Diagnosis and pharmacological management of acute otitis media

Pediatric Nursing, Sept-Oct, 1998 by Nancy H. Montville, Mary A. White

* Order CBC with differential and blood cultures in infants less than 3 months who appear toxic, have a high fever, or are immunocompromised

* Consider audiometry posttreatment

Treatment

Amoxicillin/Amoxil (40 mg/kg/day) in three divided doses for 10 days. Initial drug of choice because it is inexpensive and has few side effects. Two disadvantages are its ineffectiveness against B-lactamase producing pathogens, and its inability to be used in clients with penicillin allergies.

Initial therapy in the penicillin allergic child:

* Erythromycin ethylsuccinate sulfisoxazole acetyl/ Pediazole (50 mg/kg/day) in four divided doses for 10 days; or

* Trimethoprim sulfamethoxazole/Bactrim[R]/Septra[R] (8 mg/kg/day TMP, 40 mg/kg/day SMX) in two divided doses.

For B-lactamase producing organisms give one of the following:

* Cefprozil (Cefzil[R]) (30 mg/kg/day) in 2 divided doses for 10 days.

* Amoxicillin/clavulanate potassium (Augmentin[R]) (40 mg/kg/day) in three divided doses or (45 mg/kg/day) in two divided doses.

* Erythromycin-sulfisoxazole)/Pediazole not in infants < 2 months; 40-50 mg/kg/day in 4 divided doses.

* Bactrim/Septra not in infants < 2 months old; TMP 8 mg, SMX 40 mg/kg/day in 2 divided doses.

Complications

1. Tympanic membrane perforation; purulent drainage in the ear canal is visible. Healing of TM will occur spontaneously most of the time.

2. Mastoiditis: suppuration and osteomyelitis of mastoid air sacs. Area behind ear is red, swollen and tender. Auricle may protrude. Refer to ENT.

3. Meningitis: a child who does not have marked improvement in 24-48 hours and develops vomiting associated with fever; child will appear toxic.

4. Hearing loss; usually resolves.

5. Speech and language delay if chronic OM with failed tympanograms; especially during periods of language acquisition.

Patient Education

1. Follow-up if resolution of symptoms does not occur in 48-72 hours.

2. In routine cases follow-up visit should be scheduled after completion of antibiotic therapy.

Note: Adapted from Graham, M.V., & Uphold, C.R. (1994). Clinical guidelines in child health. Gainsville, FL: Barmarrae Books; and Burns, C., Barbar, N., Brody, M., & Dunn, A. (1996). Pediatric primary care: A handbook for nurse practitioners. Philadelphia: W.B. Saunders Company.

References

American Society for Microbiology. (1995). Report of the ASM task force on antibiotics. Washington, DC: American Society for Microbiology.

Barnett, E.D., & Klein, J.O. (1995). The problem of resistant bacteria for the management of acute otitis media. Pediatric Clinics of North America, 42(3), 509-516.

Behrman, R.E., & Kleigman, R.M. (1994). Essentials of pediatrics. Philadelphia: W.B. Saunders Company.

Benitz, W.E., & Tatro, D.S. (Eds.). (1995). The pediatric drug handbook. St. Louis: C.V. Mosby Company.

Berman, S. (1995). Current concepts: Otitis media in children. The New England Journal of Medicine, 332(23), 1560-1565.

Bluestone, C.D., Stephenson, J.S., & Martin, L.M. (1992). Ten-year review of otitis media pathogens. Pediatric Infectious Disease Journal, S11, 7-11.