1. Continuity Clinic Acute Otitis Media

2. 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

3. Continuity Clinic 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 Middle ear disorder that can have symptoms similar to otitis media, such as hearing loss, otalgia, and tinnitus, but middle ear effusion is usually absent. 1 1999 7 th International Symposium on Recent Advances in Otitis Media

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

5. Continuity Clinic 1993 - 1995 (NCHS), 2 OM accounted for  18% ambulatory visits (1-4 yr)  14% visits during the 1 st yr of life AOM episodes diagnosed 2  81% in pediatric practices  13% in hospital ED  6% in hospital outpatient departments Prevalence of Otitis Media

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

7. Continuity Clinic Prevalence of Otitis Media  AOM and OME, segments of a disease continuum 7  Mean cumulative time with MEE (AOM or OME) 5  20.4% in 1 st yr  16.6% in 2 nd yr

8. 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

9. 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

10. 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

11. Continuity Clinic Exposure to Household Cigarette Smoke  Positive relationship between smokers in household and OM during 1 st but not 2 nd year 5  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 Environmental Risk Factors

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

13. Continuity Clinic Eustachian tube (ET) functions include ventilation, 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 Pathophysiology of AOM

14. Continuity Clinic Resistant (MICs  2 µg/mL) Intermediate (MICs 0.12-1 µg/mL) Microbiology: Antimicrobial Resistance 1988-89 1 476 1990-91 1 524 1992-93 1 799 1994-95 2 1527 1997-98 2 1601 1999-00 2 1531 2001-02 3 1925 Year # Isolates 1.Doern GV. Am J Med. 1995; 99:3S-7S 2.Doern GV. ACC. 2001;45:1721 3.Doern GV. Unpublished data

15. β-lactamase enzymes inactivate β-lactam antibiotics Bacterial Resistance Against β-Lactam Abx Cytoplasm Altered PBPs Peptidoglycan cell wall Plasma membrane Clavulanic acid irreversibly binds to β-lactamase protecting β-lactam antibiotics from enzymatic cleavage Antibiotic β-lactamase Clavulanic acid Normal PBP Altered PBP Resistance increases as altered PBPs accumulate Jacobs MR. Am J Manag Care. 1999;5(suppl 11):S651-S661.

16. Cytoplasm Ribosomes 50 30 50 30 50 30 Bacteria alter macrolide binding site (ermAM gene, MLS B phenotype)  Macrolide unable to block protein synthesis Bacterial Resistance Against Macrolides Macrolide Bacterial efflux pumps (mefE gene, M phenotype)  Macrolide excreted from cell Jacobs MR. Am J Manag Care. 1999;5(suppl 11):S651-S661

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

18. 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

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

20. Continuity Clinic Acute Otitis Media?

21. Continuity Clinic Acute Otitis Media?

22. Continuity Clinic What is your diagnosis?

23. Continuity Clinic What is your diagnosis?

24. Continuity Clinic Bonus Question -What is this?