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.