Selective Use of Antibiotics for Acute Otitis Media

from Practice Update, Winter 2007

Friedman NR, McCormick DP, Pittman C, Chonmaitree T,
Teichgraeber DC, Uchida T, Baldwin CD, Saeed KA.
Development of a practical tool for assessing the severity of
acute otitis media. Pediatr Infect Dis J. 2006 Feb;25(2):101-7.
PMID: 16462284

Norman Friedman, MD, D, ABSM, Department of Otolaryngology, The Children’s Hospital
Associate Professor of Otolaryngology and Pediatrics, University of Colorado at Denver and Health Sciences Center Director, Rocky Mountain Sleep Disorders Unit

Acute otitis media is a common childhood disease. Almost all children experience at least one episode by their third birthday, and a significant number have repeated episodes. Acute otitis media consistently leads the list of the most common indications for outpatient antimicrobial use in the United States . With increasing use, the emergence of multi-drug resistant bacteria has become a major problem. The Centers for Disease Control and Prevention and national experts have spearheaded a campaign to reduce antibiotic prescription rates in the U.S. While the benefits have been clearly demonstrated in patients with severe acute otitis media, the majority of uncomplicated, non-severe ear infections resolve spontaneously without the need for antibiotics. The American Academy of Pediatrics and the American Academy of Family Physicians recently published guidelines suggesting that watchful waiting, with symptom management only, may be an appropriate treatment option for some children with non-severe acute otitis media.

Diagnostic Certainty

Standard Definition: Acute otitis media exists in “the presence of middle-ear effusion in conjunction with the rapid onset of one or more signs or symptoms of inflammation of the middle ear.”

• Acute Onset
• Symptoms or Signs
  • Distinct Otalgia
  • Distinct errythema of the tympanic membrane
• Middle Ear Effusion present
  • Bulging Tympanic Membrane
  • Limited TM mobility
  • Air-Fluid level

As important, clinicians need to make an accurate diagnosis. A screaming child with a red but mobile tympanic membrane should not be diagnosed with acute otitis media. Pneumatic otoscopy is essential to more accurately detect the presence of fluid. A child who presents with an opacified tympanic membrane, but is asymptomatic, does not have acute otitis media.

To assist with determining which patients may qualify as non-severe AOM, Norman Friedman, MD, and the UTMB ear treatment group have developed a card that assesses both parent’s perception of the child’s illness and physician’s physical exam findings of the ear.**

Children with non-severe acute otitis media may be candidates for a “safety net” antibiotic prescription, given with instructions for parent to fill only if infection worsens. On the other hand, an anxious parent who suspects that his/her child is quite ill is less likely to accept a watchful waiting approach and the clinician may feel likewise. Both parent and physician perceptions need to be considered when deciding on treatment. The acute otitis media card may assist the clinician in identifying parents amenable to watchful waiting and help initiate the discussion of an appropriate treatment plan. For a watchful waiting program to be effective, parent education, management of acute ear symptoms, access to follow-up care and initiation of antibiotics for worsening infection are necessary.

When tympanostomy tubes are present, the clinical management is different. A draining ear heralds an acute ear infection. With minimal systemic symptoms, one can prescribe topical rather than oral antibiotics. Topical antibiotics deliver high concentrations of antibiotics directly to the middle ear, with rare systemic side effects and minimal risk of resistant organism development.

When prescribing topical otic drops for a draining ear, a consensus statement from the American Academy of Otolaryngology – Head and Neck Surgery recommends that the clinician prescribe a non-ototoxic medication. The two drugs with FDA indications to treat a draining ear are Ciprodex and Floxin.

**(Dr. David McCormick will e-mail a copy of the AOM Card to interested persons upon request (david.mccormick@utmb.edu ). The AOM Card may be used for teaching and research but not for further publication or sale.)