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__NOTOC__ | __NOTOC__ | ||
{{Otitis media}} | {{Otitis media}} | ||
{{CMG | {{CMG}} | ||
==Overview== | ==Overview== | ||
Acute otitis media (AOM) usually follows a [[viral]] [[upper respiratory tract]] [[infection]] leading to [[Eustachian tube]] dysfunction with impaired clearance and pressure regulation of the [[middle ear]]. Current guidelines recommend observation for children age 6 to 24 months with unilateral AOM without [[otorrhea]] or children older than 2 years with unilateral or bilateral AOM without [[otorrhea]].<ref>{{Cite journal| doi = 10.1136/archdischild-2013-305550| issn = 1743-0593| last1 = Siddiq| first1 = Somiah| last2 = Grainger| first2 = Joe| last3 = Prentice| first3 = Philippa| title = The diagnosis and management of acute otitis media: American Academy of Pediatrics Guidelines 2013| journal = Archives of Disease in Childhood. Education and Practice Edition| date = 2014-11-12| pmid = 25395494}}</ref> Antibiotics covering common bacterial pathogens (e.g., ''[[Streptococcus pneumoniae]]'', ''[[Moraxella catarrhalis]]'', and non-typeable ''[[Haemophilus influenzae]]'') have been used with success in selected patients to accelerate the recovery and lower the risk of [[tympanic membrane perforation]]s and contralateral AOM episodes.<ref>{{Cite journal| doi = 10.1002/14651858.CD000219.pub3| issn = 1469-493X| volume = 1| pages = –000219| last1 = Venekamp| first1 = Roderick P.| last2 = Sanders| first2 = Sharon| last3 = Glasziou| first3 = Paul P.| last4 = Del Mar| first4 = Chris B.| last5 = Rovers| first5 = Maroeska M.| title = Antibiotics for acute otitis media in children| journal = The Cochrane Database of Systematic Reviews| date = 2013| pmid = 23440776}}</ref> High-dose [[amoxicillin]] (90 mg/kg/day) is the drug of choice for initial antibiotic therapy; high-dose [[amoxicillin-clavulanate]] or [[intramuscular]] [[ceftriaxone]] should be reserved for patients who fail to respond to first-line treatment within 48 to 72 hours. The optimal duration of antibiotics remains uncertain: a 10-day course of antibiotic therapy is recommended for children younger than 2 years and children with severe symptoms. In the absence of severe symptoms, a 7- or 5-day course is advisable for children 2 to 5 years of age or children 6 years and older, respectively. [[Otalgia]] is generally managed with [[acetaminophen]], [[ibuprofen]], or [[narcotic]] [[analgesic]]s with [[codeine]].<ref>{{Cite journal| doi = 10.1136/archdischild-2013-305550| issn = 1743-0593| last1 = Siddiq| first1 = Somiah| last2 = Grainger| first2 = Joe| last3 = Prentice| first3 = Philippa| title = The diagnosis and management of acute otitis media: American Academy of Pediatrics Guidelines 2013| journal = Archives of Disease in Childhood. Education and Practice Edition| date = 2014-11-12| pmid = 25395494}}</ref> | Acute otitis media (AOM) usually follows a [[viral]] [[upper respiratory tract]] [[infection]] leading to [[Eustachian tube]] dysfunction with impaired clearance and pressure regulation of the [[middle ear]]. Current guidelines recommend observation for children age 6 to 24 months with unilateral AOM without [[otorrhea]] or children older than 2 years with unilateral or bilateral AOM without [[otorrhea]].<ref>{{Cite journal| doi = 10.1136/archdischild-2013-305550| issn = 1743-0593| last1 = Siddiq| first1 = Somiah| last2 = Grainger| first2 = Joe| last3 = Prentice| first3 = Philippa| title = The diagnosis and management of acute otitis media: American Academy of Pediatrics Guidelines 2013| journal = Archives of Disease in Childhood. Education and Practice Edition| date = 2014-11-12| pmid = 25395494}}</ref> Antibiotics covering common bacterial pathogens (e.g., ''[[Streptococcus pneumoniae]]'', ''[[Moraxella catarrhalis]]'', and non-typeable ''[[Haemophilus influenzae]]'') have been used with success in selected patients to accelerate the recovery and lower the risk of [[tympanic membrane perforation]]s and contralateral AOM episodes.<ref>{{Cite journal| doi = 10.1002/14651858.CD000219.pub3| issn = 1469-493X| volume = 1| pages = –000219| last1 = Venekamp| first1 = Roderick P.| last2 = Sanders| first2 = Sharon| last3 = Glasziou| first3 = Paul P.| last4 = Del Mar| first4 = Chris B.| last5 = Rovers| first5 = Maroeska M.| title = Antibiotics for acute otitis media in children| journal = The Cochrane Database of Systematic Reviews| date = 2013| pmid = 23440776}}</ref> High-dose [[amoxicillin]] (90 mg/kg/day) is the drug of choice for initial antibiotic therapy; high-dose [[amoxicillin-clavulanate]] or [[intramuscular]] [[ceftriaxone]] should be reserved for patients who fail to respond to first-line treatment within 48 to 72 hours. The optimal duration of antibiotics remains uncertain: a 10-day course of antibiotic therapy is recommended for children younger than 2 years and children with severe symptoms. In the absence of severe symptoms, a 7- or 5-day course is advisable for children 2 to 5 years of age or children 6 years and older, respectively. [[Otalgia]] is generally managed with [[acetaminophen]], [[ibuprofen]], or [[narcotic]] [[analgesic]]s with [[codeine]].<ref>{{Cite journal| doi = 10.1136/archdischild-2013-305550| issn = 1743-0593| last1 = Siddiq| first1 = Somiah| last2 = Grainger| first2 = Joe| last3 = Prentice| first3 = Philippa| title = The diagnosis and management of acute otitis media: American Academy of Pediatrics Guidelines 2013| journal = Archives of Disease in Childhood. Education and Practice Edition| date = 2014-11-12| pmid = 25395494}}</ref> | ||
==Initial Management of Uncomplicated AOM with High Certainty of Diagnosis== | |||
{| style="font-size: 85%;" | {| style="font-size: 85%;" | ||
|+ '''Clinical Practice Guideline from the American Academy of Pediatrics'''<ref>{{Cite journal| doi = 10.1136/archdischild-2013-305550| issn = 1743-0593| last1 = Siddiq| first1 = Somiah| last2 = Grainger| first2 = Joe| last3 = Prentice| first3 = Philippa| title = The diagnosis and management of acute otitis media: American Academy of Pediatrics Guidelines 2013| journal = Archives of Disease in Childhood. Education and Practice Edition| date = 2014-11-12| pmid = 25395494}}</ref> | |+ '''Clinical Practice Guideline from the American Academy of Pediatrics'''<ref>{{Cite journal| doi = 10.1136/archdischild-2013-305550| issn = 1743-0593| last1 = Siddiq| first1 = Somiah| last2 = Grainger| first2 = Joe| last3 = Prentice| first3 = Philippa| title = The diagnosis and management of acute otitis media: American Academy of Pediatrics Guidelines 2013| journal = Archives of Disease in Childhood. Education and Practice Edition| date = 2014-11-12| pmid = 25395494}}</ref> | ||
| Line 31: | Line 29: | ||
<SMALL><sup>†</sup> A toxic-appearing child, persistent otalgia more than 48 h, temperature ≥39°C (102.2°F) in the past 48 h, or if there is uncertain access to follow-up after the visit.</SMALL> | <SMALL><sup>†</sup> A toxic-appearing child, persistent otalgia more than 48 h, temperature ≥39°C (102.2°F) in the past 48 h, or if there is uncertain access to follow-up after the visit.</SMALL> | ||
==Observation== | |||
Due to the self-limited nature of most episodes of AOM (particularly in children 2 years and older), initial observation is advisable for selected patients if close follow-up can be ensured and rescue antibiotics administered for persistent or worsening symptoms in 48 to 72 hours. | Due to the self-limited nature of most episodes of AOM (particularly in children 2 years and older), initial observation is advisable for selected patients if close follow-up can be ensured and rescue antibiotics administered for persistent or worsening symptoms in 48 to 72 hours. | ||
==Antibiotic Therapy== | |||
===Rationale for Antibiotic Choice=== | ===Rationale for Antibiotic Choice=== | ||
| Line 48: | Line 48: | ||
* The patient has concurrent [[purulent]] [[conjunctivitis]]. | * The patient has concurrent [[purulent]] [[conjunctivitis]]. | ||
* The patient has a history of recurrent AOM unresponsive to [[amoxicillin]]. | * The patient has a history of recurrent AOM unresponsive to [[amoxicillin]]. | ||
===Duration of Therapy=== | |||
The optimal duration of antibiotics remains unsettled. Standard 10-day course of antibiotic therapy is recommended for children younger than 2 years and children with severe symptoms. In the absence of severe symptoms, a 7- or 5-day course is advisable for children 2 to 5 years of age or children 6 years and older, respectively. | |||
===Antibiotic Regimens=== | ===Antibiotic Regimens=== | ||
| Line 53: | Line 56: | ||
====Initial (Immediate or Delayed) Antibiotic Treatment==== | ====Initial (Immediate or Delayed) Antibiotic Treatment==== | ||
=====Preferred Regimen===== | ======Preferred Regimen====== | ||
{{abx|Amoxicillin (80–90 mg/kg/d bid)|Amoxicillin (90 mg/kg/d) with Clavulanate (6.4 mg/kg/d)}} | {{abx|Amoxicillin (80–90 mg/kg/d bid)|Amoxicillin (90 mg/kg/d) with Clavulanate (6.4 mg/kg/d)}} | ||
=====Alternative Regimen (if Allergic to Penicillin)===== | ======Alternative Regimen (if Allergic to Penicillin)====== | ||
{{abx|Cefdinir (14 mg/kg/d qd or bid)|Cefuroxime (30 mg/kg/d bid)|Cefpodoxime (10 mg/kg/d bid)|Ceftriaxone (50 mg IM/IV qd)}} | {{abx|Cefdinir (14 mg/kg/d qd or bid)|Cefuroxime (30 mg/kg/d bid)|Cefpodoxime (10 mg/kg/d bid)|Ceftriaxone (50 mg IM/IV qd)}} | ||
====After Failure of Initial Antibiotic Treatment==== | ====After Failure of Initial Antibiotic Treatment==== | ||
=====Preferred Regimen===== | ======Preferred Regimen====== | ||
{{abx|Amoxicillin (90 mg/kg/d) with Clavulanate (6.4 mg/kg/d)|Ceftriaxone (50 mg IM/IV qd)}} | {{abx|Amoxicillin (90 mg/kg/d) with Clavulanate (6.4 mg/kg/d)|Ceftriaxone (50 mg IM/IV qd)}} | ||
=====Alternative Regimen===== | ======Alternative Regimen====== | ||
{{abx|Clindamycin (30–40 mg/kg/d tid) ± 3° Cephalosporin ± Tympanocentesis}} | {{abx|Clindamycin (30–40 mg/kg/d tid) ± 3° Cephalosporin ± Tympanocentesis}} | ||
==Pain Management== | |||
Episodes of AOM are commonly associated with [[otalgia]]. [[Acetaminophen]] and [[ibuprofen]] are the mainstay of management for mild to moderate [[ear pain]]. [[Narcotic]] [[analgesia]] with [[codeine]] should be used with caution in the treatment of severe [[otalgia]] due to the risk of [[respiratory depression]], [[altered mental status]], [[abdominal pain|gastrointestinal upset]], and [[constipation]].<ref>{{Cite journal| doi = 10.1542/peds.2012-3488| issn = 1098-4275| volume = 131| issue = 3| pages = –964-999| last1 = Lieberthal| first1 = Allan S.| last2 = Carroll| first2 = Aaron E.| last3 = Chonmaitree| first3 = Tasnee| last4 = Ganiats| first4 = Theodore G.| last5 = Hoberman| first5 = Alejandro| last6 = Jackson| first6 = Mary Anne| last7 = Joffe| first7 = Mark D.| last8 = Miller| first8 = Donald T.| last9 = Rosenfeld| first9 = Richard M.| last10 = Sevilla| first10 = Xavier D.| last11 = Schwartz| first11 = Richard H.| last12 = Thomas| first12 = Pauline A.| last13 = Tunkel| first13 = David E.| title = The diagnosis and management of acute otitis media| journal = Pediatrics| date = 2013-03| pmid = 23439909}}</ref> | Episodes of AOM are commonly associated with [[otalgia]]. [[Acetaminophen]] and [[ibuprofen]] are the mainstay of management for mild to moderate [[ear pain]]. [[Narcotic]] [[analgesia]] with [[codeine]] should be used with caution in the treatment of severe [[otalgia]] due to the risk of [[respiratory depression]], [[altered mental status]], [[abdominal pain|gastrointestinal upset]], and [[constipation]].<ref>{{Cite journal| doi = 10.1542/peds.2012-3488| issn = 1098-4275| volume = 131| issue = 3| pages = –964-999| last1 = Lieberthal| first1 = Allan S.| last2 = Carroll| first2 = Aaron E.| last3 = Chonmaitree| first3 = Tasnee| last4 = Ganiats| first4 = Theodore G.| last5 = Hoberman| first5 = Alejandro| last6 = Jackson| first6 = Mary Anne| last7 = Joffe| first7 = Mark D.| last8 = Miller| first8 = Donald T.| last9 = Rosenfeld| first9 = Richard M.| last10 = Sevilla| first10 = Xavier D.| last11 = Schwartz| first11 = Richard H.| last12 = Thomas| first12 = Pauline A.| last13 = Tunkel| first13 = David E.| title = The diagnosis and management of acute otitis media| journal = Pediatrics| date = 2013-03| pmid = 23439909}}</ref> | ||
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[[Category:Disease]] | [[Category:Disease]] | ||
[[Category:Inflammations]] | [[Category:Inflammations]] | ||
[[Category:Otolaryngology]] | [[Category:Otolaryngology]] | ||
[[Category:Otology]] | [[Category:Otology]] | ||
[[Category:Pediatrics]] | [[Category:Pediatrics]] | ||
Latest revision as of 06:36, 28 July 2020
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Acute otitis media (AOM) usually follows a viral upper respiratory tract infection leading to Eustachian tube dysfunction with impaired clearance and pressure regulation of the middle ear. Current guidelines recommend observation for children age 6 to 24 months with unilateral AOM without otorrhea or children older than 2 years with unilateral or bilateral AOM without otorrhea.[1] Antibiotics covering common bacterial pathogens (e.g., Streptococcus pneumoniae, Moraxella catarrhalis, and non-typeable Haemophilus influenzae) have been used with success in selected patients to accelerate the recovery and lower the risk of tympanic membrane perforations and contralateral AOM episodes.[2] High-dose amoxicillin (90 mg/kg/day) is the drug of choice for initial antibiotic therapy; high-dose amoxicillin-clavulanate or intramuscular ceftriaxone should be reserved for patients who fail to respond to first-line treatment within 48 to 72 hours. The optimal duration of antibiotics remains uncertain: a 10-day course of antibiotic therapy is recommended for children younger than 2 years and children with severe symptoms. In the absence of severe symptoms, a 7- or 5-day course is advisable for children 2 to 5 years of age or children 6 years and older, respectively. Otalgia is generally managed with acetaminophen, ibuprofen, or narcotic analgesics with codeine.[3]
Initial Management of Uncomplicated AOM with High Certainty of Diagnosis
| Age | AOM With Otorrhea | AOM With Severe Symptoms† | Bilateral AOM Without Otorrhea | Unilateral AOM Without Otorrhea |
| 6 mo to 2 y | Antibiotic therapy | Antibiotic therapy | Antibiotic therapy | Antibiotic therapy or additional observation |
| ≥ 2 y | Antibiotic therapy | Antibiotic therapy | Antibiotic therapy or additional observation | Antibiotic therapy or additional observation |
† A toxic-appearing child, persistent otalgia more than 48 h, temperature ≥39°C (102.2°F) in the past 48 h, or if there is uncertain access to follow-up after the visit.
Observation
Due to the self-limited nature of most episodes of AOM (particularly in children 2 years and older), initial observation is advisable for selected patients if close follow-up can be ensured and rescue antibiotics administered for persistent or worsening symptoms in 48 to 72 hours.
Antibiotic Therapy
Rationale for Antibiotic Choice
The rationale for antibiotic therapy in children with AOM is based on a high prevalence of bacteria from tympanocentesis cultures. A significant benefit of immediate antibiotic therapy is most evident in bilateral AOM, AOM with severe symptotms, AOM with otorrhea, or Streptococcus pneumoniae infection.[5] Antibiotic therapy is recommended in the following settings:
- AOM (bilateral or unilateral) in children 6 months and older with severe signs or symptoms (i.e., moderate or severe otalgia or otalgia for at least 48 hours, or temperature 39°C [102.2°F] or higher)
- Bilateral AOM in children younger than 24 months without severe signs or symptoms
When a decision to treat with antibiotics has been made, high-dose amoxicillin is recommended if all of the following criteria are fulfilled:[6]
- The patient has not received amoxicillin in the past 30 days.
- The patient does not have concurrent purulent conjunctivitis.
- The patient is not allergic to penicillin.
Additional β-lactamase coverage should be considered if any of the following criteria is fulfilled:[7]
- The patient has received amoxicillin in the past 30 days.
- The patient has concurrent purulent conjunctivitis.
- The patient has a history of recurrent AOM unresponsive to amoxicillin.
Duration of Therapy
The optimal duration of antibiotics remains unsettled. Standard 10-day course of antibiotic therapy is recommended for children younger than 2 years and children with severe symptoms. In the absence of severe symptoms, a 7- or 5-day course is advisable for children 2 to 5 years of age or children 6 years and older, respectively.
Antibiotic Regimens
Initial (Immediate or Delayed) Antibiotic Treatment
Preferred Regimen
Amoxicillin (80–90 mg/kg/d bid) OR Amoxicillin (90 mg/kg/d) with Clavulanate (6.4 mg/kg/d)
Alternative Regimen (if Allergic to Penicillin)
Cefdinir (14 mg/kg/d qd or bid) OR Cefuroxime (30 mg/kg/d bid) OR Cefpodoxime (10 mg/kg/d bid) OR Ceftriaxone (50 mg IM/IV qd)
After Failure of Initial Antibiotic Treatment
Preferred Regimen
Amoxicillin (90 mg/kg/d) with Clavulanate (6.4 mg/kg/d) OR Ceftriaxone (50 mg IM/IV qd)
Alternative Regimen
Clindamycin (30–40 mg/kg/d tid) ± 3° Cephalosporin ± Tympanocentesis
Pain Management
Episodes of AOM are commonly associated with otalgia. Acetaminophen and ibuprofen are the mainstay of management for mild to moderate ear pain. Narcotic analgesia with codeine should be used with caution in the treatment of severe otalgia due to the risk of respiratory depression, altered mental status, gastrointestinal upset, and constipation.[8]
References
- ↑ Siddiq, Somiah; Grainger, Joe; Prentice, Philippa (2014-11-12). "The diagnosis and management of acute otitis media: American Academy of Pediatrics Guidelines 2013". Archives of Disease in Childhood. Education and Practice Edition. doi:10.1136/archdischild-2013-305550. ISSN 1743-0593. PMID 25395494.
- ↑ Venekamp, Roderick P.; Sanders, Sharon; Glasziou, Paul P.; Del Mar, Chris B.; Rovers, Maroeska M. (2013). "Antibiotics for acute otitis media in children". The Cochrane Database of Systematic Reviews. 1: –000219. doi:10.1002/14651858.CD000219.pub3. ISSN 1469-493X. PMID 23440776.
- ↑ Siddiq, Somiah; Grainger, Joe; Prentice, Philippa (2014-11-12). "The diagnosis and management of acute otitis media: American Academy of Pediatrics Guidelines 2013". Archives of Disease in Childhood. Education and Practice Edition. doi:10.1136/archdischild-2013-305550. ISSN 1743-0593. PMID 25395494.
- ↑ Siddiq, Somiah; Grainger, Joe; Prentice, Philippa (2014-11-12). "The diagnosis and management of acute otitis media: American Academy of Pediatrics Guidelines 2013". Archives of Disease in Childhood. Education and Practice Edition. doi:10.1136/archdischild-2013-305550. ISSN 1743-0593. PMID 25395494.
- ↑ Rovers, Maroeska M.; Glasziou, Paul; Appelman, Cees L.; Burke, Peter; McCormick, David P.; Damoiseaux, Roger A.; Gaboury, Isabelle; Little, Paul; Hoes, Arno W. (2006-10-21). "Antibiotics for acute otitis media: a meta-analysis with individual patient data". Lancet. 368 (9545): 1429–1435. doi:10.1016/S0140-6736(06)69606-2. ISSN 1474-547X. PMID 17055944.
- ↑ Lieberthal, Allan S.; Carroll, Aaron E.; Chonmaitree, Tasnee; Ganiats, Theodore G.; Hoberman, Alejandro; Jackson, Mary Anne; Joffe, Mark D.; Miller, Donald T.; Rosenfeld, Richard M.; Sevilla, Xavier D.; Schwartz, Richard H.; Thomas, Pauline A.; Tunkel, David E. (2013-03). "The diagnosis and management of acute otitis media". Pediatrics. 131 (3): –964-999. doi:10.1542/peds.2012-3488. ISSN 1098-4275. PMID 23439909. Check date values in:
|date=(help) - ↑ Lieberthal, Allan S.; Carroll, Aaron E.; Chonmaitree, Tasnee; Ganiats, Theodore G.; Hoberman, Alejandro; Jackson, Mary Anne; Joffe, Mark D.; Miller, Donald T.; Rosenfeld, Richard M.; Sevilla, Xavier D.; Schwartz, Richard H.; Thomas, Pauline A.; Tunkel, David E. (2013-03). "The diagnosis and management of acute otitis media". Pediatrics. 131 (3): –964-999. doi:10.1542/peds.2012-3488. ISSN 1098-4275. PMID 23439909. Check date values in:
|date=(help) - ↑ Lieberthal, Allan S.; Carroll, Aaron E.; Chonmaitree, Tasnee; Ganiats, Theodore G.; Hoberman, Alejandro; Jackson, Mary Anne; Joffe, Mark D.; Miller, Donald T.; Rosenfeld, Richard M.; Sevilla, Xavier D.; Schwartz, Richard H.; Thomas, Pauline A.; Tunkel, David E. (2013-03). "The diagnosis and management of acute otitis media". Pediatrics. 131 (3): –964-999. doi:10.1542/peds.2012-3488. ISSN 1098-4275. PMID 23439909. Check date values in:
|date=(help)