incidence of these complications are unlikely to be influenced by initial treatment of AOM with antibiotic agents. 2, 3 Furthermore, the following outcomes do not appear to be affected by antibiotic use: 7
associated with acute otitis media as a regular component of care, irrespective of any decision concerning antibiotic treatment. 9
Prescribing antibiotics to all children with AOM is discouraged by the clinical practice guidelines. However, the children that clearly would merit and benefit from antibiotic prescription also are clearly discussed. The guidelines do not espouse an all-or-none approach; rather, practitioners are strongly encouraged to use antibiotics judiciously. In order to assist practitioners to prescribe antibiotics wisely, the guidelines differentiate between nonsevere and severe illness associated with AOM, as well as certain and uncertain diagnosis (Table 1). Similarly, the age of the child is very key in determining if antibiotics should be prescribed or not (Table 2).
Based on these guidelines, the wait-and-see prescription would be appropriate for children 2 years of age and older with nonsevere illness and/or an uncertain diagnosis. Interestingly, the observation option for AOM has been an official policy in the Netherlands and an unofficial policy in Denmark, Norway and Sweden for many years. 2, 3
However, the WASP would not be appropriate for most children under 2 years of age, children with severe illness at any age or with other co-existing medical conditions, or where active parental involvement and appropriate follow-up cannot be assured. 2 If an antibiotic agent is used, high-dose amoxicillin (80 to 90 mg/kg/ day) is the treatment of choice for most children at the time of initial presentation, unless the disease is particularly severe or the child recently has failed a previous course of the antibiotic. 2, 9 If there is no improvement of the patient in 48 to 72 hours, the patient should be reassessed and the antibiotics should be changed as indicated.
Finally, the guidelines also support practitioners in providing parents with ongoing counsel as to what they can do in their households to lessen the risk of future disease. 2, 9 Factors that can predispose to increased risk of AOM include genetic predisposition, premature birth, male gender, Native American/Inuit ethnicity, family history of recurrent AOM,
TAblE 1
Nonsevere illness
• Pain resolution at 24 hours;
• Pain and fever resolution at four to seven days;
• Tympanic membrane perforation;
• One-month tympanometry; and • Recurrent AOM.
Severe illness Certain diagnosis Uncertain diagnosis
Mild otalgia and fever < 39° C orally or < 39.5° C rectally in the past 24 hours Moderate to severe otalgia or higher fever Clinical picture suggesting AOM with a high probability of a middle ear effusion Clinical picture suggesting AOM with anything less than a high probability of middle ear effusion
Finally, usage of antibiotics has an associated cost, with an individual course of antibiotics ranging from $10 to more than $100.2 In addition, there can be side effects with any antibiotic, including rash, urticaria, allergic reaction, anaphylactic reaction, abdominal pain and diarrhea, as well as potential disturbance of the nasopharyngeal flora. 8 Long-term follow-up of children treated with amoxicillin compared with placebo showed that 54% of children receiving placebo did not have another episode, versus 36% recurrence of AOM in those who received amoxicillin. 8 Furthermore, the prescription of antibiotics increases the likelihood of their use in future illness. 8
In addition, the issue of antibiotic resistance continues to grow, and is especially of concern among children in school and day care settings. Nationwide, an average of 30% (between 15% and 50%) of upper respiratory tract isolates of Streptococcus pneumoniae are not susceptible to penicillin, and approximately 50% of these are highly resistant to penicillin. 2
TAblE 2
Child’s age
Under 6 months
6 months to 2 years
Uncertain diagnosis
Antibiotics Antibiotics (if severe illness);
Observe (if nonsevere illness)
Antibiotics (if severe illness); Observe (if nonsevere illness)
Observe
Certain diagnosis
Antibiotics Antibiotics
2 years and older
presence of other siblings in the household, day care attendance and exposure to tobacco smoke. 2 Parents and caregivers can modify certain environmental factors to decrease incidence of AOM in children; these include doing more breast-feeding, avoiding “bottle propping,” decreasing day care attendance, minimizing exposure to tobacco smoke and waiting until 4 to 6 months of age to introduce solid foods, as well as avoiding certain allergenic foods. 2, 10
In an effort to provide practitioners with management guidelines based upon the best scientific evidence available, in 2004 the AAP and the AAFP published Clinical Practice Guideline for the Diagnosis and Management of Acute Otitis Media. 9 These guidelines emphasize the importance of making a certain diagnosis of AOM, which includes a history of acute onset and signs of middle-ear effusion, as well as signs and symptoms of middle-ear inflammation, such as otalgia, which clearly interferes with normal activity or sleep. 9 The guidelines also discuss the significance of treating the pain
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