Patient Encounter 1 Part 1

A 15-month-old girl presents to the pediatric clinic with 2 days of fever (38.9°C [102°F]), runny nose, and fussiness. Her mother states that she is more irritable than usual and cries many times throughout the night. She is not as interested in eating today. She attends daycare and has a 5-year-old brother who recently had a cold. Physical examination reveals erythema and bulging of the right tympanic membrane and the presence of middle ear fluid. The left tympanic membrane is obscured with cerumen.

What information is suggestive of acute otitis media (AOM)? Does the child have risk factors for AOM?

Is there any additional information you need to know before recommending a treatment plan?

Table 72-1 Risk Factors for Otitis Media

Viral respiratory tract infection/

winter season Daycare attendance* Siblings Male sex

Tobacco smoke exposure Allergies

Anatomic: defect s tue h as deft pafate

Positive family history/genetic predisposition aRisk factors for infection with a resistant pathogen (daycare attendee, age under 2 years, recent antibiotic use in previous 3 months).

Bacteria are isolated from middle ear fluid in up to 70% of children with AOM, but viruses also play a predominant role.5 Streptococcus pneumoniae traditionally has

been the most common organism, responsible for up to half of bacterial cases. ' Haemophilus influenzae and Moraxella catarrhalis cause 15% to 30% and 3% to 20% of cases, respectively. The microbiology of AOM has shifted toward a prevalence of H. influenzae because of routine childhood immunization with pneumococcal conjugate vaccine.8,9 Bacteria that are less frequently associated with AOM include Streptococcus pyogenes, Staphylococcus aureus, and Pseudomonas aeruginosa. Viruses such as respiratory syncytial virus, influenza, parainfluenza, enteroviruses, rhinovirus, and adenoviruses are isolated from middle ear fluid with or without concomitant bacteria in about half of AOM cases.5,10 Lack of improvement with antibiotic therapy is often a result of viral infection and subsequent inflammation rather than antibiotic resistance.

Bacterial resistance has significantly affected treatment options for AOM. Penicillin-resistant S. pneumoniae (PRSP) encompasses both intermediate resistance (minimum inhibitory concentrations between 0.1 and 1.0 mcg/mL) and high-level

Native American or inuit ethnicity Low socioeconomic status Pacifier use Lack of breast-feed ng Young age at first diagnosis" Immunodeficiency Gastroesophageal reflux resistance (minimum inhibitory concentration of 2.0 mcg/mL and higher). Altered penicillin-binding proteins cause resistance in approximately 35% of respiratory pneumococcal isolates, about half of which are highly penicillin-resistant.11 Amoxicillin resistance occurs in less than 5% of pneumococcal isolates.11 PRSP are also commonly resistant to other drug classes, including sulfonamides, macrolides, and clindamycin, and increasingly resistant to fluoroquinolones. Treatment for pneumo-coccal AOM is recommended because infection caused by S. pneumoniae is unlikely to resolve spontaneously and is the most common cause of recurrent infections.5 fi-Lactamase production occurs in 30% and nearly 100% of H. influenzae and M. ca-tarrhalis, respectively.12 Although infections caused by these organisms are more likely to resolve without treatment, they should be considered in cases of treatment failure.

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