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When you go to make the diagnosis of otitis media, see the whole tympanic membrane. Diagnose it based on some criteria. Try to make that diagnosis as strict as you can. And then use your antibiotics in as precise a fashion as you can and follow them up until you know they are better ear infection, ear infecton, earache, earach, otitis media, otitis medea
Otitis media is any kind of inflammation in the middle ear and there are two basic kinds. There’s acute otitis media and there’s otitis media with effusion and we’ll talk a little bit about the difference and why we really want to make a clean distinction on those a little bit later. What’s interesting is that up to a third of them come in for
What shall we tell the parents when they come in for their first well-check? This is the time you hit them up with this. Because you know everybody is going to have some. So you tell people about this. That while 15% don’t get otitis media by the time they are three, almost everybody else does. What we expect is for every child to have three otitis’s every winter. If you can stay to three or less, you are normal. You are average. That’s out goal. Keep it to
What are the problems? Well, there’s this plumbing problem - as I call it - where the eustachian tube and the palate are not very mature. You know the eustachian tube, that straight shot, that short floppy eustachian tube can’t keep things from refluxing up there and then the muscles don’t coordinate well and flush it all back out. Things get trapped up there and cause inflammation. In addition to that, you’ve got a nasopharynx full of bacteria. It’s the dirtiest place
There is a protective layer where we have antibodies and all these cells and there is some built-in stuff that really should help us, but the problem is we haven’t developed immunity to all those things that are out there. In fact, you can’t make antibody to pneumococcus until you are bout two-years-old because it’s a capsule with polysaccharide. Until we have a conjugate vaccine we can’t even immunize people to it. So the first two years are kind of like a
Now, some of that is avoidable. How is that avoidable? Keep them out of daycare. If you’ve got to use daycare, you are going to see us a lot more. You are going to see us twice as frequently for URI’s. Almost three times as
What are the risk factors? Aged less than two years, big risk, big risk. That’s a problem. The viral respiratory illness, the daycare, the pacifier over two. Passive smoke, we know about. The propping the bottle. As you get a little older, the risk factors are not as high. And then males have more problems. Around the middle of May things get better and breast feeding tends to reduce otitis media for about 50% while you are breast feeding.
These are the real hard core that you know to deal with. First episode: less than six months. That means that the maternal antibody that came across isn’t enough to protect them. That’s a red flag going up saying "I’ve got the worst eustachian tubes on the planet." So predict them. They are going to be in a lot more. You’ll look like you know what you’re doing because they’ll be back. Three episodes in the last six months: that’s kind of a give away. Native Americans, Down’s syndrome, cleft palate, they all are at least twice as frequent to have otitis media and have half the rate of
The major difference, as you can see, is there are two. One is the position. If it’s bulging, as opposed to neutral or retracted - infection stretches things, makes things swell. When it’s cleaning up and it’s just the fact that the eustachian tube can’t pump enough air up and get the mucus out, it will tend to retract or sit in that neutral position. So position is a very important thing to do.
Mobility: does it move when you both blow in and come out, or does it just move when you come out? Because see, if there’s a vacuum back there you can’t push it but you can suck it back. Because you can pull back and it will overcome the vacuum in the middle ear. If it’s already full of pus you can’t compress it and it’s already stretched out so you can’t pull it at you. It turns out that that movement alone, if you get it right, will be a 65% predictor of infection. You add to that a bulging position you are up to about 85% prediction. What the color adds is about 5% to 6% and there are
If we take the pathogens and break them down by - all in that left column - the ones who have intermittent otitis in the middle and the recurrent ones on the other side in yellow here, you can see the difference in the rates of resistance. The intermediate resistant to penicillin and amoxicillin and cephalosporins, as it turns out. Over there, 15% to 40% beta-lactamase producing. H. flu, 25% to 40% with recurrent persisting. And those are just so much higher and that tells us where we have to really apply our more potent drugs.
If we then look at this thing that we talked about before, in the antibiotic lecture, you’ll see that we really have had problems with drug resistant pneumococcus getting more frequent and the thing I want to point out to you here is that down there at the bottom, January to May has twice as
I will not spend any time going over this in detail. This is my "Oh, my God" slide. What I want you to just take away from this is the second line here: amoxicillin, here’s the MIC for the intermediately resistant pneumococcus. Here’s the MIC-90 over, 8 to 16 for the highly resistant. You get 4 to 8 in middle ear effusion, so you can see why it should work against the relatively resistant, but not the highly resistant pneumococci. Now that’s at a
This is why we like to think about how we can use amoxicillin b.i.d. now, and if that little line, that dotted one, that’s the old dose. That’s the t.i.d. dosing and you had three of those little peaks going up during the day. If you look at the bottom line going across, that bottom black line, that’s the
So microbiologists - here’s our primitive microbiologists using their old microscopes - trying to figure out what’s happened. What’s happening with otitis media? Well, we pretty well know that we need to look at susceptibilities and if we try to take all the drugs and lump them together in to low, mid and high potency, we can kind of figure out where we’re going. In the box over there on the far right side you can see there’s lots of things that have high potency to kill regular old 80’s kind of pneumococci. The drug susceptible stuff. The weak sisters turn out to be cefixime, which is Suprax, Ceftibuten, which is Cedax, Bactrim which we know is recently slipping badly against pneumococcus, and ciprofloxacin. All the others work just fine and you don’t really have a problem. If this was the only pneumococcus we had, we wouldn’t have much the problems that we have right now. But if we put drug resistant pneumococcus on that same sort of sliding scale, a bunch of stuff falls way over here. Including: cefaclor, Ceclor, loracarbef which is Lorabid. They’ve become weak sisters as well. Then we’ve got the mid-potency stuff. A lot of stuff in the middle. Then we have the extra-potency drugs over there and amoxicillin clavulanic acid is only high potency if you get the amoxicillin dose up to about 60 to 100 per kilo. You see clindamycin plus sulfa, and actually levofloxacin is a little bit better than it looks on there, but not a whole lot better. It should be a
If we take H. influenza, one of the other pathogens that’s kind of hard to treat, the beta-lactamase producers, you can see there’s a lot that don’t get beta-lactamase producing H. influenza and there are a lot that do. The ones that you’ve really got to worry about here are clarithromycin, cefprozil, Ceclor and amoxicillin. But amoxicillin, as I said, shouldn’t be used as a backup anyway. So I think that’s why it’s still … because of its potency against drug susceptible pneumococcus, still allows it, if we put them all together, and make them who’s going to be the contenders, we can see that first line drugs: amoxicillin, Pediazole, and trimethoprim sulfa are still okay. If we could do those others - I mean, Ceftibuten, cefixime, clarithromycin - would all be reasonable first line drugs but they cost too much. If people fail those, then you would probably want to go farther to the right than you could, so I think using the amoxicillin clavulanic acid in the way I like to use it in kids, is give the 45 - they are high risk patients - 45 per kilo divided twice a day of the Augmentin. Just like it says in the PDR. Give them another prescription for 40 to 50 per kilo of amoxicillin and have them split that b.i.d. You take your dose of Augmentin followed by your dose of amoxicillin and that way you get your 80 to 100 per kilo of amoxicillin without having to buy extra Augmentin and you also don’t increase the GI side effects. So you get sort of what we affectionately like to call, augmented Augmentin and that’s what gets you the best of both worlds. You’ve got beta-lactamase stability and you’ve got the high dose of amoxicillin. If they are allergic to the penicillins, you can use clindamycin at 30 per kilo per day, divided t.i.d. and Gantrisin, 150 per kilo divided three times a day as sort of what I want to use as my big guns, if I’m allergic to penicillins.
This is just to tell us that previous antibiotic use, that daycare attendee who is less than two-years-of-age and anybody who has failed prophylaxis, are high risk for drug resistant pneumococcus. These are the ones that you really want to think about. If they have been in the ER and had Rocephin lately, as we call it, that’s also going to select for drug resistant pneumococcus. Remember winter and spring is worse than summer and fall. So if you
A couple of quick things here. Just to show you the Cefuroxime, the drug does not absorb very well. The higher the MIC on pneumococcus the less activity. This isn’t in your handout, but there’s 43% failures if they have a little bit higher rate. Of course Ceclor is 75% failure rate. That’s kind of like placebo, as we all kind of know. If we were to take the penicillin drugs, the amoxicillin clavulanic acid, even with the higher MIC’s we are still getting good activity and that probably relates to absorbability and the fact that it is more bactericidal. Finally one of the things, the CRO, the red bars there. That’s sort of the laboratory name for ceftriaxone and you can see ceftriaxone really isn’t any better than Bactrim and is a little worse than amoxicillin-clavulanate, which is Augmentin, in treating low-risk patients with one dose. So it’s about 80% effective and so that’s what you want to pass on to folks. If they want that shot, 80% effective as long as it’s not drug resistant pneumococcus.
How long do we treat? I think there’s a place for no antibiotics. So the patients who come in and say, "I would rather not use antibiotics" - I think they don’t want to be on antibiotics and I think if the patient has mild otitis, doesn’t have a high fever, doesn’t have a lot of ear pain, is not under two, is not in daycare, and it’s okay with the folks, try masterful inactivity, as the Dutch have. Which is just ibuprofen. See if it gets better. If they aren’t better in 48-72 hours, then you can apply your antibiotics. If they have bad GI symptoms I think you can give a does of ceftriaxone. If you are worried about drug resistant pneumococcus, the alternative to two more doses of ceftriaxone is give them seven days of high dose amoxicillin orally. So you stun them with the IM stuff and then give them the oral thereafter: in five days for people who have intermittent or low risk and are over three, and don’t want to do without the antibiotics, five days works as well as ten if you don’t have recalcitrant otitis. Then the people who are really problem cases, we still go ten days. Ten days is still the rule on those regardless of what people say.
Prophylaxis: We’d rather have sulfa than amoxicillin because it turns out amoxicillin induces three times as many drug resistant pneumococcus. So Gantrisin, 50 to 75 per kilo. One dose at bedtime. Try to give it to them for six weeks then get them off. Don’t put them on in the fall and wait until
And tubes - they break through and they go above your three rule and they go about three months for their effusion rule, that’s when they need PE tubes.