antibiotic stewardship

1. Otitis media

2. Course content
Course
roadmap
Basic concepts
Common infections
1

3. “Antimicrobial resistance is a global
health emergency that will seriously
jeopardize progress in modern
medicine."
Dr Tedros Adhanom
Ghebreyesus
September 2017
2

4. Core competencies for
antimicrobial prescribing
C1: Understands the patient and the patient’s clinical needs
C2: Understands treatment options and how they support the
patient’s clinical needs
C3: Works in partnership with the patient and other healthcare
professionals to develop and implement a treatment plan
C4: Communicates the treatment plan and its rationale clearly to
the patient and other health professionals
C5: Monitors and reviews the patient’s response to treatment
3
Core Competencies

5. Objectives
• Understand the importance of accurate physical exam
findings in distinguishing middle ear conditions that respond to
antibiotics and those that do not.
• Emphasize adhering to clinical evidence-based practice
guidelines in the management of acute otitis media and otitis
media with effusion
• Demonstrate non-antimicrobial therapeutic interventions and
preventive measures in managing patients with acute otitis
media.
4

6. 5
Otitis media with
effusion
Acute otitis media
Core Competencies 1, 2, 3 & 4
Middle ear infections

7. 6
• Diminish selective
pressure that allows for
emergence of MDROs
• Avoid adverse
reactions
Otitis media with
effusion
Acute otitis media

8. Middle ear infections
7
Otitis media with
effusion
Acute otitis media

9. Case #1
Subsequent evaluation
Initial evaluation
Clinical
assessment
Diagnostic
work-up
Patient
education
Therapeutic
decisions
Modify
antimicrobials
Data
review
Clinical
re-assessment
8
Core Competencies 1, 2, 3 & 4

10. 18 month-old female with:
3 days of fever
frequent awakening at night
pulling at left ear for 48 hours
fluid in middle ear
left tympanic membrane is red, opaque,
bulging, immobile
9

11. Acute otitis media
10
Age
Incidence Most common:
6 – 24 months of age

12. Middle ear syndromes
11
Caused by viral respiratory
tract infection leading to
Eustachian tube
dysfunction
WHO/S Nahrgang

13. 12
Otitis media with
effusion
Acute otitis media
Middle ear fluid
WITHOUT evidence
of inflammation
Middle ear fluid
WITH evidence of
inflammation
Middle ear syndromes

14. 13
Acute otitis media
Middle ear fluid
WITH evidence of
inflammation
Moderate to severe bulging of the
tympanic membrane
New otorrhea without evidence of
otitis externa
Mild bulging of the tympanic
membrane AND recent otalgia
Mild bulging of the tympanic
membrane AND intense tympanic
membrane erythema
Diagnosis

15. Management of acute otitis media
14
Most cases resolve
without any
intervention and
without complications

16. 15
Management of acute otitis media
Many guidelines
promote withholding
antibiotics in some
cases of non-severe
acute otitis media

17. Management of acute otitis media
Antibiotics No antibiotics
Severe AOM Non-severe unilateral AOM in
children 6-24 months of age
Non-severe bilateral AOM in
children < 24 months of age
Non-severe unilateral or
bilateral AOM in children > 24
months of age
16
AAP 2013

18. Management of acute otitis media
Antibiotics
Tympanic membrane perforation or otorrhea
Children < 24 months of age with one of the following:
• Bilateral AOM
• Bulging tympanic membrane
• AOM-SOS Score of >8
17
NICE guidance

19. AOM-SOS
18
Over the past 12 hours, has your child been:
No
A
little
A
lot
… tugging, rubbing, or holding the ear(s) more than usual?
… crying more than usual?
… more irritable or fussy than usual?
… having more difficulty sleeping than usual?
… less playful or active than usual?
… eating less than usual?
… having fever or feeling warm to touch?

20. The clinician-patient encounter
Subsequent evaluation
Initial evaluation
Clinical
assessment
Diagnostic
work-up
Patient
education
Therapeutic
decisions
Modify
antimicrobials
Data
review
Clinical
re-assessment
19

21. An informed choice
Severity Source
Drug
resistance
Patient
factors
Cultures
Core Competencies 1 & 2
Optimal antibiotics
20

22. Severity Source
Drug
resistance
Patient
factors
Cultures
Not severe
How severe is the patient’s condition?
21

23. What is the likely source & pathogens?
Severity Source
Drug
resistance
Patient
factors
Cultures
• Acute otitis media
• Antibiotics per guidelines
22

24. What is the likely source & pathogens?
Severity Source
Drug
resistance
Patient
factors
Cultures
• Most common bacteria:
• S. pneumoniae
• Non-typeable H. influenzae
• M. catarrhalis
23
• Many respiratory
viral pathogens

25. Severity Source
Drug
resistance
Patient
factors
Cultures
• Most guidelines recommend
high-dose amoxicillin as 1st-line
therapy
How likely is resistance?
24

26. Other considerations?
Severity Source
Drug
resistance
Patient
factors
Cultures
• No allergies
• Good oral intake
25

27. Severity Source
Drug
resistance
Patient
factors
Cultures
Core Competencies 1 & 2
Amoxicillin 90 mg/kg
divided into 2 doses
(maximum 3g/day) 26

28. Subsequent evaluation
Initial evaluation
Clinical
assessment
Diagnostic
work-up
Patient
education
Therapeutic
decisions
Modify
antimicrobials
Data
review
Clinical
re-assessment
27
2013 AAP guidelines
• < 2 years of age
• 2-5 years of age
• > 5 years of age
10 days
7-10 days
5-7 days

29. Subsequent evaluation
Initial evaluation
Clinical
assessment
Diagnostic
work-up
Patient
education
Therapeutic
decisions
Modify
antimicrobials
Data
review
Clinical
re-assessment
28
NICE guidance
5 days

30. Subsequent evaluation
Initial evaluation
Clinical
assessment
Diagnostic
work-up
Patient
education
Therapeutic
decisions
Modify
antimicrobials
Data
review
Clinical
re-assessment
29
• Pain relief
• Smoking cessation
• Influenza vaccination

31. Case #2
Subsequent evaluation
Initial evaluation
Clinical
assessment
Diagnostic
work-up
Patient
education
Therapeutic
decisions
Modify
antimicrobials
Data
review
Clinical
re-assessment
30
Core Competencies 1, 2, 3 & 4

32. 2 ½ year old male with:
2 days of pulling on his left ear
not crying, good oral intake
Afebrile, non-toxic appearance
fluid in middle ear
left tympanic membrane is light pink,
semi-opaque and immobile
31

33. Watchful waiting
32

34. Management of acute otitis media
Antibiotics No antibiotics
Severe AOM Non-severe unilateral AOM in
children 6-24 months of age
Non-severe bilateral AOM in
children < 24 months of age
Non-severe unilateral or
bilateral AOM in children > 24
months of age
33
AAP 2013

35. The “observation option”
34
• Deferring antibacterial
therapy for 48 – 72
hours while providing
symptomatic relief.
• Follow-up plan

36. Case #2
Subsequent evaluation
Initial evaluation
Clinical
assessment
Diagnostic
work-up
Patient
education
Therapeutic
decisions
Modify
antimicrobials
Data
review
Clinical
re-assessment
35
• Advise against
antibiotics
Core Competencies 1, 2, 3 & 4

37. Review: Acute Otitis Media
Drug
Dose
Duration
Route
prescription
.............
.............
.............
36

38. Review: Acute Otitis Media
Drug
Dose
Duration
Route
prescription
.............
.............
.............
Accurately diagnose acute otitis
media

39. Review: Acute Otitis Media
Prescribe antibiotics in
accordance with national
guidelines
Drug
Dose
Duration
Route
prescription
.............
.............
.............

40. Review: Acute Otitis Media
Drug
Dose
Duration
Route
prescription
.............
.............
.............
Employ watchful waiting
appropriately and include
analgesics in your therapeutic
plan.

41. Review: Acute Otitis Media
Drug
Dose
Duration
Route
prescription
.............
.............
.............
Encourage preventive measures
(including vaccinations and
tobacco cessation) in your
therapeutic plan.

42. Quiz time!
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