Otitis Media: An Update for the Pharmacists

Informed counseling can help patients and caregivers identify, treat, and prevent painful ear infections.

Otitis Media: An Update for the Pharmacists

Otitis media is an infection of the middle ear and can be further classified into 3 forms according to symptoms and degrees of severity. These include acute otitis media (AOM), otitis media with effusion (OME), and chronic suppurative otitis media (CSOM).

Acute Otitis Media

AOM is defined by the American Academy of Pediatrics (AAP) and the American Academy of Family Physicians (AAFP) as an infection of the middle ear with acute onset, presence of middle ear effusion (MEE), and signs of middle ear inflammation.¹ AOM is considered to be the most frequent diagnosis among patients in the pediatric population, second only to the common cold.^1,2 Although AOM can affect patients of all ages, it primarily affects infants and young children with a peak incidence age between 6 and 36 months.² An estimated two thirds of all children in the United States experience at least 1 episode of AOM prior to the age of 1 year, and an estimated 80% have had at least 1 case of AOM by the age of 3 years.^1,3 There is a second peak incidence of AOM cases around the age of 5 years that is believed to be associated with entrance into school.⁴

AOM is also considered to be the most prevalent reason for physician office visits within the pediatric patient population.⁵ Annually, an estimated 20 million office visits are attributed to AOM, and this does not include visits to the emergency department.⁵ Statistics report that in the United States, AOM is the most common reason for outpatient antimicrobial treatment among the pediatric patient population. ^4,6 During the mid-1990s, treatment of otitis media cost $3.8 billion annually; 20% of the more than 110 million prescriptions for oral antibiotics were prescribed for this condition.^4,5

In 2006, statistics reveal that an estimated 9 million children, ranging in age from 0 to 17 years, were reported to have an episode of AOM.1 Of those children, 8 million visited a physician or obtained a prescription drug to diagnose and treat the condition.¹ Although AOM primarily affects the pediatric population, adults make up less than 20% of patients presenting with AOM.6 Table 1 defines the 3 types of otitis media.^5,7-9

Pathophysiology

The etiology of AOM may be viral or bacterial. ^{9, 10} Viral infections are often complicated by a secondary bacterial infection.¹⁰ Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and Streptococcus pyogenes are responsible for the majority of AOM cases in patients older than 6 weeks.³ S pneumoniae is the most common pathogen responsible for AOM and for invasive bacterial infections in children of all age groups.³ Other bacteria recovered and responsible in cases of AOM include Staphylococcus aureus, Streptococcus viridans, and Pseudomonas aeruginosa.^3,5,10

AOM typically manifests itself as a complication of a preceding upper respiratory tract infection.^1,2,11 The secretions and inflammation cause a relative obstruction of the Eustachian tubes and the middle ear mucosa absorbs air in the middle ear under normal circumstances. If the air is not replaced because of obstruction of the Eustachian tube, a negative pressure is generated, which results in interstitial fluid entering the Eustachian tube and creating an effusion.^1-3 This effusion of the middle ear provides an excellent medium for microbial growth and, if growth is rapid, a middle ear infection develops.^1,2

Risk Factors for Otitis Media

Various factors may increase an individual’s risk for developing AOM and, in general, these factors may be classified as patient related or environmental.^1,4,5 Examples of proven risk factors for otitis media include:^1,4,5

Patient Factors

• Premature or low birth weight

• Young age

• Early onset of ear infections

• Familial history

• Native American, Inuit, and Australian Aborigine populations appear to have a greater incidence

• Compromised immune system

• Craniofacial abnormalities

• Neuromuscular disease

• History of allergies and/or upper respiratory tract infections

Environmental Factors

• Day care attendance

• Crowded living conditions

• Exposure to tobacco and other pollutants

• Pacifier use

• Bottlefeeding increases risk compared with breastfeeding

• Prolonged bottle use

• Fall and winter months

Signs and Symptoms

The signs and symptoms commonly associated with AOM include fever, otalgia, headache, irritability, cough, rhinitis, listlessness, vomiting, diarrhea, and pulling at the ears.^1-3,9-11

Infants may appear cranky, have difficulty sleeping, and pull at the affected ear(s). Compared with children, adults more often present with otalgia, ear drainage, diminished hearing, and sore throat.¹⁰ Opacity and redness of the tympanic membrane are equally common in children and adults.^1-4,10

Treatment

The AAP and the AAFP published updated guidelines in 2004 for the management and treatment of AOM, which addressed pain management, initial observation versus treatment with antibiotics, and appropriate choices of antibiotics. ^10,12 According to these guidelines, the “observation option” for AOM refers to deferring antibiotic treatment for healthy children aged 6 months to 2 years with nonsevere illness and an uncertain diagnosis, as well as for patients older than 2 years of age for 48 to 72 hours and limiting management to symptomatic relief.¹² The decision to observe or treat is based on the child’s age, diagnostic certainty, and illness severity.¹² For patients under observation without initial antibiotic therapy, it is imperative that the parent/ caregiver communicate with the health care professional regarding the patient’s condition to prevent any further complications and report if the symptoms appear to worsen.¹²

The guidelines stressed the importance of an accurate diagnosis to rule out OME, which often is present before and after AOM and is not treated with antibiotics. ^4,10,12

Antibiotics are recommended in all patients younger than 6 months of age, in those between 6 months and 2 years, if the diagnosis is certain, and in children with severe infection.^10,12 The recommended first-line therapy is a dosage of 80 to 90 mg per kg/day of amoxicillin. Alternatives for those who are sensitive or allergic to penicillin and with resistant infections include the macrolide antibiotics, clindamycin, and cephalosporins.^10,12 Patients who do not respond to treatment should be reassessed.^10,12

Since pain is often present especially during the first 24 hours of AOM cases, the AAP and AAFP recommend that pain management be addressed regardless of the use of antibiotics.¹² Pain treatment options include acetaminophen, ibuprofen, and otic drops such as antipyrine/ benzocaine otic solution.^1,12 Prior to use, patients should be screened for possible allergies, drug%u2500drug interactions, and contraindications.

Preventive Measures

When counseling the parents and caregivers of patients with AOM, pharmacists can provide key information for reducing or preventing the incidence of AOM. Examples of these preventive measures include:^1,7

• If appropriate, vaccinate children against the flu annually.

• Vaccinate the child with the 7-valent pneumococcal conjugate (PCV7) vaccine. Studies show that this vaccine protects against a number of the most common bacteria that cause ear infections and is indicated for the prevention of otitis media (ear infection) caused by 7 strains of S pneumoniae.^1,7,12-14 The Centers for Disease Control and Prevention recommends that all children under age 2 years be vaccinated, starting at 2 months.^{1, 7, 13} Results from various studies have shown that vaccinated children get fewer ear infections than children who were not vaccinated. The PCV7 vaccine is strongly recommended for children in day care.^1,7

• Practice routine hand-washing techniques to prevent the transmission of germs to keep children healthy.

• Avoid exposing children to cigarette smoke fumes. Studies have shown that infants who are around smokers have more ear infections.

• Never put an infant down for a nap, or for the night, with a bottle. PT

Ms. Terrie is a clinical pharmacy writer based in Haymarket, Virginia.