Dr. Sagraves
Spring 1998

Pediatric Infectious Disease Case - Otitis Media

TS is a seven month old female infant (12 kg) with a two-day history of irritability, low-grade fever (38.5o C, rectally), and tugging on her right ear lobe. She has also been noted by her parents to have cold-like symptoms (coughing and rhinitis) which began approximately one week earlier.

PMH: TS is a normal, healthy infant who has not been seen by a physician except for her regular check-ups. She is up-to-date on her immunizations (last immunizations at age 6 months).

FH: Mother and father both work and TS stays at a day-care center during the day. Mother smokes at home.

PE: WNL with the exception of a red, bulging right TM.

MH: NKDA. Currently receiving only acetaminophen 120 mg orally every four to six hours for irritability and fever. She has received three doses in the past 48 hours.

TS is a seven month old female infant (12 kg) with a two-day history of irritability, low-grade fever (38.5o C, rectally), and tugging on her right ear lobe. She has also been noted by her parents to have cold-like symptoms (coughing and rhinitis) which began approximately one week earlier.

PMH: TS is a normal, healthy infant who has not been seen by a physician except for her regular check-ups. She is up-to-date on her immunizations (last immunizations at age 6 months).

FH: Mother and father both work and TS stays at a day-care center during the day. Mother smokes at home.

PE: WNL with the exception of a red, bulging right TM.

MH: NKDA. Currently receiving only acetaminophen 120 mg orally every four to six hours for irritability and fever. She has received three doses in the past 48 hours.

1. If TS has acute otitis media (AOM), what possible predisposing conditions for AOM are noted in this child's history? (3 pts)

2. What signs and symptoms does TS exhibit that are commonly noted in a child with AOM? (4 pts)

3. What is the most common causative organisms for AOM in a child such as TS? (4 pts)

4. What is usually the initial choice of antimicrobial therapy for AOM? Discuss the criteria you would use in selecting a particular antimicrobial agent. (5 pts)

5. When would antimicrobial prophylaxis be indicated for a patient such as TS? (1 pt)

6. What could happen if AOM is not treated appropriately? (3 pts)

Answers

- Dr. Sagraves

TS is a seven month old female infant (12 kg) with a two-day history of irritability, low-grade fever (38.5o C, rectally), and tugging on her right ear lobe. She has also been noted by her parents to have cold-like symptoms (coughing and rhinitis) which began approximately one week earlier.

PMH: TS is a normal, healthy infant who has not been seen by a physician except for her regular check-ups. She is up-to-date on her immunizations (last immunizations at age 6 months).

FH: Mother and father both work and TS stays at a day-care center during the day. Mother smokes at home.

PE: WNL with the exception of a red, bulging right TM.

MH: NKDA. Currently receiving only acetaminophen 120 mg orally every four to six hours for irritability and fever. She has received three doses in the past 48 hours.

1. If TS has acute otitis media (AOM), what possible predisposing conditions for AOM are noted in this child's history? (3 pts)

• Age (< 2 years of age)

• Day-care center

• Secondhand smoke

2. What signs and symptoms does TS exhibit that are commonly noted in a child with AOM? (4 pts)

• upper respiratory tract symptoms (e.g., cough and rhinitis)

• irritability

• fever

• ear pulling

3. What is the most common causative organisms for AOM in a child such as TS? (4 pts)

• Streptococcus pneumoniae

• Haemophilus influenzae (nontypable)

• Moraxella cattarhalis

• Group A Streptococcus

4. What is usually the initial choice of antimicrobial therapy for AOM? Discuss the criteria you would use in selecting a particular antimicrobial agent. (5 pts)

• Amoxicillin if the incidence of Haemophilius influenzae BL+ is low and the child is not subject to recurrent AOM. A dosage of 40 mg/kg/day administered q8h for a 10-day course of therapy.

• Must consider the acquisition cost of the antimicrobial, antimicrobial efficacy, compliance, dosage forms available, adverse effects, parental time lost from work due to physician visits, time lost from work to care for the child, cost of physician visits, and what insurance will cover if the patient is covered by insurance

5. When would antimicrobial prophylaxis be indicated for a patient such as TS? (1 pt)

• If the patient has recurrent otitis media (defined as = 3 episodes of AOM that occur within 6 months or four episodes within a year

6. What could happen if AOM is not treated appropriately? (3 pts)

• Possibly nothing; there could be a spontaneous cure (this occurs in 14 - 86% of cases)

• Extracranial problems (e.g., hearing loss, tympanic membrane perforation, chronic suppurative otitis media)

• Intracranial complications (e.g., meningitis, brain abscesses)

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