Thereapeutics of 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
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Anas Bahnassi 2014