Microsoft word - khf clinical guideline - otitis media - _final 2011_.docx
Clinical Practice & Referral Guideline - Acute & Chronic Otitis Media with Effusion *This guideline was developed based from the AAP’s Clinical Practice Guideline for the Diagnosis & Management of Acute Otitis Media, 2004. The recommendations in the below guideline do not indicate an exclusive course of treatment. The guidelines intent is to build a consensus of care in the pediatric market and provide a framework for clinical decision making.
Purpose: To make recommendations to the general pediatrician based on current published data on the natural history and management of uncomplicated acute Otitis media. The American Academy of Pediatrics and the American Academy of Family Physicians Clinical Practice Guideline for Acute Otitis Media states that “Acute Otitis media is the most common infection for which antibacterial agents are prescribed for children in the United States. As such, the diagnosis and management of AOM has a significant impact on the health of children, cost of providing care, and overall use of antibacterial agents.” History/Physical:
1. Confirm a history of acute onset otalgia, irritability, otorrhea, and/or fever 2. Identify signs of middle ear effusion(MEE)
Remove cerumen/adequate lighting Fullness or bulging of TM has highest predictive value for the presence of MEE Opacification or cloudiness Pneumatic otoscopy (may be supplemented by tympanometry and/or acoustic reflectometry) Reduced or absence of mobility in TM
3. Evaluate for signs/symptoms of middle-ear inflammation Redness must be
distinguished from the pink flush that accompanies crying or high fever
4. Pain Assessment: Assess patient’s pain on either a one to ten scale or ask patient
age appropriate questions to assess pain level. Some questions may include, does it hurt now? or does it feel better? Does it hurt a little or a lot? Do you feel like going to school?
5. Conjunctivitis Otitis Media Syndrome is the simultaneous appearance of
purulent and erythematous conjunctivitis at the same time as AOM, typically caused by non-typeable Haemophilus influenza. Treatment options, particularly antibiotic choice, should be effective against H. influenza.2
TABLE 1 - Treatments for Otalgia in AOM
Modality Comments Acetaminophen, ibuprofen26
Effective analgesia for mild to moderate pain, readily available, mainstay of pain management for AOM
Home remedies (no controlled studies that directly Topical agents
Antipyrine & Benzocaine Otic (A/B Otic)
Additional but brief benefit over acetaminophen in patients >5 y
Naturopathic agents (Otikon Otic Solution)28
Comparable with ametocaine/phenazone drops (Anaesthetic) in patients >6 y
No controlled studies that directly address pain
Narcotic analgesia with codeine or analogs
Effective for moderate or severe pain; requires prescription; risk of respiratory depression, altered mental status, gastrointestinal upset, and constipation
Requires skill and entails potential risk
Treatment: Observation: Observation is an option for selected children. The decision to observe is based on the child’s age, diagnostic certainty, and illness severity. (Nonsevere illness is mild otalgia and fever <39°C in the past 24 hours. Severe illness is moderate to severe otalgia or fever 39°C). A certain diagnosis of AOM meets all 3 criteria: 1) rapid onset, 2) signs of MEE, and 3) signs and symptoms of middle-ear inflammation.
Observation as an option for AOM refers to deferring antibacterial treatment of selected children for 48 to 72 hours and limit management to symptomatic relief.
• Observation is an appropriate option only when follow-up can be ensured and
antibacterial agents started if symptoms persist or worsen. Verify the presence of an adult who will reliably observe the child, recognize signs of serious illness, and be able to provide prompt access to medical care if improvement does not occur.
• This option should be limited to otherwise healthy children 6 months to 2 years of
age with nonsevere illness at presentation and an uncertain diagnosis and to children 2 years of age and older without severe symptoms at presentation or with an uncertain diagnosis.
• If no improvement in 48-72 hours: scheduled follow-up up appointment, routine
follow-up phone contact, or use of a safety net antibiotic prescription to be filled if illness does not improve.
TABLE 2- Criteria for Initial Antibacterial-Agent Treatment or Observation in Children with AOM
Antibacterial therapy if severe illness;
observation option* if nonsevere illness
Antibacterial therapy if severe illness;
observation option* if nonsevere illness
Table 4 from the AAP & AAFP Clinical Practice Guideline -Diagnosis & Management of AOM, 2004 page 1454. Antibiotics:
1. Amoxicillin 80 to 90 mg/kg per day x 10 days (up to age 6 years); x 5-7 days (6
years of age and older with mild to moderate disease). If Conjunctivitis Otitis Media Syndrome present, consider Amoxicillin-Clavulanate (Augmentin) or a Cephalosporin as 40 to 50% of H. influenza types are resistant to amoxicillin alone. (See Table 3)
2. If the patient is allergic to Amoxicillin and the allergic reaction was not a type I
hypersensitivity reaction (urticaria or anaphylaxis), Cefdinir (Omnicef) (14mg/kg per day in 1 or 2 doses), Cefpodoxime (Vantin) (10mg/kg per day, once daily), or Cefixime (Suprax) (8mg/kg per day, once daily) can be used. In cases of type I reactions, Azithromycin (Zithromax) (10 mg/kg per day on day 1 followed by 5 mg/kg per day for 4 days as a single daily dose) or Clarithromycin (Biaxin) (15 mg/kg per day in 2 divided doses) can be used in an effort to select an antibacterial agent of an entirely different class. Other possibilities include Erythromycin-Sulfisoxazole (Pediazole) (50 mg/kg per day of erythromycin) or Sulfamethoxazole-Trimethoprim (Bactrim) (6–10 mg/kg per day of trimethoprim).
3. If the patient fails to respond to the initial management option within 48 to 72
hours, reassess the patient to confirm AOM and exclude other causes of illness.
4. If AOM is confirmed after reassessment and no improvement in 48 to 72 hours,
second line antibiotics include high-dose Augmentin (90mg/kg per day of amoxicillin component, with 6.4 mg/kg per day of clavulanate in 2 divided doses) or a 2nd or 3rd generation cephalosporin such as cefdinir, cefpodoxime, cefuroxime or IM Ceftriaxone (Rocephin) (50-75 mg/kg daily for 1-3 days).
5. If AOM persists, or a child is in severe discomfort, consider tympanocentesis. If
tympanocentesis is not available, consider a course of Clindamycin (10-25 mg/kg/day divided q 6-8 hours). Please note tympanocentisis is only an option in the primary care setting if the provider has been properly trained and is experienced in the procedure.
TABLE 3- Recommended Antibacterial Agents for Patients Who Are Being Treated Initially With Antibacterial Agents or Have Failed 48 to 72 Hours of Observation or Initial Management With Antibacterial Agents. Clinically Defined Treatment Clinically Defined Treatment At Diagnosis for Patients Failure at 48–72 Hours After Failure at 48–72 Hours After Presence of Being Treated Initially With Initial Management With Initial Management With Temperature Antibacterial Agents Observation Option Antibacterial Agents Table 6 from the AAP & AAFP Clinical Practice Guideline -Diagnosis & Management of AOM, 2004 page 1459. Prevention: Reduction of risk factors: Implementation of breastfeeding for at least the first 6 months of life Avoiding supine bottle feeding (bottle propping) Reducing or eliminating pacifier use in the second 6 months of life Eliminating exposure to passive tobacco smoke Altering day care center attendance patterns Potential Benefits and Risks of Complementary Alternative Medicine: No recommendations based on limited and controversial data. Physicians should ask about use of homeopathic, acupuncture and herbal remedies, chiropractic treatments and nutritional supplements and be prepared to discuss them. Referrals: Referral to ENT for PE tubes should be considered if:
• 3-4 episodes of AOM requiring antibiotics within 6 months, or
• 5-6 episodes of AOM in a 12 month period;
• Failure to respond to at least a three drug regimen, including IM Ceftriaxone for 3
days or a full oral clinidamycin course, with no improvement for a single case of AOM;
• Any concerns of complications from AOM, including extension of the
infection to surrounding soft tissue or bony structures such as the mastoid process; Symptoms of inner ear disease/labyrinthitis;
• Persistent effusion of 3 to 4 months with bilateral loss of hearing or concerns
Acknowledgement: Special thanks to James Thomsen, MD a physician at Pediatric Ear Noise and Throat of Atlanta, PC for his assistance with preparing this document.
References: American Academy of Pediatrics and the American Academy of Family Physicians, Clinical Practice Guidelines, Diagnosis and Management of Acute Otitis Media. Vol. 113. No. 5. May, 2004, pp. 1451-1465 http://aappolicy.aappublications.org/cgi/reprint/pediatrics;113/5/1451.pdf
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