Acute Otitis Media in Children - Essay Example

Acute Otitis Media in Children Acute Otitis Media (AOM) is one the most common diagnosis in children and the use of advanced antibiotics is debatabledue to the inherent risk for the development of antibiotic resistance. However, as young children are susceptible to complications due to low innate immunity in some cases, the use of antibiotics cannot be avoided totally. An individual evidence based decision has to be taken judiciously in each case while treating AOM. A search for the current recommendations and research in this aspect was conducted on the internet and a wide variety of online medical databases were explored which includes the Cochrane database, the American Center for Disease Control (CDC) website, the Bandolier database for evidence based research, AHRQ website and Google Scholar. The main keywords used for conducting the search were ‘Acute Otitis Media’, ‘Evidence based pediatric practice’, ‘use of antibiotics in AOM’ and ‘current trends in antibiotic use’. Twelve pertinent articles were shortlisted for analysis for this study. The first article provided secondary evidence of antibiotic usage and its benefits/adverse effects after an extensive review of research articles on the topic conducted at the Southern California Evidence-based Practice Center at Santa Monica (AHRQ). A second article from the AHRQ website provided primary evidence of antibiotic prescribing patterns in Otitis media, the cost involved in the treatment and the need for a second course of antibiotics (Berman et al, 1997). The third review article from the Cochrane database provided primary evidence of the futility of antibiotic use in AOM due to the spontaneous regression of pain and deafness in children older that two years of age (Glasziou et al, 2004). The fourth article from the Cochrane database however suggested that antibiotics administered over a long term period of at least six weeks was essential for preventing future infections of the middle ear in young children (Leach & Morris, 2006). The fifth article obtained from the Cochrane database however advocated the benefit of a short five-day course of antibiotics as compared to a ten-day course for otherwise healthy children with uncomplicated middle ear infection (Kozyrskyl et al, 2000). An article on general advice to people on ear infections at the CDC website elaborated the different kinds of AOM, the etiological agents involved and the necessity of antibiotics to treat only specific kinds of middle ear infections. Another article obtained from the CDC website elaborated upon the genetic diversity of the main bacteria responsible for middle ear infections in young children and the risk factors associated with acquiring infection with such organisms in the United States (Sauver et al, 2000). Another review article obtained from the bandolier database reviewed the clinical trials conducted till the date of the review on the existing literature on antibiotic usage patterns and their success or failure rates in reducing the complications of AOM (Kozyrskyi et al, 1998, 8). Another study obtained from the bandolier database suggested the futility of applying the law of averages in arriving at a consensus about the use or disuse of antibiotics in AOM due to individual variations in children and recommended that each case has to be treated based on individual peculiarities of the child and after analyzing the risk factors associated with the spread of infection (Rovers et al, 2006). Another meta analysis study obtained from the bandolier database suggested that antibiotic use in the initial treatment of AOM is essential indeed as it is difficult to establish which child will suffer complications at the initial stage of diagnosis and one cannot take the risk of treating the disease without antibiotics despite the evidence of spontaneous recovery in majority of the children (Rosenfeld et al, 1994, 10). In an interesting secondary analysis of randomised controlled trial cohort, the authors endeavored to develop predictors of poor outcome or benefit from antibiotic use for the treatment of acute Otitis media (Little et al, 2002). Yet another study however predicted that routine treatment of AOM with antibiotics may increase the risk of recurrent middle ear infection (Bezakova et al, 2009). A secondary review article compares the clinical guidelines published by two eminent organizations, the Scottish intercollegiate Guidelines Network (SIGN) and the American Academy of Pediatrics (AAP) on the approaches to be adopted while treating AOM (Baumer, 2004). The three articles shortlisted for review are: 1. Risk Factors for Otitis Media and Carriage of Multiple Strains of Haemophilus influenzae and Streptococcus pneumonia (Sauver et al, 2000) 2. Predictors of poor outcome and benefits from antibiotics in children with acute Otitis media: pragmatic randomized trial (Little et al, 2002) 3. Comparison of two Otitis media guidelines (Baumer, 2004) Comparison Chart Research Articles Scientific Rigor Protocol Employed Results & Analysis Implementation Applicability Statistical Tools Used Flaws if Any Study I A novel approach has been used to identify the prevalence of genotypes of the most prevalent bacterial organisms found commonly in throat swabs from susceptible age groups. Throat swabs collected from shortlisted children sequentially four times in four weeks for cultural isolation of H. influenzae and S. pneumonia and further genetic identification. Children exposed to smoking and susceptible to allergies were found to carry more genetically diversified H. influenzae organisms which were associated with higher susceptibility to AOM. The results suggest that children who were relatively younger (36-47 months age) are at higher risk of being subject to AOM due to inherent susceptibility to allergy, smoking and other precipitating factors such as pacifier use were more prone to suffer from Otitis media. Fisher’s exact test (2 tailed) was used to determine the significance of differences in the number of genetic types of bacteria. Determination of risk factors was made using univariate generalized estimating equation Collection of swabs from throat could have limited actual organisms responsible for AOM. Any differences in the subjects under study for S. influenzae could not be determined. Study II Authors have tried to define predicting factors for the decision to use antibiotics in children suffering from AOM which shows the right approach in an endeavor to establish clinical guidelines Randomized controlled study to compare two types of prescribing strategies with and without the use of antibiotics by thorough follow up. Children exhibiting symptoms of high fever and vomiting were found to be benefitted more by early initiation of antibiotic therapy. Such systemic indicators provide a good hint for decisions regarding early antibiotic use. The study results suggest that if the physicians as well parents observe and watch for the predictors like fever and incidence of vomiting, they can make a sound therapeutic decision. Nquery sample size program was used for 80% power and 95% confidence limits to determine the predictors from diary data obtained over the course of the observation period from two groups from a total sample size of 315 children divided equally. Compliance or non compliance factors with the suggested protocol for recording systemic symptoms recorded by parents were not studied. Data recorded by untrained parents may have been erroneous. Study III An effort has been made to compare the recommendations made by two eminent organizations in diverse geographical locations to arrive at a consensual strategy in handling acute Otitis media. A tabulated comparative study for direct observation of the primary recommendations made for handling cases of AOM. The authors have shortlisted the key points and guidelines for both parents and physicians to follow. Well directed hints to serve as cues for deciding the therapeutic approach to be adopted. Comparative study No flaws. Generic Clinical Recommendation While deciding for the therapeutic approach to be adopted for treating cases of AOM, the initial decision should be made by taking into account the predisposing factors such as age, home environment, immunity status and presence of comorbidities. Antibiotic use is recommended in very young children according to the following pattern: 1. Less than 6 months age: Use antibiotic 2. 6-months to 2 years: Use antibiotic 3. Greater than 2 year’s age: Antibiotic use only after close observation of persisting symptoms for 3 days. Diagnosis should be established by watching for the following tell tale symptoms (Baumer, 2004): 1. Earache, fever and irritability. 2. Discharge from middle ear. 3. Opaque drum observed in otoscopy. 4. Bulging Drum 5. Impaired drum mobility 6. Hearing loss References: Baumer, J.H., Comparison of two otitis media guidelines, Arch. Dis. Child. Ed. Pract. 2004;89;76-78 Bezáková N, Damoiseaux RAMJ, Hoes AW, et al. Recurrence up to 3.5 years after antibiotic treatment of acute otitis media in very young Dutch children: survey of trial participants. BMJ 2009;338:b2525 Ear Infections, online article accessed Feb. 1, 2009 at: http://www.cdc.gov/getsmart/antibiotic-use/URI/ear-infection.html Kozyrskyi, A L,Hildes-Ripstein, G E, Longstaffe, S E et al.Treatment of acute otitis media with a shortened course of antibiotics. JAMA 1998 279: 1736-42. Kozyrskyj A, Hildes-Ripstein GE, Longstaffe SE, et al. Short course antibiotics for acute otitis media. Cochrane Database of Systematic Reviews 2000, Issue 2. Art. No.:CD001095. Leach AJ, Morris PS. Antibiotics for the prevention of acute and chronic suppurative otitis media in children. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD004401 Little, P., Gould, C., Moore, M. et al, Predictors of poor outcome and benefits from antibiotics in children with acute otitis media: pragmatic randomised trial, BMJ 2002;325:22 Management of Acute Otitis Media, online article accessed February 2, 2010 at:http://www.ahrq.gov/clinic/epcsums/otitisum.htm Percent of Children Ages 30 Months to 13 Years With Unresponsive Acute Otitis Media by Type and Cost of Oral Antibiotics, Tabulated data accessed online Feb. 2, 2010 at: http://www.ahrq.gov/qual/rxtherapies/rxriatab1.htm Rosenfeld,R.M., Vertrees,J. E., Carr, J. et al. Clinical efficacy of antimicrobial drugs for acute otitis media:metaanalysis of 5400 children from thirty-three randomized trials. Journal of Pediatrics 1994 124:355-67. Baumer, 2004 Rovers, M.M. et al. Antibiotics for acute otitis media: a meta-analysis with individual patient data. Lancet 2006 368:1429-1435. Sanders S, Glasziou PP, Del Mar C, Rovers MM. Antibiotics for acute otitis media in children. Cochrane Database of Systematic Reviews 2004, Issue 1. Art. No.: CD000219. Sauver, J.S., Marrs, C.F., Foxman, B. et al, 2000. Risk Factors for Otitis Media and Carriage of Multiple Strains of Haemophilus influenzae and Streptococcus pneumoniae, Emerging Infectious Diseases, Vol. 6, No.6, accessed online at: http://www.cdc.gov/ncidod/eid/vol6no6/stsauver.htm Read More

Another study obtained from the bandolier database suggested the futility of applying the law of averages in arriving at a consensus about the use or disuse of antibiotics in AOM due to individual variations in children and recommended that each case has to be treated based on individual peculiarities of the child and after analyzing the risk factors associated with the spread of infection (Rovers et al, 2006). Another meta analysis study obtained from the bandolier database suggested that antibiotic use in the initial treatment of AOM is essential indeed as it is difficult to establish which child will suffer complications at the initial stage of diagnosis and one cannot take the risk of treating the disease without antibiotics despite the evidence of spontaneous recovery in majority of the children (Rosenfeld et al, 1994, 10).

In an interesting secondary analysis of randomised controlled trial cohort, the authors endeavored to develop predictors of poor outcome or benefit from antibiotic use for the treatment of acute Otitis media (Little et al, 2002). Yet another study however predicted that routine treatment of AOM with antibiotics may increase the risk of recurrent middle ear infection (Bezakova et al, 2009). A secondary review article compares the clinical guidelines published by two eminent organizations, the Scottish intercollegiate Guidelines Network (SIGN) and the American Academy of Pediatrics (AAP) on the approaches to be adopted while treating AOM (Baumer, 2004).

The three articles shortlisted for review are: 1. Risk Factors for Otitis Media and Carriage of Multiple Strains of Haemophilus influenzae and Streptococcus pneumonia (Sauver et al, 2000) 2. Predictors of poor outcome and benefits from antibiotics in children with acute Otitis media: pragmatic randomized trial (Little et al, 2002) 3. Comparison of two Otitis media guidelines (Baumer, 2004) Comparison Chart Research Articles Scientific Rigor Protocol Employed Results & Analysis Implementation Applicability Statistical Tools Used Flaws if Any Study I A novel approach has been used to identify the prevalence of genotypes of the most prevalent bacterial organisms found commonly in throat swabs from susceptible age groups.

Throat swabs collected from shortlisted children sequentially four times in four weeks for cultural isolation of H. influenzae and S. pneumonia and further genetic identification. Children exposed to smoking and susceptible to allergies were found to carry more genetically diversified H. influenzae organisms which were associated with higher susceptibility to AOM. The results suggest that children who were relatively younger (36-47 months age) are at higher risk of being subject to AOM due to inherent susceptibility to allergy, smoking and other precipitating factors such as pacifier use were more prone to suffer from Otitis media.

Fisher’s exact test (2 tailed) was used to determine the significance of differences in the number of genetic types of bacteria. Determination of risk factors was made using univariate generalized estimating equation Collection of swabs from throat could have limited actual organisms responsible for AOM. Any differences in the subjects under study for S. influenzae could not be determined. Study II Authors have tried to define predicting factors for the decision to use antibiotics in children suffering from AOM which shows the right approach in an endeavor to establish clinical guidelines Randomized controlled study to compare two types of prescribing strategies with and without the use of antibiotics by thorough follow up.

Children exhibiting symptoms of high fever and vomiting were found to be benefitted more by early initiation of antibiotic therapy. Such systemic indicators provide a good hint for decisions regarding early antibiotic use. The study results suggest that if the physicians as well parents observe and watch for the predictors like fever and incidence of vomiting, they can make a sound therapeutic decision.

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