Episode 41 - Acute Otitis Media - a podcast by Rio Bravo Family Medicine Residency Program

Episode 41: Otitis Media.

Diagnosis and treatment of acute otitis media in children, when to avoid antibiotics, use of short course of antibiotics, question of the week about polyarthralgia and fatigue.

Today is February 22, 2021.  

Question of the Month  
by Claudia Carranza  

A 49-year-old female comes to clinic reporting bilateral wrist and ankle pain for 1 month. The pain is worse with movement and responds well to ibuprofen. She denies joint swelling, warmth, or morning stiffness. She reports feeling more fatigued than usual this past month. You note on her chart that she was diagnosed with COVID-19 approximately 6 weeks ago for which she did not need to be hospitalized.  She denies history of diabetes, thyroid disease, lupus, rheumatoid arthritis, trauma, or anemia. She denies fecal, urinary, or vaginal bleeding, no headaches, no chest pain, no SOB or dizziness. Exam is remarkable for a “tired look” and tenderness to palpation at bilateral wrist and ankles. No signs of inflammation on joints is noted. What do you think is the etiology of this patient’s symptoms and what workup would you order (if any)? 

Let’s repeat the question: What do you think is the etiology of the symptoms in a 49-year-old female who complains of symmetrical POLYARTHRALGIA- and fatigue for 1 month, and what workup would you order (if any)? Send us your answer to rbresidency@clinicasierravista.org before March 22, 2021. The winner will be announced and will receive a prize.

Introduction to episode:

This week we announced 3 new chief residents. Dr Manny Tu will replace Dr Lisa Manzanares, a big supporter of this podcast and chief for more than 1 year, who graduated last week as didactics chief. Dr McGill and Dr Gomes will continue to be chiefs until they hand over the baton to Dr Gina Cha and Dr Alejandro Gonzalez-Perez. Congrats, dear residents! (or should we say sorry?)

When you treat an infection, you need to know the recommended duration of treatment. Normally, the more severe an infection is, the longer the duration of treatment. 

In many instances, shorter courses of antibiotics can have similar efficacy to longer courses[1], and treating for shorter periods may also reduce the development of resistance and infections by C. difficile. 

Some infections in which this applies are, for example, community-acquired pneumonia (CAP), where treatment can be shortened to 3-5 days instead of 7-10 days; nosocomial pneumonia which can be treated for 7 days instead of 10-15 days; pyelonephritis, 5-7 days instead of 10-14 days; intra-abdominal infection (after source control) for 4 days instead of 10 days; COPD exacerbation, less than 5 days instead of more than 7 days; bacterial sinusitis, 5 days instead of 10; uncomplicated cellulitis, 5-6 days instead of 10 days. Of course, you must use your clinical judgement when deciding to use a shorter course of antibiotic treatment.

As a reminder, FDA has also warned about the relationship between fluoroquinolones and an increased risk of aortic dissection. On their website, it states that “Health care professionals should avoid prescribing fluoroquinolones to patients who have an aortic aneurysm or are at risk for an aortic aneurysm, such as patients with peripheral atherosclerotic vascular diseases, hypertension, certain genetic conditions such as Marfan syndrome and Ehlers-Danlos syndrome, and elderly patients”. They also say you “may prescribe fluoroquinolones to these patients only when no other treatment options are available”[2]. 

Other safety concerns reported by FDA about fluoroquinolones include: significant decrease in blood sugar and certain mental health side effects, disabling side effects of the tendons, muscles, joints, nerves, and central nervous system, restriction in use for certain uncomplicated infections, peripheral neuropathy, and tendinitis and tendon rupture. Therefore, think about this warning before prescribing fluoroquinolones[2].

This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. 

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Acute Otitis Media.

Dr Katherine Schlaerth is a native of Pennsylvania. She graduated from Manhattan College and received her medical degree from the State University of New York, Buffalo. Dr. Schlaerth completed her pediatrics residency at Children’s Hospital LA and an Infectious disease fellowship at LAC-USC Medical Center. She is board certified in pediatrics, pediatric infectious diseases, family medicine and has a Certificate of Added Qualifications in Geriatrics. Dr. Schlaerth was an associate professor at Loma Linda and is an associate professor emeritus at USC. She has a special interest in research and has published in addiction medicine, child development and other areas.

Some topics discussed during this episode included definition of otitis media; risk factors such as bottle feeding, tobacco exposure, viral illness; common symptoms such as fever, irritability, ear tugging; diagnosis by pneumatic otoscopy; erythema of tympanic membrane as a sign of otitis media; treatment with antibiotics; use of amoxicillin as the first line of treatment; amoxicillin/clavulanate if amoxicillin fails; use of azithromycin, cefdinir and ceftriaxone for treatment, prevention with vaccination against Hib, pneumococcus and influenza, and more. 

 

Page Break

Tips:

Tip #1: Tympanocentesis

Although impractical in primary care, tympanocentesis may be done in children with severe, ongoing symptoms despite use of multiple antibiotics. Middle ear fluid can then be cultured and antibiotics adjusted based on bacterial sensitivities. 

Tip #2: Common pathogens

Common pathogens in neonates with acute otitis media include Group B streptococci, gram-negative enteric bacteria, and Chlamydia trachomatis. Empiric sepsis treatment should be started without delay, especially in neonates younger than 2 weeks with fever and acute otitis media.

Tip #3: When to give antibiotics

Give antibiotics in these cases: acute otitis media with otorrhea or severe symptoms at any age, and BILATERAL otitis without otorrhea in younger than 2-year-olds. Observation without initial antibiotics AND follow up in 48-72 hours is an option in low-risk children who are older than 2 years old with otitis WITHOUT otorrhea. 

Tip #4: Pain control

Don’t forget to treat pain related to otitis media. To provide short term pain relief, use acetaminophen, ibuprofen, or alternating between the two. 

Tip #5: Failure of treatment

Failure of antibiotic treatment occurs when the severe symptoms do not improve within 48 to 72 hours after initiation of treatment, or if acute otitis media is diagnosed again within 30 days after appropriate treatment.

Tip #6: Duration of antibiotics

For patients under 2 years of age OR with severe symptoms, give PO antibiotics for 10 days; in patients older than 2 years without severe symptoms and without otorrhea, 5-7 days may be enough. Make sure parents understand that fever and ear pain may persist for 48-72 hours. Some signs to look for that warrant a trip back to clinic or the ER include vomiting, headaches, high fever, and pain behind the ears. If recovery is uneventful, follow up 3 months after completing antibiotics or during the next well child visit, whichever comes sooner.

Tip #7: Tympanostomy

Consider tympanostomy tubes in children with 3 or more episodes of acute otitis media within 6 months, or 4 episodes within one year, with one episode in the preceding 6 months. 

After the mics turned off: Topical treatment

After having this conversation with Dr Shclaerth, she gave me this additional information about use of topical antibiotics in acute otitis media and otorrhea:

Tympanic membrane perforation is not commonly seen in purulent otitis media, but often stops the pain because it is essentially the draining of an abscess, i.e. otitis media. A culture of the purulent material can be done if concern exists for unusual bacteria. Generally, the rupture of the tympanic membrane heals over rapidly. 

Topical ofloxacin and ciprofloxacin has not been studied extensively in the treatment of children with ACUTE otitis media with acute tympanic membrane perforation. These topical medications should be used for 7 to 10 days in children with CHRONIC suppurative otitis media or in otorrhea with TYMPANOSTOMY tube, in those cases, topical antibiotics are equivalent to oral therapy. However, ACUTE otitis media with tympanic membrane perforation is treated with ORAL antibiotics, not topical. 

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For your Sanity: Jokes
by Steven Saito and Tana Parker

Why are pediatricians always in a rush? They have little patients.

I told my wife she was drawing her eyebrows too high. She looked surprised.

Someone stole my mood ring. I don’t know how I feel about that.

Why do cows were bells? Because their horns don’t work.

Now we conclude our episode number 41 “Acute Otitis Media”. Dr Schlaerth explained when to use antibiotics and when to use a more conservative approach in the treatment of acute otitis media. Remember that antibiotics are not always the right answer, we want to avoid undesired side effects and prevent antibiotic resistance whenever possible. The question of the month is: What do you think is the etiology of the symptoms in a 49-year-old female who complains of symmetrical polyarthralgia and fatigue for 1 month, and what workup would you order (if any)? Send us your answer to rbresidency@clinicasierravista.org before March 22, 2021 and win a prize! Remember, even without trying, every night you go to bed being a little wiser.

Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email RBresidency@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Claudia Carranza, Valerie Civelli, Katherine Schlaerth, Alex Tompkins, Steven Saito, and Tana Parker. Audio edition: Suraj Amrutia. See you next week! 

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References:

Dimopoulos G, Matthaiou DK, Karageorgopoulos DE, Grammatikos AP, Athanassa Z, Falagas ME. Short- versus long-course antibacterial therapy for community-acquired pneumonia: a meta-analysis. Drugs. 2008;68(13):1841-54. doi: 10.2165/00003495-200868130-00004. PMID: 18729535. https://pubmed.ncbi.nlm.nih.gov/18729535/

 

FDA warns about increased risk of ruptures or tears in the aorta blood vessel with fluoroquinolone antibiotics in certain patients, FDA, https://www.fda.gov/drugs/drug-safety-and-availability/fda-warns-about-increased-risk-ruptures-or-tears-aorta-blood-vessel-fluoroquinolone-antibiotics

 

Gaddey HL, Wright MT, Nelson TN. Otitis Media: Rapid Evidence Review. Am Fam Physician. 2019 Sep 15;100(6):350-356. PMID: 31524361. https://pubmed.ncbi.nlm.nih.gov/31524361/

 

Wright D, Safranek S. Treatment of otitis media with perforated tympanic membrane. Am Fam Physician. 2009 Apr 15;79(8):650, 654. PMID: 19405408. https://pubmed.ncbi.nlm.nih.gov/19405408/

 

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