Ear Infections: What's New?

You may have heard the news: this year the American Academy of Pediatrics published a revised, updated set of guidelines for the diagnosis and initial treatment of acute otitis media in otherwise healthy children ages six months to twelve years.

http://pediatrics.aappublications.org/content/113/5/1451.full

You might be wondering what this means for you and your child.

The purpose of the new guidelines was to consider the substantial amount of research done since 2004, when the last guidelines were published, in order to assist primary care clinicians in the diagnosis and initial treatment of acute ear infections according to scientific evidence.

Evidence-based medical practice is important because we want to provide care to your child that is necessary, effective, and beneficial. Accurately diagnosing an ear infection is the first step in this process. The first part of the new guidelines addresses the importance of making the correct diagnosis of acute otitis media, and determining if it is a severe or not severe infection. The guidelines go on to address treatment and prevention.

DIAGNOSING ACUTE OTITIS MEDIA AND DETERMINING IF IT IS SEVERE
Acute otitis media is diagnosed when there is fluid in the middle ear (fluid behind the ear drum, a middle ear effusion) PLUS one of the following circumstances:
1. There is moderate to severe bulging of the ear drum (tympanic membrane), OR new ear drainage that is not caused by swimmer's ear (otitis externa).
2. There is mild bulging of the ear drum PLUS severe ear drum redness or recent onset of ear pain (or signs of ear pain such as holding/tugging/rubbing the ear in a child who cannot talk).

The guidelines further define acute otitis media as SEVERE if there are severe signs or symptoms such as moderate to severe pain, over 48 hours of pain, or fever of equal to or greater than 102.2 degrees.

NONSEVERE acute otitis media is diagnosed when the pain is mild, less than 48 hours, and fever is less than 102.2 degrees.

PAIN RELIEF
The recommended first step in management of acute otitis media is assessment and treatment of pain. Over-the-counter pain relievers such as ibuprofen and acetaminophen are the first choice because they are effective, best tolerated, easiest to give, and most available of all the options. Managing pain is important even when antibiotics are used to treat acute otitis media, because pain may continue for 48 to 72 hours after starting an antibiotic.

DECIDING TO USE ANTIBIOTICS
The next step in managing acute otitis media is deciding if antibiotics will be necessary. That's right, not all children with ear infections need antibiotics! The guidelines state that children who are 24 months of age and older, who have NONSEVERE acute otitis media in either one or both ears, may be safely and effectively treated with initial observation and pain management. The decision to hold off on antibiotic treatment is made jointly between the pediatrician and parent. A plan is put in place to ensure follow up or treatment if symptoms get worse or are not improving in 48 to 72 hours.

In general the guidelines recommend antibiotic treatment for SEVERE acute otitis media at any age, or for children under 24 months of age with NONSEVERE acute otitis media that is BILATERAL (on both sides).

DECIDING WHICH ANTIBIOTIC TO USE
Amoxicillin is the first choice if the decision has been made to treat with an antibiotic AND the child has not had amoxicillin in the last 30 days, is not allergic to penicillin, and does not have signs of bacteria that is resistant to amoxicillin (such as repeated poor response to amoxicillin or purulent conjunctivitis--"pink eye" with lots of thick, crusted, colored drainage).

Raising the amoxicillin dose from the traditional 40 milligrams of amoxicillin per kilogram of the child's weight per day to 80-90 mg per kilogram per day will overcome most common bacterial resistance to amoxicillin seen in acute ear infections.

If amoxicillin has been used in the last 30 days, the child is allergic to penicillin, or the bacteria is believed to be resistant to amoxicillin, then amoxicillin-clavulanate (Augmentin) or a cephalosporin (such as cefdinir, cefuroxime, cefpodoxime, cefixime, or ceftriaxone) are the next choices.

Of note, recently (as of 4/14/2013) there have been back-orders on certain cephalosporins, or a delay in pharmacies being able to supply prescribed liquid cephalosporins to our patients. Effectiveness, availability, taste, and cost affect the choice of the prescribed antibiotic.

FOLLOW UP
If symptoms worsen or do not respond to initial antibiotic treatment in 48 to 72 hours, then the child may need to be reevaluated. Even with effective antibiotic treatment pain may worsen for the first 24 hours or not improve for 48-72 hours. Most of the time pain will be treated with ibuprofen or acetaminophen.

PREVENTION
All children are recommended to receive the pneumococcal conjugate vaccine when they are eligible (the routine vaccination schedule for pneumococcal conjugate vaccine is ages 2 months, 4 months, 6 months, and 12-15 months). Annual flu vaccine is recommended for all eligible children (starting at age six months). Six months of breastfeeding is encouraged. Avoidance of tobacco smoke exposure is important. Avoiding giving a bottle while the child lays flat on her back may help prevent ear infections. Reducing or eliminating pacifier use after the age of six months may also help. Decreasing the frequency of viral upper respiratory infections may help reduce ear infections--the only identified way to do this is to reduce exposure to group day care.

A few studies have show xylitol (which is "birch sugar") is effective in reducing ear infection frequency by 25 percent for children in group day care. The best way to give it is in chewing gum or lozenge form, 3-5 times a day, every day throughout the cold and flu season. Gum and lozenges are not appropriate to use in young children because they are a choking hazard. Xylitol does not help treat an active ear infection and does not work if used only occasionally. Of note, xylitol is not really considered a practical solution for the prevention of ear infections at this time due to the limitations in availability for younger children and the difficulties in regular and consistent administration.

Preventative antibiotics (such as a daily small dose of an antibiotic) should NOT be used because they are likely to be more harmful than helpful.

Ear tubes may be an option for recurrent acute otitis media (three episodes in six months, or four episodes in one year with one episode in the preceding six months), however the benefits versus the risks of the procedure must be considered.

ALTERNATIVE MEDICINE
The new guidelines point out that many families turn to complementary or alternative medicine for the treatment and prevention of ear infections. However, in the comprehensive review of the available research-based evidence, no good studies of the effectiveness of such treatments have been published. The guidelines made recommendations about the need for research in this area, and cautioned about the potential costs of treatments that have not been proven to be effective.

Get Smart About Antibiotics

Did you know that this week has been deemed "Get Smart About Antibiotics Week?" As a health care provider I am supposed to help educate the public about the proper use of antibiotics. You might wonder why it's important to educate people other than health care providers about when to use an antibiotic. After all, isn't it up to me (and other prescribers) to decide when to write a prescription? As you will see, it's not always that easy. I need YOUR help to prescribe antibiotics appropriately!

First of all you need the basic information. Germs cause infectious illnesses like colds, flu, strep throat, pneumonia, sinusitis, conjunctivitis (pinkeye), bronchitis, croup, etc. Many of these germs are viruses, some are bacteria. Viruses cause most of the coughs and colds we see all winter. They are contagious, can cause fevers, coughs, runny noses, green and yellow mucous, sore throats, body aches, red eyes, and other symptoms. They are not treatable (except for a very few, specific, viruses--and these don't cause cold symptoms) with antibiotics. If you take an antibiotic and you have a virus it will not help you get better. It probably won't even help prevent you from getting a bacterial complication later. In fact, an unnecessary antibiotic is more likely to cause problems for you later by making the bacterial organisms already living in you more able to resist the effects of an antibiotic.

Wow, that sounds really good, even easy. Don't take an antibiotic if you have a virus. Don't prescribe an antibiotic if your patient has a virus. Simple. Done. No worries.

It is up to me to decide, and at the same time, sometimes it isn't. You might be surprised to learn that there are some grey areas when it comes to prescribing antibiotics. Some illnesses are clearly bacterial. Others are clearly viral. And then there are some which could be either, or are probably from a virus, but could be from a bacteria. And, because of these uncertain types of illnesses, there are some situations in which it can be just easier to write a prescription than to explain why one might not be needed, or why the parent will have to bring the child back in a few days if things get worse. Don't be too shocked. Did you really think we (doctors) are beyond influence?

So what should I do in the following situation? My patient has missed several days of school. Dad had to take time off work to bring her to the office. They have a $30 copay for an office visit. She has been sick for at least a week with a cough and low-grade fever. I diagnose bronchitis, because I can hear the phlegm and mucous in her lungs. Yet I don't think it is pneumonia because most of this clears with her cough. I know that about 85% of the time, bronchitis is likely to be caused by a virus (this is true). There is nothing I can do to determine if I am dealing with a virus or bacteria. It could develop into pneumonia, but usually doesn't. Still, there is no way to tell if it will, or not. This is a grey area!

I can hear my professors in medical school saying "NO ANTIBIOTIC is needed in this situation. Have the patient return in a few days and recheck her. Educate the family about the proper use of antibiotics." Then I look at my patient and her family and explain my dilemma. They might say "What do you recommend, Doc?" Or "What would you do if it were your daughter?" Or "We'll take the antibiotic, because we can't afford to miss more work or school." Or "Can we just have the prescription? We can't afford another copay." Or "Last time this happened you didn't let us have the antibiotic and we ended up in the ER because she developed pneumonia." And then, the unspoken reproach, not said but seen in the family's facial expression, "We've been waiting for you for an hour and you're going to send us home with nothing?"

Another common scenario is that of a toddler who has had a runny nose and cough, and now a low-grade fever plus difficulty sleeping. Examination reveals some fluid behind both ear drums. This is called serous otitis media, and is not usually caused by a bacteria. It is just fluid in the middle ear, building up because of all the congestion. It probably has an 80% chance of clearing on its own, without ever needing antibiotics. However, let's say in this case the little one has already had six full blown ear infections in the last eight months. We could just be days away from another one. Ideally I should not prescribe an antibiotic, but should have the patient return for rechecks (as a toddler he won't be able to let us know in a reliable way if he is feeling worse) and give the antibiotic if I start seeing pus in the middle ear. Then I am obligating the family to take more time off of work, pay additional copays, and possibly have difficulty scheduling the follow-up appointment(s).

I'm here to tell you that sometimes, as the one prescribing the antibiotic, faced with the above scenarios, it's easier just to write the prescription.

I try to do as much education as I can--about the strong possibility that what I am looking at is a virus, my uncertainty that an antibiotic would be helpful, the possible need for a follow-up appointment. If I don't give an antibiotic prescription I am often asked "Can I just call back for a script if things get worse, or will they make me come in?" Sometimes I can agree to just call something in if things get worse--but in the case of a small child or infant I can't safely do that. Occasionally I will give a prescription and extract a promise from the family not to fill it for 48 hours, then only if nothing has improved. I have started to write an expiration date on those prescriptions as I have noticed they sometimes get filled a month later, for a totally different illness! I don't think that's a good idea at all--at that point how do I know an antibiotic is needed, let alone if it's the right one?

An antibiotic is not a back up plan or a safety net, "just in case." Antibiotics don't "ward off" complications of viruses. They have no magic. An antibiotic will work only in a very specific situation: when the infection is caused by a bacteria and the antibiotic is the correct one for that particular bacteria.

As a parent you can help by not asking for, expecting, or even wanting an antibiotic when your child has a virus. That could mean waiting a little longer before making an appointment to check out minor symptoms like a runny nose or slight cough. It could mean a statement when you come in for an appointment such as "I know it could just be a virus, but we wanted to make sure we weren't missing anything." It could mean educating yourself a bit about common cough and cold viruses, understanding that symptoms from these viruses easily last two weeks (and sometimes three!), mucous color doesn't mean much in terms of diagnosing a virus versus a bacterial infection, and being willing to simply comfort your child as the cold symptoms run their course.

Hey, look--I know it's frustrating to have a sick child and not have anything you can do to make it get better faster. I have three children of my own, remember? I know the grey areas make it even harder to know what to do. I can offer you my pledge--to treat your children the way I would want my own children to be treated, to communicate to you what I am thinking, and why, and to try my hardest to do what is best for your child. I need your pledge that you will try to want what is the best thing for your child, to understand and listen to what I am saying, and not just to extract an antibiotic prescription from the appointment. I want you to trust me, work with me, communicate with me. I will work with you!

The CDC has a website about antibiotics. I can't get the linking option to work on my blog--but you can type this in yourself.
www.cdc.gov/getsmart