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CPS acute otitis media guidelines
Wait & see A 72-hour
observation may be recommended if your patient
is over two years old, and follow-up can be arranged.
Choose your weapon AOM
is usually bacterial, and amoxicillin's the drug
of choice. It's cheap, and just as effective as
extended spectrum, penicillinase-resistant oral
antibiotics when the cause of AOM is either penicillin-susceptible
or -resistant bacteria. It has fewer side effects
and may foster less bacterial resistance.
Careful timing 10 days
of antibiotics is a safe bet, although the literature
isn't clear if this is overkill. An exception:
azithromycin is recommended for 5 days.
To jab or not? Parenteral
therapy can be considered if barriers to 10-day
oral therapy exist, but generally shouldn't be
used in simple uncomplicated AOM. There's little
evidence they're better than oral treatments,
possibly even hastening drug resistance.
Penicillin allergies? Cephalosporins
are usually safe, although there's always a possibility
of a cross reaction when using beta-lactam alternatives.
Second pass If treatment
doesn't clear up pain, fever and irritability
in 72 hours, determine if compliance was an issue.
Tympanocentesis should be considered -- it can
relieve pressure, and guide subsequent antibiotic
choice. Amoxicillin clavulanate is an alternative
if tympanocentesis isn't practical.
Don't go overboard Middle
ear effusion can persist for months. Continued
or altered treatment's not suggested if other
symptoms are resolved.
Adapted from Canadian Paediatric
Society
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When doctors manage pediatric acute
otitis media (AOM), they don't necessarily practise
what they preach, according to a study in the August
issue of Pediatrics. The survey of pediatricians
exposes a big gap between the recommended guidelines
and actual practices.
AOM has an extremely high rate
of spontaneous recovery. The American Academy of Pediatrics
and the Academy of Physicians guidelines suggest that
pediatricians allow a 48-72 hour observation period
before they prescribe antibiotics in cases where a diagnosis
is uncertain and symptoms aren't severe. Most docs said
the suggestion was reasonable, but just not for them
-- the approach was used only in a median of 15% of
AOM cases.
THE
PARENT TRAP
So why don't doctors wait before writing the kid a script?
In the Pediatrics study, doctors overwhelmingly
blame the parents: mum and dad demand antibiotics for
their suffering child, and so doctors oblige. Docs also
said follow-up visits are often inconvenient to patients,
so they prescribe an antibiotic right off the bat.
Immediate antibiotics for AOM is
common practice, but sets off alarm bells in infectious
diseases circles. "The increased bacterial resistance
to many commonly-used antibiotics poses a serious threat
to public health," writes Dutch GP, R A M J Damoiseaux
in a CMAJ commentary on the subject. "Nor should
we ignore the risks to the individual patient of an
allergic reaction, gastrointestinal symptoms or the
potential disturbance of the nasopharyngeal flora."
The flora issue was raised in a Winnipeg study in June's
Chest which linked early antibiotic use to rising
asthma rates.
On the other hand, some MDs point
out that mastoiditis, which can be a significant cause
of child mortality, a common complication of AOM, is
greatly reduced when antibiotics are liberally prescribed.
There isn't consensus among Canadian
guidelines over what is the best approach, and the literature
isn't unequivocal. The Canadian Paediatrics Society's
guidelines for AOM propose observation on a case-by-case
basis. Other guidelines suggest antibiotics as a first-line
treatment.
A middle way is to propose a waiting
period to parents. Write a provisional prescription,
and tell parents to fill it if their child's symptoms
don't clear up in a few days.
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