Latest guidance on diagnosing, treating acute otitis media

In addition to upper respiratory infections, acute otitis media is one of the most common complaints that a pediatrician hears in day-to-day practice. In a session at the American Academy of Pediatrics 2019 National Conference & Exhibition, Ellen R. Wald, MD, FAAP, Chair of the Department of Pediatrics at the University of Wisconsin School of Medicine and Public Health and Pediatrician-in-Chief of the American Family Children's Hospital, in Madison, covered the latest guidance for diagnosing and treating the condition.

Dr. Wald discussed the risk factors to consider when diagnosing acute otitis media, which includes:

• a patient aged 6 to 12 months,

• attendance at daycare,

• a family history of acute otitis media,

• a personal history including eczema or rhinitis, and

• no history of breastfeeding.

Recurrent acute otitis media is considered 3 occurrences in a span of 6 months or 4 occurrences in the span of a year.

There was good news regarding incidence of the condition: It has decreased by roughly 25% to 35%, due in large part to the use of pneumococcal conjugate vaccines (PCVs) and utilization of the flu shot.

The PCV7 and subsequent PCV13 vaccine have radically changed the otopathogens found to cause acute otitis media in children. Before the introduction of the vaccine, Streptococcus pneumoniae was found in 40% to 50% of acute otitis media cases, but now it is found in 20% to 25% of cases. In the wake of this change, non-typeable Haemophilus influenzae has become the most common pathogen found in cases of acute otitis media, going from 25%-30% to 45% to 60%.

Management of the condition

Covering management of the condition, Dr. Wald discussed amoxicillin, which should be a high dose when S penumoniae is the common pathogen and antibiotic resistance is seen, and a regular dose otherwise.

When S pneumoniae is not the likely pathogen but H influenzae or Moraxella catarrhalis is likely, a usual dose of amoxicillin and clavulanate is recommended to combat beta-lactamase.

For children non-type 1 hypersensitivity or mild type 1 hypersensitivity, second- or third-generation cephalosporins are recommended, and levofloxacin is recommended for children with life-threatning type 1 hypsensitivity reactions.

For patients who can’t keep food or medication down, a single dose of cenftriaxone (50 mg/kg) delivered intravenously or intramuscular is recommended; when the patient is able to keep food and medication down, an oral antibiotic should be prescribed. Although a shorter duration of antibiotics has been examined, children younger than 2 years should still receive a full 10-day course of antibiotics to ensure resolution.

Recommendations for your practice

Dr. Wald concluded her presentation with two changes to make to your practice:

1. Avoid prescribing azithromycin for treating acute otitis media because it’s only effective in treating penicillin-sensitive S pneumoniae, but not the other pathogens that can cause the condition.

2. Examine the tympanic membrane of all children who have upper respiratory infections but no fever with the same level of diligence as children with upper respiratory infections and fever.