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Otitis media
DIPIRO 9th ED
Sub-tipe
1) Akut  drug of choice : amoxicillin (80–90 mg/kg/day). Jika diperkirakan patogen β-lactamase-producing : (90 mg/kg/day amoxicillin
+ 6.4 mg/kg/day clavulanate dalam 2 dosis terbagi).
2) w/ effusion
3) kronik
goals
1) pain management  utk Akut, analgesik (pct,ibuprofen)
2) prudent AB
3) 2nd disease prevention

AKUT OTITIS MEDIA

*severe : suhu ≥ 39˚C dan atau severe otalgia.
Dipiro 9th MEDSCAPE  ngga dijelasin utk otitis media,tp Cuma
dose adjustment secara umum
Akut : keterangan Renal impairment
Initial Amoxicillin 80-90 mg/kg/day divided twice First-line (non severe) GFR <30 mL/min: Should not receive 875 mg (immediate
Diagnosis daily release) or 775 mg (extended release)
GFR 10-30 mL/min: 250-500 mg q12hr, depending on
severity of infection
GFR <10 mL/min: 250-500 mg q24hr depending on
severity of infection
Hemodialysis patients: 250-500 mg q24hr depending on
severity of infection

CrCl < 10 : 250mg-1g 8h

Amoxicillin clavulanate : 90 mg/kg/day First-line (severe)
amoxicillin + 6.4 mg/kg/day Clavulanate)
divided twice daily
Cefdinir, cefuroxime,cefpodoxime Non–type 1 allergy
(nonsevere)
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Cefdinir :
 CrCl <30 mL/min (adults): Not to exceed 300 mg/day
PO
 CrCl <30 mL/min (children): 7 mg/kg PO q24hr; not
to exceed 300 mg/day

Ceftriaxone (1–3 days) Non–type 1 allergy (severe) CrCl <10 : dosis normal, max 2 g/day
Azithromycin, clarithromycin Type 1 allergy (non severe) Azitro : dosis normal
Klaritro : CrCl 10-30 : 250-500mg 12h ;; CrCl < 10 : 250-
500mg 12h
Failure at Amoxicillin clavulanate (90 mg/kg/day First-line (non severe)
48–72 amoxicillin +6.4 mg/kg/day clavulanate)
Hours divided twice daily
Ceftriaxone (1–3 days) First-line (severe) and
non–type 1 allergy (non
severe)
Clindamycin Non–type 1 allergy (severe) Klinda : dosis normal
and type 1allergy
(nonsevere and severe)

Tulisan hijau utk dose adjustment for renal impairment secara umum. Ngga ketemu yg otitis media, dapusnya dari :
https://www.nuh.nhs.uk/handlers/downloads.ashx?id=60983

*treatment utk anak, mirip sama utk dewasa yg di Dipiro 9th

Akut otitis media pada anak
steps
1.pain management
2.observasi dulu sebelum memutuskan memakai AB  (Initial or Delayed)
3.kalau gak ada perbaikan setelah 48-72 jam, mungkin ada penyakit lain atau treatment yg dikasih ngga adekuat, gunakan AB berdasarkan
patogen yg ada pd pasien
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http://pediatrics.aappublications.org/content/pediatrics/131/3/e964.full.pdf
AMERICAN ACADEMY OF PEDIATRICS : The Diagnosis and Management of Acute Otitis Media. March 2013

Recommended Antibiotics for (Initial or Delayed) Treatment and for Patients Who Have Failed Initial Antibiotic Treatment
Initial Immediate or Delayed Antibiotic Treatment Antibiotic Treatment After 48–72 h of Failure of Initial Antibiotic
Treatment
Recommended First-line Alternative Treatment (if Recommended First-line Alternative Treatment
Treatment Penicillin Allergy) Treatment
Amoxicillin (80–90 mg/kg/day in Cefdinir (14 mg/kg per day in 1 Amoxicillin-clavulanatea (90 Ceftriaxone, 3 d Clindamycin
2 divided doses) or 2 doses) mg/kg per day of amoxicillin, (30–40 mg/kg per day in 3
with 6.4 mg/kg per day of divided doses), with or without
Or Cefuroxime (30 mg/kg per day in clavulanate in 2 divided doses) third-generation cephalosporin
2 divided doses)
Amoxicillin-clavulanatea (90 Cefpodoxime (10 mg/kg per day Or Failure of second antibiotic
mg/kg per day of amoxicillin, in 2 divided doses)
with 6.4 mg/kg per day of Ceftriaxone (50 mg IM or IV for Clindamycin (30–40 mg/kg per
clavulanate [amoxicillin to Ceftriaxone (50 mg IM or IV per 3 d) day in 3 divided doses) plus
clavulanate ratio, 14:1] in 2 day for 1 or 3 d) third-generation cephalosporin
divided doses)
Tympanocentesisb
Consult specialistb

Duration of Therapy
The optimal duration of therapy for patients with AOM is uncertain; the usual 10-day course of therapy was derived from the duration of
treatment of streptococcal pharyngotonsillitis. Several studies favor standard 10-day therapy over shorter courses for children younger than 2
years.
A 7-day course of oral antibiotic appears to be equally effective in children 2 to 5 years of age with mild or moderate AOM
For children 6 years and older with mild to moderate symptoms, a 5- to 7-day course is adequate treatment.
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Otitis media pd Ibu Hamil  guideline spesifik nggak ketemu

European Archives of Oto-Rhino-Laryngology.2008. Treating common ear problems in pregnancy: what is safe?
https://link.springer.com/article/10.1007%2Fs00405-007-0534-3
http://sci-hub.la/https://doi.org/10.1007/s00405-007-0534-3

relatif aman: beta-lactam antibiotics (category B) (with dose adjustment), In case of allergy, the macrolides (also belonging to category B) can
be used as alternatives (although the use of erythromycin and clarithromycin carries a certain risk), and acyclovir.

Otitis externa might also occur in pregnancy. Even though scarce information is available about the use of local aminoglycosides in gestation,
with the exception of streptomycin, which is strictly contraindicated, local treatment with gentamycin, with or without the use of an ear wick,
could be considered in serious cases. Nevertheless, experiments in animals have proven the potential systematic absorption of local
aminoglycosides in the ear canal. Therefore, they should be given only when the expected benefit outweighs the potential risk
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Faringitis  viral causes are most common, group A β-hemolytic Streptococcus (GABHS), or Streptococcus pyogenes, is the primary bacterial
cause.
Dipiro 9th ED
Goals
1) Hilangkan gejala
2) Minimalisir ES
3) Cegah penularan
4) Cegah rheumatic fever dan komplikasi peritonsillar abscess, cervical lymphadenitis, dan mastoiditis.

Some European guidelines for the treatment of pharyngitis only recommend antibiotics for patients with culture-positive GAS pharyngitis who
are high-risk for acute rheumatic fever or very ill.

Pain  berikan analgesik (pct, NSAID)

1st line AB : Penicillin and amoxicillin
Batasi penggunaan AB bagi pasien GABHS (group A beta-hemolytic streptococcal) pharyngitis.

Antibiotics and Doses for Group A β-Hemolytic Streptococcal Pharyngitis

AB DOSIS DURASI ngga dijelasin utk utk faringitis,tp
Cuma dose adjustment secara
umum  renal impairment
Penicillin Children: 250 mg twice daily or three times daily orally 10 days
adolescents and adults: 250 mg 4 times daily or 500 mg twice daily
(https://www.cdc.gov/groupastrep/diseases-hcp/strep-throat.html )

Penicillin G Less than 27 kg: 0.6 million units; 27 kg or greater: 1.2 million units One dose
benzathine intramuscularly
Amoxicillin 50 mg/kg once daily (maximum 1,000 mg); 25 mg/kg (maximum 10 days Amox : CrCl < 10 = 250mg-1g 8h
500 mg) twice daily
Penicillin Allergy
Cephalexin 20 mg/kg/dose orally twice daily (maximum 500 mg/dose) 10 days Cefalexin : CrCl 20-10 = 250-500mg
every 8- 12 hours ;; CrCl < 10 : 250-
500mg every 8-12hr
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Cefadroxil 30 mg/kg orally once daily (maximum 1 g) 10 days

Clindamycin 7 mg/kg/dose orally thrice daily (maximum 300 mg/dose) 10 days Klinda : dosis normal
Azithromycinb 12 mg/kg orally once daily (maximum 500 mg) 5 days Azitro : dosis normal
Clarithromycin 15 mg/kg orally per day divided in two doses (maximum 250 mg 10 days Klaritro : CrCl 10-30 : 250-500mg
twice daily) 12h ;; CrCl < 10 : 250-500mg 12h
duration of therapy for group A streptococcal pharyngitis is 10 days to maximize bacterial eradication.

Tulisan hijau utk dose adjustment for renal impairment secara umum. Ngga ketemu yg otitis media, dapusnya dari :
https://www.nuh.nhs.uk/handlers/downloads.ashx?id=60983

Hepatic Impairment  secara umum

http://www.apiindia.org/pdf/medicine_update_2012/hepatology_08.pdf

AB should be avoided : macrolides like erythromycin, azithromycin,

chloramphenicol, lincomycin, and clindamycin; they are excreted
and detoxified by liver and hence the potential for their toxicity.
Tetracycline, isoniazid and Rifampin have prolonged half life in
patients with liver cirrhosis. Metronidazole ketoconazole,
miconazole, fluconazole, itraconazole, and nitrofurantoin
pyrazinamide should be used with caution. Beta-lactam antibiotics
can cause leucopenia, while amino glycosides can increase
susceptibility to renal failure. Vancomycin can cause increased
toxicity in patients with liver failure. Antibiotics which can produce
hepatitis or cholestasis should be again used with caution.