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Acute Otitis Media
- 1. Pharmacotherapy of Infectious Diseases A Case-Based Approach Acute Otitis Media Anas Bahnassi PhD Pharmacotherapy of Infectious Diseases Anas Bahnassi 2014 A Case-Based Approach
- 2. Pharmacotherapy of Infectious Diseases A Case-Based Approach Clinical Presentation •Irritable child with fever and runny nose for the last 2-3 days. •Most children with this clinical presentation would have viral infection and do not require antibiotics. •Some have AOM evident with physical examination that can be treated with antibiotics. Anas Bahnassi 2014
- 3. Pharmacotherapy of Infectious Diseases A Case-Based Approach Causes •Can be caused by both viral (70%) and bacterial(92%) pathogens or both (66%). Anas Bahnassi 2014 Viral Infection of URT Alteration of URT Defences Eustachian Tube Dysfunction Pathogens Colonizing Nasopharynx Otitis Media Disturbing Epithelium Impairing Mucociliary Clearance
- 4. Pharmacotherapy of Infectious Diseases A Case-Based Approach Prevention Strategies •Vaccination. •Modification of Risk Factors: –Cigarette smoke exposure. –Exposure to other children. •Breastfeeding. Anas Bahnassi 2014
- 5. Pharmacotherapy of Infectious Diseases A Case-Based Approach Goals of Therapy •Relieve symptoms (pain, fever, irritability). •Sterilize the middle ear. •Prevent complications (mastoiditis, intracranial infection, facial paralysis). •Avoid inappropriate therapy which may lead to the emergence of resistance pathogens and adverse drug reactions. Anas Bahnassi 2014
- 6. Pharmacotherapy of Infectious Diseases A Case-Based Approach Investigations: •History –Fever. –Non-specific symptoms of URT infection such as cough and coryza. –Otalgia; cannot be always communicated by children (disturbed sleep, irritability, tugging the ear). •Physical examination –Focus on head and neck to rule out other causes of pain (mastoiditis, and dental abscesses). –Visual inspection of tympanic membrane. –Assess for signs of middle ear effusion and/or inflammation. Anas Bahnassi 2014
- 7. Pharmacotherapy of Infectious Diseases A Case-Based Approach Investigations: •Physical examination –4 key features of the tympanic membrane should be evaluated. 1.Colour. 2.Position. 3.Transluency. 4.Mobility. A red, displaced/bulging, opaque, and immobile membrane is a sign of AOM •Referral. –For treatment failures or reoccurrences not respondent to treatment. –Children with frequent, recurrent episodes (>3/6m or 4/12m) should be referred to a specialist for myringotomy and tympanostomy. –Audiology assessment need to be conisdered. Anas Bahnassi 2014
- 8. Pharmacotherapy of Infectious Diseases A Case-Based Approach Therapeutic Choices •Non pharmacologic –Watchful waiting for children > 2yrs, mild, uncomplicated disease. •Pharmacologic –Analgesic. •Acetaminophen (10-15 mg/kg) q 4-6 h •Ibuprofen (10mg/kg) q 4-6 h. •If pain is not responding Codeine can be used in the first 24h (1-2 doses) to control the pain. Narcotics have more side effects than Acetaminophen and Ibuprofen. –Antibiotics Anas Bahnassi 2014
- 9. Pharmacotherapy of Infectious Diseases A Case-Based Approach Management of AOM Anas Bahnassi 2014 Child suspected with AOM History of fever, irritability, otagia, and URT infection Otoscopic examination reveals red bulging, opaque, immobile membrane >2years < 2years Risk Factors Risk Factors •Analgesics •Regular dose of Amoxicillin X 10days •Analgesics •High dose of Amoxicillin X 10days •Analgesics •High dose of Amoxicillin X 5days •Analgesics •If uncertain watchful waiting for 72h •If certain Amoxicillin X5days Yes Yes No No
- 10. Pharmacotherapy of Infectious Diseases A Case-Based Approach Antibiotic Treatment Recommendations Anas Bahnassi 2014 Characteristics Therapeutic Tips First Choice Treatment Failure on day 3 Treatment failure on day 10 Age < 1 month •Investigate for bacteria. •AOM is usually due to g- bacteria. •Refer to ER. •Fever may be a symptom of sepsis in this group. N/A N/A Age < 2 yrs No risk factors. No AB for the last 3 months. No daycare attendance. •Treat most cases with AB for 10 days •Standard dose Amox (40-45 mg/kg/d)TID •High dose Amox 80-90 mg/kg/d) BID or TID. •High dose of Amox/Clav or Cefprozil, Cefuroxime, Ceftriazone for 3 days. •High dose of Amox/Clav or Cefprozil, Cefuroxime, Ceftriazone for 3 days.
- 11. Pharmacotherapy of Infectious Diseases A Case-Based Approach Antibiotic Treatment Recommendations Anas Bahnassi 2014 Characteristics Therapeutic Tips First Choice Treatment Failure on day 3 Treatment failure on day 10 Age < 2 yrs Existing risk factors. Received AB over the last 3 months. Attending daycare. •Treat most cases with AB for 10 days •High dose Amox 80- 90 mg/kg/d) BID or TID. •High dose of Amox/Clav or Cefprozil, Cefuroxime, Ceftriazone for 3 days. •Consider tympanocynlosis •High dose of Amox/Clav or Cefprozil, Cefuroxime, Ceftriazone for 3 days. •Consider tympanocynlosis Age > 2 yrs No risk factors. No AB over the last 3 months. No daycare. •Consider watchful waiting for 72 hrs. •Treat for 5 days if needed. •High dose Amox 80- 90 mg/kg/d) BID or TID. •High dose of Amox/Clav or Cefprozil, Cefuroxime, Ceftriazone for 3 days. •High dose of Amox/Clav or Cefprozil, Cefuroxime, Ceftriazone for 3 days. •Consider tympanocynlosis
- 12. Pharmacotherapy of Infectious Diseases A Case-Based Approach Antibiotic Treatment Recommendations Anas Bahnassi 2014 Characteristics Therapeutic Tips First Choice Treatment Failure on day 3 Treatment failure on day 10 Age > 2 yrs Existing risk factors. Received AB over the last 3 months. Attending daycare. •Consider watchful waiting for 72 hrs. •Treat for 5 days if needed. •High dose Amox 80- 90 mg/kg/d) BID or TID. •High dose of Amox/Clav or Cefprozil, Cefuroxime, Ceftriazone for 3 days. •Consider tympanocynlosis •High dose of Amox/Clav or Cefprozil, Cefuroxime, Ceftriazone for 3 days. •Consider tympanocynlosis Any Age Frequent bouts of AOM •Verify AOM. •Treat for ≥ 10 d. •Flu vaccine q year. •High dose Amox 80- 90 mg/kg/d) BID or TID. •Ceftriaxine IM for 3 days. •Consider tympanocynlosis •High dose of Amox/Clav or Cefprozil, Cefuroxime, Ceftriazone for 3 days.
- 13. Pharmacotherapy of Infectious Diseases A Case-Based Approach Antibiotic Treatment Recommendations Anas Bahnassi 2014 Characteristics Therapeutic Tips First Choice Treatment Failure on day 3 •Clari-thromycin 15mg/kg/d •Azi-thromycin Penicillin Allergy: Existing risk factors. Received AB over the last 3 months. Attending daycare. •Verify Allergy: Anaphylactic type Hives Wheezing Swollen lips BP •Clari- thromycin 15mg/kg/d •Azi- thromycin Tympanocynlosis Clarithromycin 15mg/kg/d Azithromycin Tympanocynlosis
- 14. Pharmacotherapy of Infectious Diseases A Case-Based Approach Medications used in AOM Anas Bahnassi 2014 Class Drug Dose ADRs Comments Cost Penicillins Amoxicillin Standard dose: 40mg/kg/d BID or TID Excellent safety Profile Most active agent against pneumococci $ High dose: 80- 90mg/kg/d BID or TID Occasional mild diarrhea Maculo-papular rash uncommon but hard to distinguish from concomitant viral exanthema.
- 15. Pharmacotherapy of Infectious Diseases A Case-Based Approach Medications used in AOM Anas Bahnassi 2014 Class Drug Dose ADRs Comments Cost Penicillins Amoxicillin/ Clavulanate High dose: 80- 90mg/kg/d BID or TID Excellent safety Profile Active against most kinds of pathogens that cause AOM $$ Best given in two prescriptions Amox 40mg/kg/day And Amox/Clav 200 or 400 @ a dose of Amox 40mg/kg/d Frquent mild diarrhea. Do not use high dose of the formulation due to high conc. of Clavulanate which may cause diarrhea. Always write high dose intended on Rx to avoid confusion.
- 16. Pharmacotherapy of Infectious Diseases A Case-Based Approach Medications used in AOM Anas Bahnassi 2014 Class Drug Dose ADRs Comments Cost Cephalosporins Cefprozil 30mg/kg/d divided BID Low incidence of diarrhea. Tastes good and well absorbed. $$$$ Ceftriaxone 50mg/kg max of 1g IM qd X3 days. Injection pain can be minimized using Lidocaine 1% Second or 3rd line agent. $$$$$ Cefuroxime 30mg/kg/d divided BID Low incidence of diarrhea. Available as Suspension $$$$$
- 17. Pharmacotherapy of Infectious Diseases A Case-Based Approach Medications used in AOM Anas Bahnassi 2014 Class Drug Dose ADRs Comments Cost Macrolides Azithromycin Day 1: 10mg/kg/d Days 2-5: 5mg/kg/d Administer once at bedtime Low incidence of diarrhea. Tastes good and well absorbed. Pneumococci may be resistant. Short course improves compliance. Use in case of proven allergy to Penicillins. $$$$ Clarithromycin 15mg/kg/d divided BID Take with food or juice to disguise bitter aftertaste Diarrhea or vomiting Pneumococci may be resistant. Short course improves compliance. Use in case of proven allergy to Penicillins. $$$
- 18. Pharmacotherapy of Infectious Diseases A Case-Based Approach Therapeutic Tips •Encourage the use of flu and pneumonia vaccines to eligible patients. •Most children will have middle ear effusions after completion of therapy. There is no need to treat an abnormal- appearing tympanic membrane for asymptomatic child (assess hearing). •Nasal and oral decongestants alone or in combination with antihistamines have not shown to be effective and their use should be discouraged. Anas Bahnassi 2014
- 19. Pharmacotherapy of Infectious Diseases A Case-Based Approach Case Presentation •An otherwise healthy 17 month old boy had a cold accompanied by two days of rhinorrhea, cough, and fever (temperature of up to 38.8 C). •On day 5 he became fussy and woke up crying multiple times during the night. •The following day he was afebrile, and a physical exam was normal except for findings of slight redness of the left tympanic membrane with no middle ear fluid and a bulging right tympanic membrane with white fluid behind it obstructing the umbo. •How should this child be treated? Anas Bahnassi 2014
- 20. Pharmacotherapy of Infectious Diseases A Case-Based Approach Practical •Background info on otitis media. •What is the etiology and pathophysiology of otitis media? •What are the risk factors associated with otitis? •What are the most common pathogenic organisims? •What are the differences between acute otitis media and otitis media with effusion? •When do you treat? Anas Bahnassi 2014
- 21. Pharmacotherapy of Infectious Diseases A Case-Based Approach Pharmacotherapy: Infectious Diseases: Anas Bahnassi PhD abahnassi@gmail.com http://www.twitter.com/abpharm http://www.facebook.com/pharmaprof http://www.linkedin.com/in/abahnassi Anas Bahnassi 2014