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Acute Otitis Media

Continuity

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

1 Serous. and tinnitus.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. pathogenesis. subacute or chronic). but middle ear effusion is usually absent. fever. Erythema is an inconsistent finding.1 Middle Ear Effusion (MEE) Liquid in the middle ear but not the etiology.1 . otalgia.1  Serous: thin. such as hearing loss. or duration (recent onset. opaque. and has limited mobility. irritability. Signs and symptoms of acute infection absent. anorexia. Otorrhea Discharge from:1  external auditory canal  middle ear  mastoid  inner ear or intracranial cavity Eustachian Tube Dysfunction Continuity Middle ear disorder that can have symptoms similar to otitis media.1 One or more local or systemic signs are present: otalgia. The tympanic membrane is full or bulging. 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. otorrhea. watery liquid  Mucoid: a thick. vomiting or diarrhea. secretory or non-suppurative otitis media are terms that are no longer recommended. acute. 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.

41:373-390 (reprinted with permission) Continuity . Clinical Pediatr 2002.Distinguishing AOM from OME Hoberman A.

Prevalence of Otitis Media • 1993 .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 .1995 (NCHS).

Prevalence of Otitis Media • Peak incidence of OM occurs during the first 2 years • 60%-70% of children have >1 AOM before 1st birthday4. ~ 20% of children Continuity .5 • Early onset (<6 mo) associated with recurrent AOM and chronic OME • Recurrent AOM. >3 episodes/6 mo or >4 episodes/yr.

4% in 1st yr  16. segments of a disease continuum7  Mean cumulative time with MEE (AOM or OME)5  20.Prevalence of Otitis Media  AOM and OME.6% in 2nd yr Continuity .

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 .

higher cumulative time with OME Continuity . horizontal lying eustachian tube  Males.Host-Related Risk Factors Age/Gender  AOM most prevalent between 6 and 11 mo  Shorter.

hours spent. use of antibiotics. age at entry and siblings in daycare influence risk  Day care increases risk of infection. thus increasing selection of resistant organisms Continuity .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.

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 .

Pediatr Infect Dis J.Pathophysiology of AOM Otitis Media Infection Host Factors Anatomic/Physiologic Dysfunction • Immature/impaired • Eustachian tube dysfunction • Cleft Palate immunology • Familial predisposition • Type of milk (breast or formula) • Gender • Race Allergy Environmental Factors Bluestone CD. 1996:15:281-291 (reprinted with permission) Continuity .

protection and clearance of secretions • Impairment ET function MEE • URI  inflammation of nasopharynyx (NP) and ET • Inflammation  ET dysfunctionnegative middle ear pressure • Organisms colonizing NP aspirated into middle ear resulting in AOM Continuity .Pathophysiology of AOM • Eustachian tube (ET) functions include ventilation.

2001. 99:3S-7S Doern GV. Am J Med. 3. 1995. Unpublished data .12-1 µg/mL) Year 1988-891 1990-911 1992-931 1994-952 1997-982 1999-002 2001-023 # Isolates 476 524 799 1527 1601 1531 1925 1. ACC.Microbiology: Antimicrobial Resistance Resistant (MICs 2 µg/mL) Intermediate (MICs 0. 2.45:1721 Doern GV. Continuity Doern GV.

. Am J Manag Care. 1999.5(suppl 11):S651-S661.Bacterial Resistance Against β-Lactam Abx β-lactamase enzymes inactivate Peptidoglycan cell wall Plasma membrane β-lactam antibiotics Altered PBPs Cytoplasm Clavulanic acid irreversibly binds to β-lactamase protecting Resistance increases as altered PBPs accumulate Antibiotic β-lactamase Clavulanic acid Normal PBP Altered PBP β-lactam antibiotics from enzymatic Jacobs MR.

Bacterial Resistance Against Macrolides Bacteria alter macrolide binding site (ermAM gene. MLSB phenotype)  Macrolide unable to block protein synthesis Bacterial efflux pumps (mefE gene. Am J Manag Care. 1999.5(suppl 11):S651-S661 Macrolide . M phenotype)  Macrolide excreted from cell Ribosomes 50 30 50 30 50 30 Cytoplasm Jacobs MR.

Antibiotic Options • 1st Line – Amoxicillin : low versus high dose – Augmentin – PC allergy  Zithromax • 2nd Line – Cephalosporins – Zithromax Continuity .

2 F.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. severe otalgia Older than 2 years if nonsevere illness Family has access to doctor. and family member to close eye on patient Continuity . What defines a severe illness? fever ≥ 39 C or 102.

A picture is worth a thousand words……. Continuity .

Acute Otitis Media? Continuity .

Acute Otitis Media? Continuity .

What is your diagnosis? Continuity .

What is your diagnosis? Continuity .

Bonus Question -What is this? Continuity .