IMPORTANT NOTE: JAAPA CME activities consist of 2 articles. To obtain credit, you must also read Management of migraine headache: An overview of current practice; the post-test will include questions related to both articles. AAPA Fellow members should complete and submit the post-test on the AAPA Web site by going to www.aapa.org and searching for keyword JAAPA post-tests. All others may complete and submit the post-test online at no charge at www.mycme.com. To obtain 1 hour of AAPA Category I CME credit, PAs must receive a score of 70% or better on each test taken.

KEY POINTS

■ PAs should be familiar with pneumatic otoscopy in order to aid in the proper diagnosis of acute otitis media (AOM).

■ The three common bacterial pathogens responsible for AOM may remit spontaneously without antibiotics.

■ The safety-net approach to antibiotic prescriptions (SNAP) is an alternative that eliminates the risk of side effects and reduces public health concerns for antibiotic resistance.

■ PAs must assume the responsibility for educating parents on antibiotic misuse and not succumb to parental/guardian demand to initiate antibiotic treatment.

A 3-year-old boy with right ear pain is brought to a pediatric practice by his concerned mother. She is worried about an infection and urges the PA to prescribe an antibiotic so that her son can begin to feel better. After visualizing an erythematous tympanic membrane without signs of effusion, mastoid tenderness, edema, or outward displacement of the auricle, the PA diagnoses acute otitis media (AOM) and writes a prescription for antibiotic therapy. The mother asks if the antibiotic will cause diarrhea or any other GI upset. The PA explains that diarrhea is a side effect associated with antibiotic therapy but emphasizes that it is experienced by only a small number of patients who are taking antibiotics and that she should not be worried about it. 


This is a common scenario for many health care practitioners faced with a condition that could be treated without antibiotics by using the safety-net approach to antibiotic prescriptions (SNAP). 


AOM is the most common illness affecting children between the ages of 3 and 6 years and is frequently treated with antibiotics.1 It is the reason behind nearly 30 million outpatient appointments per year and cost the United States $2.2 billion to $3.4 billion in 2005.2,3 The financial burden for treating AOM is enormous, especially when research demonstrates that between 70% and 90% of cases resolve spontaneously, without the use of antibiotic therapy.4 As far back as 2004, publications from major medical organizations such as the American Academy of Pediatrics (AAP) urged implementation of the SNAP approach in the treatment of AOM, and yet the use of antibiotics has actually increased. Evidently, only a small percentage of practitioners are using the SNAP approach, whereas the rest appear to be sticking to old habits.5,6 The cost of a potentially unnecessary treatment supports the need to educate both health care practitioners and the caregivers of young children about the risks of overusing and misusing antibiotics, while presenting a viable and potentially safer treatment approach. This article outlines the traditional approach to AOM management and presents a successful alternative treatment strategy emphasizing the safety-net concept. Implementation of SNAP will decrease antibiotic overuse and hopefully assist with reducing antibiotic resistance. 


PATHOPHYSIOLOGY AND RISK FACTORS


AOM results when an inflammatory response to bacteria or viruses causes malfunctioning of the eustachian tube.7,8 The muscular eustachian tube connects the middle ear with the throat and allows for proper ventilation within these two structures.7 Infection of the upper respiratory tract leads to mucosal inflammation, which diminishes the diameter of the eustachian tube.8 This results in inadequate ventilation and leads to backflow of secretions from the throat up and into the middle ear, causing an accumulation of microorganisms that precipitates infection (Figure 1).7,8


Several risk factors, many of which are modifiable, are associated with recurrent acute otitis media infections. Modifiable risk factors include bottle and pacifier use, day-care attendance, and exposure to secondhand smoke.7,8 Pacifier use leads to a backflow of secretions from the pharynx and nasal cavity to the middle ear that fosters the growth of infection-causing bacteria.9 In the Western world, 75% to 85% of children use a pacifier, and a 2008 study revealed that 35% of 216 children who used pacifiers acquired AOM at least once.9 Bottle feeding also creates reversal in secretion flow, while breastfeeding protects the infant by avoiding the risk of reversed secretion flow and allowing transmission of maternal antibodies.10 Exposure to secondhand smoke as well as to viral and bacterial pathogens in a day-care environment results in more AOM infections.11,12 


Nonmodifiable risk factors include atopic states and craniofacial abnormalities. Atopic states lead to a deficiency of IgA, which can impair a child's ability to fight off an AOM infection. IgA deficiency also leads to an increased buildup of secretions in the nasopharynx that causes congestion of the eustachian tube.7 Craniofacial and developmental abnormalities, such as cleft palate and trisomy 21 (Down syndrome), are nonmodifiable risk factors that lead to abnormal development of the palate or eustachian tube and subsequent interference with normal ventilation.7 Overall, most risk factors are modifiable and revolve around environmental exposures and habitual practices, providing ample opportunities for caregiver education. 


As has been reported with other illnesses, ethnic and socioeconomic disparities may affect the diagnosis and treatment of acute otitis media. Recent studies have placed socioeconomic status among the top risk factors associated with the development of AOM. Children of a lower socioeconomic status, including those who are African American and Hispanic, often have limited access to medical care, thereby hindering appropriate recognition and treatment.13,14 These critical factors need to be identified by PAs in clinical practice so that they may attempt to bridge the gap in health care access and appropriate treatment and thus minimize future risk for complications. 


CLINICAL PRESENTATION


The manifestations of AOM vary with the age of the child. Young children who are unable to express their symptoms verbally often present with fever, irritability, crying, drainage from the ears, and altered sleep habits.7,15 Ear pulling is believed by many caregivers to be an early sign of AOM. However, research demonstrates that in the absence of other symptoms, ear pulling is often not associated with infection of the tympanic membrane. Caregivers should be educated about the lack of significance in ear pulling and the importance of other symptoms commonly associated with a true AOM infection.16 


Older children who can describe their symptoms often experience sudden onset of pain in a specified ear, with tenderness to touch as well as fever.7 These manifestations need to be differentiated from those of similar ear-related illnesses, including otitis media with effusion (OME) and viral myringitis. OME involves fluid buildup in the middle ear that is unassociated with fever or pain.15,17 Viral myringitis is inflammation of the tympanic membrane resulting from bulla formation and is often associated with a recent viral infection of the upper respiratory tract.18 Differentiating AOM from these other conditions requires that the practitioner be skilled in performing pneumatic otoscopy and assessing other diagnostic clues specific to each condition.7,8 Appropriate identification of serious complications of AOM, such as mastoiditis and hearing loss, will lead to prompt treatment and avoid any future developmental sequelae.19


MAKING THE DIAGNOSIS


Pneumatic otoscopy is helpful in distinguishing AOM from other causes of otalgia.20 The tympanic membrane can be visualized clearly by pulling the auricle upward, ensuring that the patient is in a still position, and removing any excessive cerumen that could be obstructing the ear canal.20 Using an insufflator bulb, the clinician blows air at the tympanic membrane in an attempt to assess its mobility clinically.21 Tympanometry, another diagnostic technique, provides a graphic representation of the movement of the tympanic membrane on a printout called a tympanogram.8,22,23 This technique is often avoided because it is expensive, starting at $3,000, compared with an insufflator bulb, which can cost as little as $12.24,25 Unfortunately, the insufflator bulb is underutilized in clinical practice as well; the omission of pneumatic otoscopy from the physical examination needs to be rectified in order to correctly diagnose AOM. The costs of these two procedures should be weighed against the thousands of dollars that are spent each year in the treatment of this common pediatric illness. The diagnostic findings of these techniques are shown in Table 1. Mastering these diagnostic procedures goes a long way toward proper diagnosis of AOM and supports a best treatment approach. 


TREATMENT


The conventional approach Strategies for treating AOM target the common infection-causing organisms. Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis are responsible for 25% to 50%, 25%, and 12.5% of AOM cases, respectively.8,26 Traditionally, the pathogen most commonly associated with AOM was S pneumoniae, but with increased use of the pneumococcal vaccine, this may no longer be true. Recent evidence has revealed that nontypeable H influenzae may be surpassing S pneumoniae as the most common organism causing AOM.27 Other pathogens are either not identified or comprise a group of viruses, including respiratory syncytial virus (RSV) and the influenza and parainfluenza viruses.8 The only definitive method for identifying the organism is to perform tympanocentesis, a modality generally reserved for patients with resistant cases of AOM for which no definitive treatment has proven effective.28 


Health care practitioners want to eliminate infection as quickly as possible, a goal that is often achieved by prescribing antibiotics. In otherwise healthy children, however, AOM due to S pneumoniae, H influenzae, or M catarrhalis has a spontaneous resolution rate of 20%, 50%, and 80%, respectively, without antibiotic use.8 Despite these data, AOM continues to be the diagnosis for which antibiotics are most commonly prescribed. 


Amoxicillin remains the drug of choice for AOM, starting at 40 mg/kg/day and increasing to 80 mg/kg/day when resistance is suspected.8,28 Treatment usually continues for 10 days, but a 7-day course is often used to treat children older than 2 years who have no evidence of a damaged tympanic membrane.8 In AOM that is refractory to amoxicillin, cephalosporins are the next choice, including ceftriaxone (Rocephin, generics) and cefdinir (Omnicef).28 While data from clinical trials indicate that these antibiotics are useful in the eradication of AOM infections, many children in these studies were prescribed antibiotics for potentially self-limiting infections. Thus, the observed improvement may be related to the condition's simply running its course rather than to any antibiotic effect.28 


The SNAP approach Health care practitioners can treat the child and prevent overuse of antibiotics by using the safety-net approach to antibiotic prescriptions, an alternative form of treatment for AOM. SNAP was first used by a family practice physician from England by the name of Cates, who enforced a treatment policy for all children who presented with a suspected AOM infection. Based on his clinical suspicion of AOM, he would provide a prescription for the caregiver but urged that the prescription be filled only if the child did not respond to analgesics after 2 days or if the condition worsened. This policy led to a 20% reduction in filled prescriptions. Not only does SNAP minimize the use of antibiotics, it also provides the caregiver with a sense of security that the prescription can be filled immediately if the child's condition worsens.4,8 Parents should also be made aware that the prescription can be filled only within 3 days of receiving it in order to eliminate its future use. 


Otalgia is the most distressing symptom experienced by a child with AOM, and yet it often goes untreated.20 The SNAP approach focuses on addressing the pain and turns to antibiotics only if symptoms do not resolve.4,8,20 Pain relief can be accomplished by prescribing oral or topical analgesics, such as acetaminophen or ibuprofen, thereby easing the patient's discomfort.4,8 In the Cates study, 76% of children improved with symptomatic treatment for pain alone, without any need to fill the antibiotic prescription.20 Health care practitioners need to recognize that curing AOM does not always revolve around targeting the causative organism and that providing otalgic pain relief improves the potential for spontaneous resolution. 


The SNAP approach should not be used in children with any of the following: 


  • Temperature greater than 101.5°F 

  • Damaged tympanic membrane 

  • AOM infection in the past 3 months 

  • Symptoms lasting longer than 2 days 

  • Known bacterial infection 

  • Clinical signs and symptoms of a possible tympanic membrane perforation

  • Toxic appearance 

  • Impaired immunity 

  • Caregivers unable to seek prompt medical attention with a worsening condition 

  • Inability of caregivers to understand the SNAP treatment approach.8 


By avoiding antibiotics for conditions that do not warrant their use, practitioners eliminate the risk of possible side effects as well as difficulty with adherence. Although side effects of antibiotics are rare, they can be worse than the actual infection itself.29 These include nausea, vomiting, diarrhea, oral thrush, rash, Clostridium difficile infection, and a potential anaphylactic reaction.29 The anaphylactic reaction is the most threatening to a child because of his or her inexperience with the drug and the possibility of a severe bronchospasm that can potentially be fatal if not recognized and treated promptly.29 


The other important issue in overprescribing antibiotics is the possibility of nonadherence and misuse.30 If children are given antibiotics for nonbacterial infections or self-limiting conditions, or if the recommended duration of treatment is not followed, then future successful treatment of more complicated infections, such as one involving methicillin-resistant Staphylococcus aureus (MRSA), may be impaired.30 Undoubtedly, improving public awareness of antibiotic overuse is a major concern for health care providers, and patient education can only assist in resolving this widespread concern of antibiotic resistance.31 


EDUCATING PARENTS


Parental demand is a major reason why practitioners pull out their prescription pads. Even though most infectious conditions are viral, 30% to 90% of adults demand antibiotics from their practitioners.32 Because parents desire this treatment for their own illnesses, they are often even more insistent when it comes to their sick children and may be reluctant to accept the idea that a condition will simply resolve on its own. Studies have revealed that most parents seek antibiotic treatment for an upper respiratory tract infection because they believe that their child improves faster on antibiotics and that, by comparison, the duration of their child's illness is longer than that of most other children.32 Evidently, parents are misinformed regarding their own illnesses and the necessity for treatment, and this translates to misinformation about their children. 


Practitioners must provide proper education, take the time to explain the nature of a child's illness, and emphasize that antibiotic therapy may not be a quicker or better solution. Listening to parents' concerns with an empathetic ear is also crucial in order to address any concerns they may have and to let them know that you want to earn their trust and determine together what treatment is best for their children. 


FOLLOW-UP


With a better understanding of the SNAP approach for AOM treatment, the initial case scenario can be further analyzed. The 3-year-old child is experiencing otalgia that is causing most of his distress, and this is concerning for his mother. The PA makes the immediate decision to treat with an antibiotic simply by examining the tympanic membrane with an otoscope. If the practitioner had used pneumatic otoscopy or tympanometry to aid in diagnosis, the AOM could have been differentiated from other probable causes of pediatric otalgia. Of greatest importance is the benefit that could have been derived from demonstrating and explaining to the parent that antibiotics are not always necessary in AOM treatment and that by avoiding giving antibiotics to the child, any potential risk of side effects would be eliminated. Clearly, before using this conservative approach, the PA would have had to make sure that none of the exclusion criteria existed. Primary treatment with analgesics could have been used to ease the discomfort experienced by the child and calm the fears of his concerned mother. The antibiotic prescription would only be filled if the child's symptoms persisted or worsened. 


The SNAP approach provides emergency, family practice, and pediatric practitioners with an alternative treatment option for AOM. Eliminating unnecessary use of antibiotics would prevent children from being exposed to the side effects of these medications and the potential for resistance. The historical information presented by the parent, in addition to physical examination findings and clinical judgment, are necessary for the clinician to determine whether this conservative treatment approach is appropriate. Undoubtedly, it is the job of PAs to educate parents on the situations in which antibiotics are deemed appropriate and not succumb to pulling out the prescription pad to please them. JAAPA


Kristina Mancini practices family medicine at the Avenel-Iselin Medical Group, Iselin, New Jersey. Ellen Mandel is an associate professor in the PA program at Seton Hall University, South Orange, New Jersey, and a clinical associate professor in the Pace University-Lenox Hill Hospital PA program, New York, NY; she practices internal medicine with the Summit Medical Group, Berkeley Heights, New Jersey. The authors have indicated no relationships to disclose relating to the content of this article.




IMPORTANT NOTE: JAAPA CME activities consist of 2 articles. To obtain credit, you must also read Management of migraine headache: An overview of current practice; the post-test will include questions related to both articles. AAPA Fellow members should complete and submit the post-test on the AAPA Web site by going to www.aapa.org and searching for keyword JAAPA post-tests. All others may complete and submit the post-test online at no charge at www.mycme.com. To obtain 1 hour of AAPA Category I CME credit, PAs must receive a score of 70% or better on each test taken.

REFERENCES


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4. Siegel RM, Kiely M, Bien JP, et al. Treatment of otitis media with observation and a safety-net antibiotic prescription. Pediatrics. 2003;112(3 pt 1):527-531. 


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7. Kerschner JE. Otitis media. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, PA: Elsevier; 2007:2632-2646. 


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15. Ear infections. Centers for Disease Control & Prevention Web site. http://www.cdc.gov/getsmart/antibiotic-use/URI/ear-infection.html#c. Updated May 23, 2011. Accessed January 9, 2012. 


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17. Rosenfeld RM, Culpepper L, Doyle KJ, et al. Clinical Practice Guideline: otitis media with effusion. Am Fam Physician. http://www.aafp.org/online/en/home/clinical/clinicalrecs/children/otitismedia.html. Published May 3, 2004. Accessed January 9, 2012. 


18. McCormick DP, Saeed KA, Pittman C, et al. Bullous myringitis: a case-control study. Pediatrics. 2003;112(4):982-986. 


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IMPORTANT NOTE: JAAPA CME activities consist of 2 articles. To obtain credit, you must also read Management of migraine headache: An overview of current practice; the post-test will include questions related to both articles. AAPA Fellow members should complete and submit the post-test on the AAPA Web site by going to www.aapa.org and searching for keyword JAAPA post-tests. All others may complete and submit the post-test online at no charge at www.mycme.com. To obtain 1 hour of AAPA Category I CME credit, PAs must receive a score of 70% or better on each test taken.