Stewardship in the pediatrician’s office: Diagnostic certainty in acute otitis media
In this bimonthly column, pediatric infectious disease specialists Asif Noor, MD, FAAP, and Ulka Kothari, MD, share valuable insight on antimicrobial stewardship in pediatric outpatient settings and explain why it is important for your practice. Antimicrobial stewardship programs, or ASPs, have become a crucial intervention to spare patients and facilities from the burden of antibiotic-resistant pathogens, which are responsible for one death every 15 minutes, according to estimates from the CDC.
Diagnoses of acute otitis media or suppurative middle ear infection relies chiefly on examination findings of the tympanic membrane. In 2013, the AAP revised its initial 2004 guidelines to include stringent diagnostic criteria and emphasized the need for accurate diagnosis of AOM and otitis media with effusion.
AOM is a common infection in young children, with a peak incidence between 6 and 24 months of age. This infection is responsible for more than 12 million antibiotic prescriptions annually. Over the past 2 decades, office visits due to AOM have declined primarily due to universal immunization with pneumococcal conjugate vaccine, first PCV-7 in 2000 and then PCV-13 in 2010.
In a 10-year prospective study of 615 children from 2006 through 2016, 23% experienced at least one episode of AOM by 1 year of age. By 3 years of age, 60% had at least one episode of AOM, and 24% had at least three episodes. This is a sharp decline compared with rates during the pre-pneumococcal vaccination era. For example, before the vaccines were available, the percentages of children who developed at least one episode of middle ear effusion between age 61 days and ages 6, 12 and 24 months, respectively, were 47.8%, 78.9% and 91.1%.
However, AOM continues to be one of the most common upper respiratory tract infections requiring antibiotic prescription in children aged younger than 6 years, particularly among those aged 3 to 36 months.
1. Confronting the conundrum of appropriate antibiotic prescription:
In this section we will discuss diagnostic accuracy based on examination findings, and choice of appropriate antibiotic.
Accurate diagnosis of AOM is critical in clinical decision-making. Diagnosis is based on symptoms and signs compatible with AOM. In terms of symptoms, Shaikh and colleagues validated a seven-item, parent-reported symptom score (Acute Otitis Media Severity of Symptom Scale) for children with AOM. Symptoms included ear tugging, rubbing, holding, excessive crying, irritability, difficulty sleeping, decreased activity or appetite and fever. The diagnosis of AOM in infants and young children is often challenging and met with uncertainty.
Examination of the tympanic membrane should preferably be performed with pneumatic otoscopy and, if unavailable, otoscopy alone. Regarding the signs of AOM, Karma and colleagues reported impaired mobility had the highest sensitivity and specificity (95% and 85%, respectively). Cloudiness had the next best combination of high sensitivity (74%) and high specificity (93%). Bulging had high specificity (97%) but lower sensitivity (51%).
Pneumatic otoscopy also permits the assessment of the contour of the tympanic membrane (normal, retracted, full, bulging), its color (gray, yellow, pink, amber, white, red, blue), its translucency (translucent, semiopaque, opaque) and its mobility (normal, increased, decreased, absent). Available tools for learning ear examination include a New England Journal of Medicine video, which includes examination techniques and findings, and a video detailing the 2013 AAP guidelines.
AOM is caused by a bacterial pathogen and typically follows an upper respiratory viral infection. Microbiological analysis in most of these cases detected bacterial and viral coinfection.
Streptococcus pneumoniae, Haemophilus influenzae and Moraxella are the three most commonly associated bacterial pathogens. After the PCV13 introduction, colonization and infection due to penicillin-nonsusceptible and multidrug-resistant S. pneumoniae, primarily serotype 19A, declined dramatically to current levels of 20% or less.
In a meta-analysis, a bacterial pathogen was identified in 64.7% of AOM episodes in which bacteria were isolated. S pneumoniae was isolated in 44.1%, H. influenzae in 36.3%, Moraxella catarrhalis in 7.5% and Streptococcus pyogenes in 5.5%.
Choice of antibiotic
If diagnosis is certain, antibiotics should be used in infants aged younger than 6 months. The initial management is an opportunity for shared decision-making with the children’s family.
In children aged 6 to 24 months, antibiotics should be used in unilateral AOM with otorrhea, bilateral AOM without otorrhea or AOM with severe symptoms. Observation is an option for unilateral AOM without otorrhea. In children aged older than 2 years, antibiotics are indicated in unilateral AOM with otorrhea or AOM with severe symptoms. Observation is an option for unilateral or bilateral AOM without otorrhea.
Amoxicillin is the antibiotic of choice for uncomplicated AOM if the child has not received amoxicillin in the past 30 days or the child does not have concurrent purulent conjunctivitis. Otherwise, amoxicillin clavulanate should be used for beta-lactamase-producing S. pneumonia or H. influenzae coverage. If the community prevalence of S. pneumoniae is high or unknown, high-dose amoxicillin at 80 to 90 mg/kg per day should be used. In a child with a non-type I hypersensitivity allergic reaction, a third-generation cephalosporin such as cefdinir should be used. In a child with type I hypersensitivity reaction, either clindamycin or azithromycin are the options. If the child cannot tolerate antibiotic by mouth, one dose of ceftriaxone should be considered. In terms of duration, in children aged younger than 2 years, the standard 10-day course is recommended. In children aged 2 to 5 years, a 7-day course is recommended, and in children aged 6 years or older, a 5- to 7-day course is adequate.
2. Practice guidelines for outpatient settings:
In its revised guidelines on AOM, the AAP made recommendations for pediatricians managing uncomplicated AOM in children aged 6 months to 12 years. These guidelines provide stringent diagnostic criteria.
The implementation of clinical pathways for the treatment of AOM have led to behavioral changes among physicians, including increased use of the wait-and-see approach and decreases in the use of broad-spectrum antibiotics other than amoxicillin as the first-time agent.
3. Operationalizing an ASP in your office through quality improvement and EHRs:
As discussed in previous articles, operationalizing antibiotic stewardship in otitis media starts with defining measures. For example:
- outcome: the percentage of patients with appropriate prescription of antibiotics; and
- process: the percentage of patients with documentation of otitis media with effusion via tympanometry or pneumatic otoscope.
Multifaceted interventions that aim to change provider behavior (education, anonymous internal reporting of antimicrobial stewardship practices by physicians), change workflow (tympanometry for patients with ear pain, increasing availability of pneumatic otoscopes), educate patients (handouts, posters) and leverage technology (electronic medical record alerts, templates, decision support) may be employed. Start by identifying gaps in care, workflow analysis and defining the problem. When clinicians are not confident in using a no-antibiotic strategy, a delayed antibiotics approach may be an acceptable compromise in place of immediate prescribing to significantly reduce unnecessary antibiotic use for respiratory tract infections, and thereby reduce antibiotic resistance while maintaining patient safety and satisfaction levels.
Telehealth, especially given the current COVID-19 pandemic, may lead to increases in both appropriate and inappropriate use of antibiotics in otitis media. Ear pain is challenging for most pediatricians performing telehealth. Studies have found higher rates of inappropriate antibiotic prescription for upper respiratory tract infections including otitis media via telemedicine. Watchful waiting is appropriate for a select group of patients with a physical examination finding of otitis media. For a child who appears well, offering reassurance and a contingency plan, including a follow-up in-person visit if there is no improvement, is consistent with best practice guidelines.