Clinical Practice Guideline for Acute Otitis Media

Disease and Background

            Clinical practice guidelines are important components of the nursing profession as they provide clear and concise recommendations on how to diagnose and manage particular illnesses and conditions. Through this paper, a current, primary care clinical practice guideline for acute otitis media is examined. Otitis media generally refers to the inflammation of the mucoperiosteal lining within the middle ear with acute otitis media indicating the rapid onset of symptoms and signs of infection in the ear (Valdez, & Vallejo, 2016). Acute otitis media is the most common antibacterial condition affecting children within the United States (Lieberthal et al, 2013). The infection accounts for at least a quarter of all clinical visits for children between the ages of 1-3 years as well as healthcare related costs running in excess of three billion dollars each year (Valdez, & Vallejo, 2016).

            Although acute otitis media remains a common infection among children, there has been a downward trend in clinical visits in the United States from 950 to 634 per 100children between 1995 and 2006 and reductions in antibiotic prescriptions from 760 to 484 per 1000 children within the same period (Lieberthal et al, 2013). Marom, Tan, Wilkinson, Pierson, Freeman, & Chonmaitree (2014) also observed that clinical visits related to acute otitis media have significantly reduced between 2004 and 2011. The pathophysiology of the disease involves dysfunction of the Eustachian tube (Valdez, & Vallejo, 2016) as a result of the migration of nasopharyngeal organisms leading to middle ear bacterial infection. Although it mainly affects children, acute otitis media can affect people of all age groups. The clinical manifestation of the disease within a few days to a couple of weeks and includes malaise, severe pain, coryzal symptoms, and visible inflammation of the tympanic membrane.

Publication and Applicability in Primary Care

            The current clinical practice guideline is a revision of a previous practice guideline. The CPG was developed by the American Academy of Pediatrics (AAP) and the American Academy of Family Physicians (AAFP) in 2013 (Lieberthal et al, 2013). This is the latest and only revision to the initial publication which was developed in the year 2004. After seeing that most clinicians were hesitant to adopt the recommendations in the initial guideline, a committee made of primary care physicians and experts from a variety of fields was assembled to revise the CPG and develop and updated version that would be more useful and easy to use. The authors include Allan Lieberthal, Carrol Aaron, Chonmaitree Tasnee, Theodore Ganiats, Hoberman, Alejandro, Mary Anne Jackson, Mark Joffe, Donald Miller, Richard Rosenfield, Sevilla Xavier, Richard Schwartz, Thomas Pauline, and David Tunkel.

Clinical practice guidelines perform important roles within the clinical environment, and the current clinical practice guideline for acute otitis media is no different. The clinical practice guideline is applicable within the primary care setting. It could be used by a variety of primary care physicians including family physicians and pediatricians, nurse practitioners, physician assistants, otolaryngologists, and physicians in the emergency department (Lieberthal et al, 2013). The guideline provides relevant recommendations that facilitate proper diagnosis and management of uncomplicated acute otitis media in children between the ages of 6 months and 12 years (Lieberthal et al, 2013). Through the guideline, primary care physicians are oriented with a clear and concise definition of AOM, guided on how to address pain management, carry out initial observation and diagnosis, prescribe antibiotic agents, and initiate preventive measures. The guideline also highlights how to deal with recurrent acute otitis media. Therefore, it helps enhance the quality and efficiency of primary healthcare delivery with regard to AOM.

Key Action Statement and Body of Evidence

1. Key Action Statement 1a: Clinicians should diagnose AOM in children who present with moderate to severe bulging of the TM or new onset of otorrhea not due to acute otitis externa  
   1. Evidence quality – Grade B, rec Strength – recommendation)
2. Key action statement 1b: AOM should be diagnosed in children with mild TM bulging and intense erythema of the TM or recent onset of ear pain
   1. Evidence quality – Grade C, rec strength – recommendation

High quality care and sound decision making is dependent on accurate diagnosis of acute otitis media (Lieberthal et al, 2013). The purpose of the above action statements is to guide clinicians to ensure that they conduct appropriate and accurate diagnosis of AOM and in so doing facilitate better decision-making. 

3. Key action statement 2: AOM management should include pain assessment. Whenever pain is present, the clinician should recommend pain-reduction treatment
   1. Evidence quality – Grade B, rec strength – strong recommendation

Pain is one of the major symptoms of acute otitis media and so primary care clinicians should make it one of their primary objective to help alleviate pain as soon as possible (Lieberthal et al, 2013). The purpose of the action statement two above is to provide clinicians with a relevant framework for effective pain management in patients with AOM.

4. Key action statement 3a: Antibiotic therapy for IOM should be prescribed by the clinicians in children who are six months and older with severe signs or symptoms
   1. Evidence quality – Grade B, rec strength – strong recommendation
5. Key action statement 3b: The clinician should prescribe antibiotic therapy for bilateral AOM in children younger than 24 months without severe signs or symptoms
   1. Evidence quality – Grade B, rec strength – recommendation
6. Key action statement 3d: Clinician should either prescribe antibiotic therapy or offer observation with close-follow up based on joint decision-making with parents/caregivers for both bilateral and unilateral AOM in children 24 months or older without severe signs or symptoms
   1. Evidence quality – Grade B, rec strength – strong recommendation

After the primary care clinician has made an appropriate diagnosis of acute otitis media using the recommended strategies and criteria, and distinguished between the role of antibiotics and analgesics, the next step is now to manage the condition (Lieberthal et al, 2013). The above action statements offer extensive guidance to primary care physicians on the initial management of AOM by helping them choose between either initial observation or initial antibiotic therapy. 

7. Key action statement 4a: Clinicians should prescribe amoxicillin for AOM when a decision to treat with antibiotics has been made and the child has not received amoxicillin in the past 30 days or the child does not have concurrent purulent conjunctivitis or the child is not allergic to penicillin
   1. Evidence quality – Grade B, rec strength – recommendation
8. Key action statement 4b: Clinicians should prescribe an antibiotic with additional β-lactamase coverage for AOM when a decision to treat with antibiotics has been made and the child has received amoxicillin in the past 30 days or has concurrent purulent conjunctivitis or has a history of recurrent AOM unresponsive to amoxicillin
   1. Evidence quality – Grade C, rec strength – recommendation
9. Key action statement 4c: Clinicians should reassess the patient if the caregiver reports that the child’s symptoms have worsened or failed to respond to the initial antibiotic treatment within 48 to 72 hours and determine whether a change in therapy is needed
   1. Evidence quality – Grade B, rec strength – recommendation

In case an antibiotic is to be used to treat a child with AOM, then the clinician should ensure that the best and most effective antibiotic has been used (Lieberthal et al, 2013). The above action statements provide clear directions on the best first-and-second line antibiotics that have the highest likelihood of being effective. 

10. Key action statement 5a: Clinicians should NOT prescribe prophylactic antibiotics to reduce the frequency of episodes of AOM in children with recurrent AOM.
    1. Evidence quality – Grade B, Rec strength – recommendation

This action statement provides clear and concise directions on how to handle recurrent acute otitis media.

11. Key action statement 6a: Clinicians should recommend pneumococcal conjugate vaccine to all children according to the schedule of the Advisory Committee on Immunization Practices, AAP, and AAFP.
    1. Evidence quality – Grade B, rec strength – strong recommendation
12. Key Action Statement 6b: Influenza Vaccine: Clinicians should recommend annual influenza vaccine to all children according to the schedule of the Advisory Committee on Immunization Practices, AAP, and AAFP.
    1. Evidence quality – Grade B, rec strength – recommendation
13. Key Action Statement 6c: Breastfeeding: Clinicians should encourage exclusive breastfeeding for at least 6 months.
    1. Evidence quality – Grade B, rec strength – recommendation
14. Key Action Statement 6d: Clinicians should encourage avoidance of tobacco smoke exposure    
    1. Evidence quality – grade c, rec strength – recommendation

Prevention is an important consideration for primary care clinicians. The above action statements provide preventive guidelines by discussing issues of breastfeeding, immunizations, and lifestyle changes that might significantly reduce the risk of acquiring AOM.

Application in Clinical Environment

            John’s diagnosis and treatment for acute otitis media compares with the recommendations given in the guideline in several ways. The diagnosis was done according to action statement 1b for recent onset of ear pain. Then, an assessment of pain was conducted according to action statement 2 and appropriate treatment to reduce pain recommended. Also, an appropriate management of AOM was developed according to key action statement 3d where initial antibiotic therapy was proposed. Afterward, amoxicillin for acute otitis media was prescribed according to key action statement 4a because a decision to treat with antibiotics had bene made and John had not received any antibiotic therapy within the past 30 days. Also, a provision was made according to key action statement 4c to reassess the patient in case there will be no response to antibiotic therapy. All the above actions were done well.

            However, there were areas where the diagnosis and treatment did not adhere to the guidelines provided in the clinical practice guidelines thereby providing room for improvement. An example of such an area was the prescription of amoxicillin-clavulanate 90 mg/kg/day for recurrent AOM rather than offering tympanostomy tubes for recurrent AOM as per key action statement 5b. Also, avoidance of tobacco smoke exposure as per key action statement 6d was not recommended although annual influenza vaccine as per key action statement 6b was proposed.

References

Lieberthal, A. S. et al. (2013). The Diagnosis and Management of Acute Otitis Media. Pediatrics, 131(3). http://pediatrics.aappublications.org/content/131/3/e964.long

Marom, T., Tan, A., Wilkinson, G. S., Pierson, K. S., Freeman, J. L., & Chonmaitree, T. (2014). Trends in Otitis Media-related Health Care Utilization in the United States, 2001-2011. JAMA Pediatrics, 168(1), 68–75. http://doi.org/10.1001/jamapediatrics.2013.3924

Valdez, T., & Vallejo, J. (2016). Infectious Diseases in Pediatric Otolaryngology: A Practical Guide. Cham: Springer International Publishing.