Changes in AOM Treatment

JANUARY 02, 2018

Acute otitis media (AOM) is a bacterial or viral infection affecting the middle ear, the space behind the eardrum that contains the tiny vibrating bones of the ear. 
 
According to Glenn Isaacson, MD, FAAP, professor of otolaryngology and pediatrics at Lewis Katz School of Medicine at Temple University, the months between October and May bring very high rates of AOM. In fact, AOM is 3 times more common in February than July. He explained that most cases of AOM are caused by Streptococcus pneumoniae, Haemophilus influenzae (non typeable), and Moraxella catarrhalis. Recently, infections due to Haemophilus influenzae are more common than the other bacteria, since children are increasingly getting S pneumoniae vaccines. Infections due to H influenzae are more difficult to treat with antibiotics, but they do not cause as severe symptoms in terms of fever and pain.  
 
In general, ear infections can be painful due to inflammation and buildup of fluids in the middle ear. Signs and symptoms of ear infection in children usually occur rapidly and include a combination of the following:

  • Ear pain, especially when lying down
  • Tugging/pulling at ear 
  • Difficulty sleeping
  •  Crying more than usual/Increased irritability 
  •  Difficulty hearing/responding to sound
  •  Loss of balance
  •  Fever 
  •  Fluid draining from the ear
  •  Headache 
  •  Loss of appetite

Most ear infections do not cause long-term issues. However, frequent infections and fluid buildup can cause hearing loss, temporary speech delays, eardrum rupture (most heal on their own, but some require surgical intervention), and mastoiditis (infection of the bone behind the ear). Because ear infections can be tricky to diagnose, it is best to see a pediatrician or ENT.  Diagnosis is based on symptoms and examination of the ear. 
 
According to Dr Isaacson, American Academy of Pediatrics guidelines recommend that all patients younger than age 2 should be treated with antibiotics for AOM. For children older than age 2, antibiotics are recommended for those with severe disease (high fever, severe pain, or an inflamed bulging drum).  The option of close observation without antibiotics should be offered to older children with mild infections. Middle ear effusion (fluid often accompanying a cold and with little or no pain) does not respond to antibiotics, and treatment should be avoided. 
 
Currently, first-line treatment for uncomplicated AOM is amoxicillin 90 mg/kg/day, in 2 divided doses, for 10 days. However, there is a movement among otitis researchers to make Augmentin the drug of choice, so we may be seeing a shift in the next few weeks. 
 
Dr. Isaacson explained that Augmentin will be first line because 25% to 50% of non typeable H influenzae strains produce beta-lactamase and are resistant to amoxicillin. Low dose Augmentin is more effective as an empiric antibiotic and will work on 97% of S pneumo, 100% of H Influenzae and 70% of M catarrhalis.  Augmentin proves to have high rates of eradication of infection, while amoxicillin fails up to 50% of the time with H influenzae and up to 70% of the time with M catarrhalis. The recommended low dose of Augmentin is 45 mg/kg/day, in 2 divided doses, for 10 days.
 
With Augmentin, 80% to 90% of the time the bacteria is gone after treatment, but fluid remains 80% of the time at 2 weeks. Most pediatricians see patients for a follow up at 2 weeks; however, Dr Isaacson explained that this is not ideal because the pediatrician would be more than likely to give a second antibiotic upon seeing fluid. It is best to see the child at 3 days only if the child is still in pain or having fever. Then, the antibiotic would be switched. Usually clindamycin or IM ceftriaxone (3 doses in 3 days) or levofloxacin (for children allergic to penicillin-not FDA approved for use in children) would be the next antibiotic if the first fails. 
 
According to Dr. Isaacson, for non-severe disease in older children, OTC pain meds are appropriate unless symptoms worsen. Acetaminophen or Ibuprofen and external warm compresses to the ear are helpful. The cure rate for non-severe disease should be almost the same, even if it is bacterial or viral in origin, because the immune system takes care of it. 
 
What about the often-prescribed antibiotic eardrops? Dr. Isaacson explained that topical otic antibiotics are not effective for children with an intact eardrum, because they cannot get to the affected area of the middle ear. If used for a long time, they can even lead to fungal otitis externa, which can be hard to treat. These eardrops are only effective for children with tubes or a perforated eardrum (from infection or previous tube placement) because they can get through to the middle ear. 
 
If the child has recurrent otitis media, the ENT may recommend myringotomy with ear tube insertion. Recurrent otitis media is generally defined as 3 episodes of infection in 6 months or 4 episodes of infection in a year with at least one occurring in the past 6 months. Otitis media with effusion is persistent fluid buildup in the ear after an infection has cleared up or fluid in the absence of a documented acute infection. Dr Isaacson explained that these are guidelines for referral, not criteria for surgery. The need for tube surgery depends not only on the number of ear infections, but also other quality of life issues such as speech delay, disrupted sleep, or intolerance of oral antibiotics.
 
Children with frequent ear infections should be monitored to assure that language development is on track.
 
In the simple outpatient procedure, a hole is made in the eardrum, fluid is suctioned out, and then a tube is placed in the hole to ventilate the eardrum and prevent fluid buildup. Grommet tubes last 9-15 months on average. (In adults with chronic ear problems there are longer-lasting tubes that may stay in for years.)
 
To prevent AOM, it is important for children to receive their vaccinations on schedule as recommended by their pediatricians. Immunization against Streptococcus pneumoniae is included in routine vaccinations. Getting a flu shot every year has some effectiveness in preventing AOM. If possible, avoid large-scale day care. A day care with fewer than six children is less likely to result in frequent AOM. Avoid secondhand smoke. Hand washing to prevent viral infections is also important in preventing spread of infection in general.
 
References
Mayo Clinic. Acute otitis media. Mayo Clinic website. 
https://www.mayoclinic.org/diseases-conditions/ear-infections/symptoms-causes/syc-20351616
Accessed December 29, 2017
 



Karen Berger, PharmD
Karen Berger, PharmD
Karen Berger, PharmD, graduated from the University of Pittsburgh School of Pharmacy in 2001. She has worked in community pharmacies for over 16 years as a Pharmacist in Charge, staff, and floater pharmacist for a large chain. Currently, she is a pharmacist at an independent pharmacy in Northern NJ. She can be reached at karenmichelleberger@gmail.com
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