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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 Continuity Clinic 1999 7th International Symposium on Recent Advances in Otitis Media Terms and Definitions Otitis 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 ear disorder that can have symptoms similar to otitis media, such as hearing Continuity ClinicMiddle loss, otalgia, and tinnitus, but middle ear effusion is usually absent. 1 Distinguishing AOM from OME At least two of : 1. Abnormal color: white, yellow, amber, blue 2. Opacification not due to scarring 3. Decreased or absent mobility Yes Or Bubbles or air-fluid interfaces behind the TM Acute purulent otorrhea not due to otitis externa Yes Middle Ear Effusion (MEE) No Acute Inflammation Acute Inflammation 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 Yes Otitis Media with Effusion (OME) Acute Otitis Media (AOM) Hoberman A. Clinical Pediatr 2002;41:373-390 (reprinted with permission) Continuity Clinic Yes Prevalence of Otitis Media • 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 Continuity Clinic Prevalence of Otitis Media • 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 Continuity Clinic 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 Continuity Clinic 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 Continuity Clinic 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 Continuity Clinic 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 Continuity Clinic Environmental Risk Factors 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 Continuity Clinic Pathophysiology of AOM Otitis Media Infection Host Factors Anatomic/Physiologic Dysfunction • Immature/impaired immunology • Familial predisposition • Type of milk (breast or formula) • Gender • Race • Eustachian tube dysfunction • Cleft Palate Allergy Environmental Factors Bluestone CD. Pediatr Infect Dis J. 1996:15:281-291 (reprinted with permission) Continuity Clinic Pathophysiology of AOM • 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 Continuity Clinic Microbiology: Antimicrobial Resistance Resistant (MICs 2 µg/mL) Intermediate (MICs 0.12-1 µg/mL) 35 Resistance (%) 30 25 20 15 10 5 0 Year 1988-891 1990-911 1992-931 1994-952 1997-982 1999-002 2001-023 # Isolates 476 524 799 1527 1601 1531 1925 1. 2. 3. Doern GV. Am J Med. 1995; 99:3S-7S Doern GV. ACC. 2001;45:1721 Doern GV. Unpublished data Continuity Clinic Bacterial Resistance Against β-Lactam Abx Peptidoglycan cell wall β-lactamase enzymes inactivate β-lactam antibiotics Plasma membrane Altered PBPs Cytoplasm Clavulanic acid irreversibly binds to β-lactamase protecting β-lactam antibiotics from enzymatic cleavage Antibiotic β-lactamase Clavulanic acid Resistance increases as altered PBPs accumulate Normal PBP Altered PBP Jacobs MR. Am J Manag Care. 1999;5(suppl 11):S651-S661 . Bacterial Resistance Against Macrolides Bacteria alter macrolide binding site (ermAM gene, MLSB phenotype) Macrolide unable to block protein synthesis Bacterial efflux pumps (mefE gene, M phenotype) Macrolide excreted from cell Ribosomes 50 30 50 30 50 30 Cytoplasm Jacobs MR. Am J Manag Care. 1999;5(suppl 11):S651-S661 Macrolide Antibiotic Options • 1st Line – Amoxicillin : low versus high dose – Augmentin – PC allergy Zithromax • 2nd Line – Cephalosporins – Zithromax Continuity Clinic 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 Continuity Clinic A picture is worth a thousand words……. Continuity Clinic Acute Otitis Media? Continuity Clinic Acute Otitis Media? Continuity Clinic What is your diagnosis? Continuity Clinic What is your diagnosis? Continuity Clinic Bonus Question -What is this? Continuity Clinic