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Slide 1 - Clinical Guidelines: Acute Otitis Media Baylor College of Medicine Anoop Agrawal, M.D.
Slide 2 - Overview Guidelines created by AAP and AAFP in conjunction with specialists Guidelines apply only to healthy kids Evidence reviewed through September 2003 AOM accounts for 25 million office visits - of which 804 out of 1000 result in an antibiotic being prescribed
Slide 3 - Committee Recommendations Diagnosis of AOM Assessment and management of pain Treatment - observation vs. antibiotics Complementary Alternative Medicine Prevention The Future
Slide 4 - Case One - Andy Biotic A 3 year old male presents with fever to 101 F since yesterday. His mother thinks he has an ear infection because ‘he keeps pulling on his ears.’ What are the criteria needed to make the diagnosis of AOM?
Slide 5 - Diagnosis of AOM Acute/abrupt onset of symptoms: otalgia Signs of middle ear effusion (MEE) - bulging or full TM (this is the best positive predictor of AOM), decreased mobility of TM (second best predictor - this alone cannot distinguish OME from AOM), air fluid levels, or otorrhea Signs and symptoms of inflammation of middle ear- erythema or hyperemia or clinical symptoms that are clearly attributable to the ear
Slide 6 - What is not considered AOM? Otalgia: discomfort clearly referable to the ear(s); diagnostic criteria no longer include tugging at ears, fever or other symptoms. The best negative predictor of AOM is a retracted TM - even if concurrent opacity, erythema or reduced mobility is present. The least predictive factor of AOM is TM erythema alone. To be of significance it must be differentiated from hypervascularity seen on the rim of the TM annulus
Slide 7 - Case A.B. Cont. On your exam, the patient appears playful and in no distress. You visualize the TM as seen on the right. What is your diagnosis? What pathogens can cause this condition?
Slide 8 - Assessment of Pain Management of pain is a cornerstone of therapy Acetaminophen and ibuprofen strongly recommended Topical anesthetic and oral narcotics are other options in older children
Slide 9 - Case A.B. Cont. Andy’s mom says he had a throat infection 3 months ago and received amoxicillin. She wants to know if he needs antibiotics again. What treatment will you prescribe?
Slide 10 - 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
Slide 11 - Why observation? The European Experience Dutch study: 2.7% of 4860 patients older than 2 years had persistent symptoms (fever, pain, discharge after 3-4 days). Only 2 developed mastoiditis. UK - in randomized trial: 76% kids in delayed group never required antibiotics. Study limited by imprecise criteria of AOM, and a set dosing of Amox (125mg tid x7 days for all ages)
Slide 12 - Porque Observacion? Incidence of mastoiditis - no clear data Incidence does not increase if patient is observed for initial 48 to 72 hours Most cases of mastoiditis develop despite therapy with antibiotics Observation has greater failure rate in younger patients
Slide 13 - Latest Data Randomized double blind trial from UT-Galveston in 2005 300 kids over 2 years of age 68% of parents given prescription did not fill kids had similar outcomes at Day 12, 30
Slide 14 - When to give antibiotics All kids under 2 years of age with certain diagnosis of AOM Kids over 2 years of age if illness is severe Social or clinical barriers to accessing medical care and follow up Any child with genetic/immune/anatomic condition should be treated with antibiotics.
Slide 15 - Case 2 A 15 month old girl presents with fever to 101.5 F. Your otoscopic exam is seen to the right. What is your diagnosis and treatment?
Slide 16 - Case 2 continued Her mother calls after 2 days and states the fever has not resolved and child is still having decreased oral intake and is fussy. What is your recommendation? Tympanocentesis or change antibiotic to augmentin (90mg/kg/d) or 2nd generation cephalosporin Mom calls again after another 2 days and states there is still no improvement...what next?
Slide 17 - Case 3 12 month old male presents for routine well child exam. Pt is afebrile and doing well. Physical exam reveals accompanying TM. The TM is immobile with insufflation. How do you approach treatment for this child?
Slide 18 - The Future Guidelines will continue to be refined in aspects of how to diagnose AOM and therapies (quinolones?). New vaccines for pneumococcus: currently we have PCV-7 a 9 serotype and 13 serotype are in the near future
Slide 19 - Conclusion Guidelines are designed to reduce unnecessary exposure to antibiotics in specific clinical scenarios. Children who are automatically excluded from observation option: all under 6mos, AOM in prior 30 days, known underlying OME, or has an immune/genetic/anatomic problem Strict criteria for diagnosis of AOM: abrupt onset of otalgia, middle ear effusion, and middle ear inflammation The option to withhold antibiotics is just that - it is an option.
Slide 20 - References Subcommittee on Management of Acute Otitis Media, Diagnosis and Management of Acute Otitis Media, Pediatrics, Vol. 113, No 5, May 2004, 1451-1462. Harrison, C. How will the new guideline for managing otitis media work in your practice?, Contemporary Pediatrics, June 1, 2004.