis media often resolves without treatment, it is frequently treated with antibiotics. The length of treatment varies widely. This review of 49 trials found that treating children with a short course (less than seven days) of antibiotics, compared to treatment with a long course (seven days or greater) of antibiotics, increases the likelihood of treatment failure in the short term. No differences are seen one month later. The amount of gastrointestinal adverse events decreased with a shorter course of antibiotics.

    Antibiotics for AOM in children younger than 2 years

    Clinical question Should we routinely use antibiotics to treat children with acute otitis media (AOM) who are younger than 2 years?

    Background The use of antibiotics for AOM is controversial because of the lack of consistent supporting data and the concerns about increasing antimicrobial resistance. Although many physicians in the United States routinely treat AOM with antibiotics, physicians in other countries do not. Meta-analysis of the treatment of otitis media in children of all ages found that from 7 to 17 children have to be treated with antibiotics for 1 to receive benefit (number needed to treat = 7 - 17). Such a large range of effectiveness makes the decision to treat more difficult. One explanation for the variable results could be that antibiotic use is important for a particular subgroup, such as for children younger than 2 years, who may be more likely to follow an abnormal course of illness. This systematic review and meta-analysis evaluated and combined the results of studies investigating antibiotic treatment in children of this age group.

    Population studied Studies selected for inclusion in this review enrolled 832 children younger than 2 years of age along with older children with AOM. The data for children younger than 2 years were extracted for analysis.

    Study design and validity Articles were located using the following key words on MEDLINE and EMBASE: otitis media, child, clinical trial, and placebo. References in those articles were also assessed. The meta-analysis included studies that trued random allocation to different treatment groups, compared antibiotic therapy with nonantibiotic therapy, and provided specific data for children younger than 2 years. The quality of the studies was assessed by blinded reviewers using criteria in 4 categories: study protocol, blinding procedures, testing procedures, and statistical analysis.

    This meta-analysis was limited by the small number of robust studies available for analysis. Only 6 studies met the main inclusion criteria. Their methodologic quality scores ranged from 27% to 73%. Only 4 studies provided quantitative data that could be separated for children younger than 2 years. Only 2 studies were truly placebo controlled. Of those, one included only recurrent AOM and the other only nonsevere episodes. No analysis of heterogeneity was reported.

    Two other problems limit this analysis. Half of the included studies used myringotomy, either for therapeutic reasons or to identify the etiology of the infection. The maneuver might have improved outcomes, especially in children treated with placebo. Also, the diagnosis of AOM was likely variable across, and perhaps within, the studies. Although 3 studies assessed clinical signs of acute infection, the fundamental diagnosis of AOM was made by the subjective assessment of otoscopic appearance in at least 5 of the 6 studies. One study did not describe the diagnostic criteria.

    Outcomes measured The primary outcome measured in all of the studies was symptomatic clinical improvement within 7 days of the start of treatment.

    Results The authors found no statistically significant difference between treatment with antibiotic and placebo for children with AOM who were younger than 2 years, judged by clinical improvement within 7 days (common odds ratio [OR] = 1.31; 95% confidence interval [CI], 0.83-2.08). Restricting the quantitative analysis to studies with a methodologic quality of 60% or more did not change the results (OR = 1.42; 95% CI, 0.85-2.39).

    Recommendations for clinical practice Although this study does not support the use of antibiotics for children with AOM who are younger than 2 years, it is not robust enough to recommend changing a physician's current practice. However, there are other more compelling research data to discourage the automatic use of antibiotics: the financial cost and potential side effects of antibiotic treatment, the increase in antibiotic resistance, and the reports that 80% of untreated children with AOM are pain-free within 24 hours. The potential benefits of treatment with antibiotics rarely outweigh their cost. This study can be added to the literature that discourages the casual use of antibiotics for treatment of AOM.

    Acute Otitis Media, Treatment of Acute Otitis Media in Children
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