Continuity Clinic
Acute Otitis Media
Continuity Clinic
Objectives
• 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 patterns
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Terms and DefinitionsOtitis 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 recommended.
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
Eustachian Tube Dysfunction Middle ear disorder that can have symptoms similar to otitis media, such as hearing loss, otalgia, and tinnitus, but middle ear effusion is usually absent.1
1999 7th International Symposium on Recent Advances in Otitis Media
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Distinguishing AOM from OME
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
At least two of : 1. Abnormal color: white, yellow,
amber, blue 2. Opacification not due to scarring 3. Decreased or absent mobility
Bubbles or air-fluid interfacesbehind the TM
Acute purulent otorrheanot due to otitis externa
Middle Ear Effusion(MEE)
Acute Otitis Media(AOM)
Otitis Media with Effusion(OME)
Yes Yes
No AcuteInflammation
Acute Inflammation
Yes
Yes
Or
Hoberman A. Clinical Pediatr 2002;41:373-390 (reprinted with permission)
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• 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
Prevalence of Otitis Media
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• Peak incidence of OM occurs during the first 2 years
• 60%-70% of children have >1 AOM before 1st birthday4,5
• Early onset (<6 mo) associated with recurrent AOM and chronic OME
• Recurrent AOM, >3 episodes/6 mo or >4 episodes/yr, ~ 20% of children
Prevalence of Otitis Media
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Prevalence of Otitis Media
AOM and OME, segments of a disease
continuum7
Mean cumulative time with MEE (AOM or
OME)5
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
Age/Gender
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 organisms
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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
smokers
Association between early AOM onset and
cotinine in urine not found
Environmental Risk Factors
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Pathophysiology of AOM
Bluestone CD. Pediatr Infect Dis J. 1996:15:281-291 (reprinted with permission)
Otitis Media
Anatomic/Physiologic Dysfunction
• Eustachian tube dysfunction• Cleft Palate
EnvironmentalFactors
Allergy
Host Factors
• Immature/impaired immunology• Familial predisposition• Type of milk (breast or formula)• Gender
• Race
Infection
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• Eustachian tube (ET) functions include ventilation,
protection and clearance of secretions
• Impairment ET function MEE
• URI inflammation of nasopharynyx (NP) and ET
• Inflammation ET dysfunctionnegative middle
ear pressure
• Organisms colonizing NP aspirated into middle ear
resulting in AOM
Pathophysiology of AOM
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0
5
10
15
20
25
30
35
Res
ista
nce
(%)
Resistant (MICs 2 µg/mL)
Intermediate (MICs 0.12-1 µg/mL)
Microbiology: Antimicrobial Resistance
1988-891
4761990-911
5241992-931
7991994-952
15271997-982
16011999-002
15312001-023
1925Year# Isolates
1. Doern GV. Am J Med. 1995; 99:3S-7S2. Doern GV. ACC. 2001;45:17213. Doern GV. Unpublished data
β-lactamase enzymes inactivate
β-lactam antibiotics
Bacterial Resistance Against β-Lactam Abx
Cytoplasm
Altered PBPs
Peptidoglycan cell wall
Plasma membrane
Clavulanic acid irreversibly binds to β-lactamase protecting β-lactam antibiotics from enzymatic cleavage
Antibioticβ-lactamaseClavulanic acid
Normal PBPAltered PBP
Resistance increases as altered PBPs accumulate
Jacobs MR. Am J Manag Care. 1999;5(suppl 11):S651-S661.
Cytoplasm
Ribosomes
5030
5030
5030
Bacteria alter macrolide binding site(ermAM gene, MLSB phenotype)
Macrolide unable to block protein
synthesis
Bacterial Resistance Against Macrolides
Macrolide
Bacterial efflux pumps(mefE gene, M phenotype)
Macrolide excreted from
cell
Jacobs MR. Am J Manag Care. 1999;5(suppl 11):S651-S661
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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?