Focus On... Critical Decisions : Acute Otitis Media in Children

by DavidC. Turell, MD, FAAP 

David C. Turell, MD, FAAP, wrote “Acute Otitis Media in Children.” Dr. Turell is a staff physician at the Cleveland Clinic, Pediatric Urgent Care, Department of General Pediatrics, in Cleveland, Ohio. Robert C. Solomon, MD, is Medical Editor of ACEP News and editor of the “Focus On… Critical Decisions” series, core faculty in the emergency medicine residency at Allegheny General Hospital, Pittsburgh, Pennsylvania, and assistant professor in the Department of Emergency Medicine at Temple University School of Medicine, Philadelphia. Mary Anne Mitchell is an ACEP staff member who reviews and manages the ACEP “Focus On… Critical Decisions” series.  

Disclosures 
In accordance with the Accreditation Council for Continuing Medical Education (ACCME) Standards and American College of Emergency Physicians policy, all individuals in control of content must disclose to the program audience the existence of significant financial interests in or relationships with manufacturers of commercial products that might have a direct interest in the subject matter. 
Dr.Turell, Dr. Solomon, and Ms. Mitchell have disclosed that they have no significant relationships with or financial interests in any commercial companies that pertain to this article. There is no commercial support for this activity. 
This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME). The American College of Emergency Physicians is accredited by the ACCME to provide continuing medical education for physicians.  
The American College of Emergency Physicians designates this enduring material for a maximum of 1 AMA PRA Category 1 CreditTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity. 
"Focus On… Critical Decisions: Acute Otitis Media in Children" is approved by the American College of Emergency Physicians for 1 ACEP Category I credit.  

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This article was published online December 1, 2013. The credit for this CME activity expires November 30, 2016.  

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From the EM Model 
7.0 Head, Ear, Eye, Nose, Throat Disorders
7.1 Ear 

Objectives 
On completion of this lesson, you should be able to: 
1.         Accurately diagnose acute otitis media (AOM). 
2.         List the likely pathogens encountered in AOM, especially considering recent advances in vaccinations. 
3.         Choose an appropriate antibiotic for treatment of AOM. 
4.         Describe the circumstances in which observation can be a viable treatment option as an alternative to the use of antibiotics. 

Acute otitis media (AOM) is common in the pediatric age group. Over the years, however, a pathogen shift in AOM and increasing antibiotic resistance have resulted in a change in treatment recommendations. In 2004, the American Academy of Pediatrics (AAP) jointly with the American Academy of Family Physicians (AAFP) unveiled a clinical practice guideline on the diagnosis and management of AOM.1,2 Then in 2007, the AAFP independently published a review of the evaluation and management of otitis media,3 using the aforementioned clinical practice guideline as its primary reference. Both of these provide a good framework for diagnosing and treating uncomplicated AOM. There is continued monitoring of susceptibilities of pediatric bacterial isolates to follow resistance patterns.  

Case Presentation 
An 18-month-old boy is brought in by his mother because he has been vomiting this morning. He has had nasal congestion and difficulty sleeping for the past 2 days. There has been no diarrhea. No foul odor of the urine is noted and no apparent dysuria. He has no significant past medical history. He does not tolerate the taste of any medications well. Today the patient awoke later than usual and has been pulling at his left ear. His mother reports that he’s been fussy and seems to have no appetite. She says that he feels hot to the touch.
Vital signs are pulse rate 160, respiratory rate 20, temperature 39.5°C (103.1°F), and oxygen saturation 97% on room air. On examination, the patient is fussy but easily consolable by his mother and not in any evident distress. The left tympanic membrane has an obvious purulent fluid level and appears thickened and erythematous. The right tympanic membrane is dull and opaque. The eye examination is normal, including no conjunctival injection.There is no drainage from the nose. His oropharynx is clear. His lungs are clear to auscultation. His heart has a tachycardic rate, but his cardiovascular examination is otherwise unremarkable. The abdominal examination is benign, and the remainder of the physical examination is unremarkable. There are no signs of dehydration. 

CRITICAL DECISION 
What are the criteria for making the most accurate diagnosis of AOM?
The diagnosis of the acute infectious process of acute otitis can be made if three components are present: rapid onset, middle-ear effusion, and signs and symptoms of middle-ear inflammation. This has helped make the distinction between AOM and otitis media with effusion, a noninfectious process that does not require antibiotic treatment. Pneumatic otoscopy can be performed to detect impaired tympanic membrane mobility. An acutely inflamed tympanic membrane with purulence bulging from behind it will have reduced mobility.3  

CRITICAL DECISION 
What bacterial pathogens are most likely to be causing episodes of AOM in children?
The types of bacterial pathogens that cause serious bacterial infections have changed in recent decades. The introduction of the heptavalent pneumococcal conjugate vaccine in 2001 has resulted in successful reduction in Streptococcus pneumoniae bacteremia, pneumonia, and meningitis.4 Similarly, the introduction, a decade earlier, of the Haemophilus influenzae type b vaccine reduced the incidence of H. influenzae type b as a cause of upper and lower respiratory tract infections and serious bacterial infections, although non-typeable H. influenzae strains are still commonly found causing upper respiratory tract infections.5 S. pneumonia, however, is still the primary bacterial cause of AOM. Respiratory viruses and Moraxella catarrhalis are the other pathogens seen in AOM. 

CRITICAL DECISION 
Which antibiotics are currently recommended for treatment of AOM? 
S. pneumoniae has developed resistance to many antibiotics. It is no longer safe to use certain antibiotics empirically, including low-dose amoxicillin, sulfa drugs, and the macrolide class of antibiotics in children at risk for exposure to resistant strains of S. pneumoniae.6-8 It has been shown that resistance rates (30% to 50%) are even higher in patients who have taken antibiotics within the past 1 month.9 In addition, AOM caused by non-typeable H. influenzae is being found at higher rates than previously seen. If a patient has recently been treated forAOM and is experiencing a recurrence, it is important to use an antibiotic with Gram-negative coverage. Cefdinir has good efficacy against Gram-negative AOM pathogens but not as good activity against resistant S. pneumoniae.10 Studies in adults and older children have shown that AOM can be treated with shorter courses of antibiotic, but it is still recommended that infants and children under 6 years of age be treated with a full 10-day course, especially as this population of patients has higher resistance rates.11-13 The AAP and its Section on Infectious Disease have made recommendations for antibiotic treatment considering these changes.2 Other recent studies have further corroborated these findings.10,14  Recommendations include amoxicillin at 80-90 mg/kg/day (divided twice daily) and, for more severe cases, amoxicillin-clavulanate (at 90 mg/kg/day of the amoxicillin component) dosed twice daily.  Alternatives include cefdinir 14 mg/kg/day (in one or two doses per day); cefpodoxime 10 mg/kg daily; and cefuroxime 30 mg/kg/day (divided twice daily).  Patients with serious beta lactam allergy can be treated with clindamycin 30-40 mg/kg/day in divided doses; a macrolide (azithromycin or clarithromycin); or trimethoprim/sulfamethoxazole, alone or in combination with erythromycin.1

CRITICAL DECISION 
Is a single dose of ceftriaxone appropriate stand-alone treatment for AOM in any situation? 
Because of the growing problem of S. pneumoniae resistance, it has been shown that a single dose of ceftriaxone, like the previously acceptable lower doses of amoxicillin (40 mg/kg divided three times daily), is not an adequate therapy.15 However, ceftriaxone may be used to initiate treatment in the emergency department when a patient is vomiting or unable to tolerate the taste of oral medication. The clinician should consider prescribing a full 10-day course of oral antibiotics to begin the following morning, by which time the patient should be showing signs of improvement. If patients have had recurrent episodes of AOM despite multiple courses of oral antibiotics, refer them to their pediatricians to receive a second and third ceftriaxone injection over the next 2 days.1,16

CRITICAL DECISION
When should observation be considered in a child with AOM rather than initiation of antibiotic treatment? 
It is important to remember that viruses are the most common cause of upper respiratory tract infection. The rates of serious bacterial infection, including mastoiditis, have not been found to increase when a less severely ill older child with AOM is observed initially, rather than immediately treated with antibiotics.1,17 This does not apply to neonates (younger than 1 month) found to have AOM. Because of a neonate’s higher risk of serious bacterial infection, evaluation for possible sepsis with hospitalization and intravenous antibiotics is recommended.18  

Case Resolution 
The 18-month-old boy who came in with vomiting and congestion fulfilled the diagnostic criteria for AOM. At his age, treatment with an appropriate antibiotic is recommended. Because he had been vomiting and did not tolerate oral medications well, ceftriaxone, 50 mg/kg X 1, was injected intramuscularly in the emergency department. He was able totolerate a Popsicle and some juice during the visit. He was sent home with a prescription for a full 10-day course of amoxicillin to start the next morning, and the parents were instructed to follow up with the pediatrician within 2 to 3 weeks to document resolution of the ear infection or sooner if vomiting continued and he was not able to hold down the oral medication. The patient was seen for recheck at the pediatrician’s office in 2 weeks and was doing fine. 

Summary
In recent years, the AAP and the AAFP have developed specific criteria to help in making a certain diagnosis of AOM. Over the past two decades, pathogen shifts and the development of bacterial resistance among common pathogens of AOM have necessitated updating treatment recommendations. Although amoxicillin remains the treatment of choice, higher doses are required to overcome bacterial resistance, and some previously accepted antibiotic choices for AOM are no longer effective. If a child is old enough and not severely ill, it is reasonable to refrain from prescribing antibiotics and have the patient follow up with a pediatrician if symptoms persist or worsen over the next 2 to 3 days.  
The goal of these recent recommendations is to lessen the frequency of antibiotic use, only prescribing them when there is a certain diagnosis of AOM and/or if the patient is at a higher risk for serious bacterial infection, recognizing that less ill patients may be experiencing a viral or less virulent bacterial infection. Taking these measures will reduce exposure to unnecessary antibiotics, slowing the increase in bacterial resistance, without harm to the patient. 

References 
1.         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 witheffusion. Pediatrics. 2004;113(5):1412-1429.
2.         American Academy of Pediatrics Subcommittee on Management of Acute Otitis Media. Diagnosis and management of acute otitis media. Pediatrics. 2004;113(5):1451-1465. 
3.         Ramakrishnan K, Sparks RA, Berryhill WE. Diagnosis and treatment of otitis media. Am Fam Physician. 2007;76(11):1650-1658. 
4.         McCracken GH Jr. Emergence of resistant Streptococcus pneumoniae: a problem in pediatrics. Pediatr Infect Dis J. 1995;14(5): 424-428.
5.         Sur DK, Bukont EL. Evaluating fever of unidentifiable source in young children. Am Fam Physician. 2007;75(12):1805-1811.
6.         Jacobs MR, Bajaksouzian S, Zilles A, et al. Susceptibilities of Streptococcus pneumoniae and Haemophilus influenzae to 10 oral antimicrobial agents based on pharmacodynamic parameters: 1997 U.S. Surveillance study. Antimicrob Agents Chemother. 1999;43:1901-1908.
7.         Jacobs MR, Johnson CE. Macrolide resistance: an increasing concern for treatment failure in children. Pediatr Infect Dis J. 2003;22(8 Suppl):S131-138.
8.         McCracken GH Jr. Prescribing antimicrobial agents for treatment of acute otitis media. Pediatr Infect Dis J. 1999;18(12):1141-1146.
9.         Dagan R, Leibovitz E, Cheletz G, et al. Antibiotic treatment in acute otitis media promotes superinfection with resistant Streptococcus pneumoniae carried before initiation of treatment. J Infect Dis. 2001;183(6): 880-886. 
10.       Harrison CJ, Woods C, Stout G, et al. Susceptibilities of Haemophilus influenzae, Streptococcus pneumoniae, including serotype 19A, and Moraxella catarrhalis paediatric isolates from 2005 to 2007 to commonly used antibiotics. J Antimicrob Chemoth. 2009;63(3):511-519. 
11.       Cohen R, Levy C, Boucherat M, et al. A multicenter, randomized, double-blind trial of 5 versus 10 days of antibiotic therapy for acute otitis media in young children. J Pediatr. 1998;133(5):634-639. 
12.       Paradise JL. Short-course antibacterial treatment for acute otitis media: not best for infants and young children. JAMA. 1997;278:1640–1642. 
13.       Pichichero ME, Marsocci SM, Murphy ML, et al. A prospective observational study of 5-, 7-, and 10-day antibiotic treatment for acute otitis media. Otolaryngol Head Neck Surg. 2001;124:381–387. 
14.       McCracken GH Jr. Diagnosis and management of acute otitis media in the urgent care setting. Ann Emerg Med. 2002;39(4):413-421. 
15.       Varsano I, Frydman M, Amir J, Alpert G. Single intramuscular dose of ceftriaxone as compared to 7-day amoxicillin therapy for acute otitis media in children. A double-blind clinical trial. Chemotherapy. 1988;34 Suppl 1:39-46. 
16.       Dowell SF, Butler JC, Giebink GS, et al. Acute otitis media: management and surveillance in an era of pneumococcal resistance – a report from the the Drug-resistant Streptococcus pneumoniae Therapeutic Working Group. Pediatr Infect Dis J. 1998;18(1):1-9. 

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