Otitis Media in Children and the Use of Antibiotics as a Form of Treatment

This paper explores 3 published articles, as well as an article from the American Academy of Pediatrics and the American Academy of Family Physicians. It will attempt to examine research and the relativity of each study compared to one another. This paper also looks at interview results from a parent with a child suffering from Otitis Media and the ethical issues pertaining to changing clinical practices in the face of emerging research. 

Definition of Otitis Media

 Acute Otitis Media, or AOM, causes the middle ear to swell and become infected. This particular infection may be caused by a virus or bacteria and results in accumulation of pustules behind the tympanic membrane. This membrane causes inflammation in the ear and can be a very excruciating pain to endure. At times, the tympanic membrane is able to permeate or open up, which can alleviate discomfort and expunge the external ear canal. Otitis Media most often afflicts children but is usually a short term condition.  

AAP's Role

The American Academy of Pediatrics assembled a committee in 2009, comprised mostly of experts in pediatric care, family medicine, otolaryngology, infectious disease, and emergency care.  Their primary focus when this group congregated, was to develop a way to adequately diagnose and provide sufficient treatment in children with AOM. They concentrated on preventative measures, observation in lieu of automatic antibiotic treatment and expanded options for other suitable antibiotic agents. The physicians also engaged in discussions over recurrent Acute Otitis Media, which had not initially been included in the previous 2004 convention guidelines. Their decisions were based on a methodical grade procedure depending on the evidentiary quality and the risk of benefit versus harm relevance.  

Source Review

Most of the sources used were unfiltered.  The articles by AAP/AAFP (2004) and Block (1997) and the interviews were unfiltered.  Only the text by Kelley, Friedman & Johnson (2007) and article by McCracken (1998) were filtered. The AAP/AAFP (2004) article resides in the servers of the American Academy of Pediatrics and the American Academy of Family Physicians website. The Block (1997) and McCracken (1998) articles are stored by the National Center for Biotechnology Information which is part of the U.S. National Library of Medicine.  The Kelley, Friedman & Johnson (2007) text and interviews are physical documents.

The AAP/AAFP (2004) article is an evidence-based guideline and is appropriate for a discussion of diagnosis and treatment of AOM. Block’s (1997) article is an evidence summary, reviewing several factors related to AOM and is appropriate for a discussion of these associated factors and their effect on AOM. The text by Kelley, Friedman & Johnson (2007) is an evidence-based guideline appropriate to a discussion of ear, nose, and throat considerations for AOM.  McCracken’s (1998) article is primary research and is appropriate for a discussion of AOM treatment with considerations for increasing microbial resistance. The interviews are none of the listed classifications of evidence and are inappropriate for an empirical analysis of AOM in children and antibiotic treatment of AOM.

What Form Of Treatment is Best?

So the overriding question is: Should antibiotics be utilized as the first line of treatment in children with Acute Otitis Media? Mills (2008) concedes that Amoxicillin is the most common antibiotic used for AOM; it is a broad-spectrum form of penicillin. The beta-lactam ring concentrated in penicillin is responsible for the majority of antimicrobial movement.  This action is created by impeding cross-linkage amongst cell walls. Most penicillins can expedite this action due to structural resemblances in peptide chains within the bacterial cells.  Amoxicillin absorbs efficiently when taken orally and it promptly radiates into gram-positive and gram-negative bacteria. 

Research Studies

Researcher Block (1997) states, the use of amoxicillin as the first line of therapy for Otitis media in young kids may be troublesome. The more recently developed macrolides such as Zithromax and Biaxin, provides greater coverage in vitro, against S. pneumoniae and beta-lactamase inducing H. influenzae. These two drugs deliver exceptionally higher and more continuous concentrations within middle ear fluid than beta-lactam antibiotics such as amoxicillin. According to a study performed by McCracken (1998), patients treated with AOM often developed a resistance to antibiotic treatment. In the study, one group found a 46 percent rate of S. pneumoniae, a penicillin-resistant antibiotic in patients. Also, 33 percent of the strains were staunchly resistant. They found most children with AOM did not reap any antimicrobial treatment benefits due to the etiology of the illness. Either the infection was viral, not bacterial, or milder forms of the infection dissipated from the immune system without the use of drugs.

Reviews

The overall review contains significant content that is applicable to a clinical setting. To briefly summarize the critical analysis of the aforementioned studies, I believe the research findings are beneficial to enhance my empirical knowledge. The consensus among all of these research studies uniformly determined that watchful waiting or deferred prescribing of antibiotics has no noticeable effect on the final results. It should be noted that these studies highlight the watchful waiting approach when more visible symptoms are initially present. This fact may not change the management of AOM if there are no added contributory factors.  

The Interview

The primary objective of my consultation with Jenna and her mom was to implement the proper treatment of her condition, Acute Otitis Media. Part of the ethical principles, in this case, was responding to her situation on a whole scale rather than a matter of watchful waiting or prescription antibiotic treatment.  My first conception of this consultation was that Jenna has AOM and her mother expected antibiotic treatment to follow. I made an agreement to watch Jenna for 48 hours and review her condition. I did not want to create any tension between myself and the parent so a follow-up appointment was made, and if Jenna's symptoms worsened, she could come to see me earlier than 48 hours. Jenna came with her mom to the follow-up examination and I recognized that she was much more energetic than she has been two days prior. As I inspected her ear, I noticed the tympanic membrane was reddish in color, but it was not bulging. The pus buildup has been extricated from Jenna's system. Her mom said she would give analgesia as needed and schedule another appointment if any symptoms worsened. I continue to check the patient's records periodically and there have been no further inquiries.  

Conventional Treatment 

Conventional medical treatment in the case of AOM, once it has been reasonably confirmed, traditionally begins with an antibiotic regimen (AAP/AAFP, 2004, pg. 1456). If AOM is slow to take hold or uncomplicated by other conditions, the patient is placed under observation without antibiotics (AAP/AAFP, 2004, pg. 1454). Unfortunately, the issue with antibiotic treatment if AOM in a more severe stage, often, bacteria or viruses are not present, rendering the antibiotics useless. Use of this method might increase the spread of drug-resistant bacteria and this can wreak havoc on future bacterial infections. Most antibiotic regimens last seven to 10 days and there is the inherent risk of recurrence and re-development of the infection. 

 The next line of defense is surgical tubes inserted into the middle if antibiotic use has not reduced the fluid buildup. The risk involved with this procedure includes loss of hearing, more infection or even hearing loss. A perforated tympanic membrane, or in Layman's terms, a ruptured eardrum, involves an eardrum tear or laceration in the tissue that separates the middle ear from the ear canal. Chronic or constant drainage, as well as the tubes used to perform this procedure,  may create more infection and the potential for surgeries in the future. 

Alternative Treatment

Chiropractic care may be one of the safest methods to use if watchful waiting does not yield improvement over a 48-72 hour period. It is gentle on the sensitive eardrum and the middle ear does not require drug use and may be more effective in less time. Try this analogy; your body is like a breaker box that controls the flow of electricity through a home. It only takes a single fuse to flip to affect multiple areas within the home. This is the case with AOM. Let's assume one of your neck vertebrae becomes inflames, this creates tensions and muscle spasms. As a result, ear drainage is hampered causing fluid to build up and other issues. One of the most common chiropractic treatments is the Endonasal Technique. This mildly conforms the spine with the use of a neck massage, permitting fewer nerve hindrances. A chiropractor can place the proper amount of pressure in the neck and spine area to help alleviate pain and promote fluid drainage. 

For most AOM cases, a treatment regimen occurs three times a week for a single week. Then, the following week, just two treatments and a single treatment for each week thereafter until symptoms improve. Often in milder cases, improvement is visible after one or two treatments and by the third, there is no recurrence of symptoms. The use of chiropractic care may be the most optimums first line of defense over antibiotics for two primary reasons; it permits the middle ear to drain, reducing pain and antibiotics can create a drug-resistant bacteria, rendering them useless. Surgical procedures increase the risk of bleeding or hearing loss. However, chiropractic care is very gentle and often produce positive results in a shorter time frame. 

The guidelines do not approve or recommend complementary and alternative treatment methods for AOM (AAP/AAFP, 2004, pg. 1459). Due to the relative guesswork and risks associated with antibiotic treatment of AOM or illnesses that convincingly present as AOM, the guidelines are inappropriately inadequate.  It would be beneficial for this organization to pursue solid research for alternative treatments of AOM to aid in establishing guidelines to proactively aid in the treatment of the disease and to determine whether alternative methods are worth pursuing when a child’s health is on the line.  The relative lack of complications associated with not implementing or changing antibiotics and the comparably positive results suggest that watching and waiting would be the best alternative treatment of all, except in the most extreme cases (AAP/AAFP, 2004, pg. 1462).

Application

 Upon final analysis of the aforementioned research studies, I believe they compensate for and complement the current guidelines of the American Academy of Pediatrics and their notion that antibiotics should not be the first line of defense for mild to moderate symptoms of AOM in children. The research clearly displays that watchful waiting accomplishes comparable outcomes with fewer side effects and avoidance of developing antibiotic resistance. It is also a more cost-effective approach. If I must determine future recommendations in a clinical setting, I would do so on a whole scale instead of personal or popular opinion. Too often, healthcare professionals are quick to administer oral antibiotic treatment, without regard to current statistical findings within the medical field. In an attempt to alter this common practice, I would present the current research to my colleagues so that the accepted method of treatment converges with evidence-based guidelines. Education about the risks associated with unnecessary or excessive use of antibiotics is the only way to convince medical care staff that they should consider alternative methods.

Ethical Issues

Ethical issues and physicians ethics are of paramount importance to professionals employed in the healthcare industry. The most common central theme to these issues is housed in the professional code of conduct that states” respect the patient as an individual.” It incorporates many facets including confidentiality, trust, competence, and consent. According to Carper (1978), ethics as moral issues include choices pertaining to sufficient patient care and management. Fry (1989) affiliates moral character with the nature of a patient-nurse relationship. Once empirical knowledge has a solid foundation, ethical knowledge can be most productive. It is insufficient to only conform to moral principles but to determine the proper decision based on the circumstances of each situation.  The empirical data gathered from multiple sources provides an ethical foundation for changing practices to allow for alternative care methods, particularly the watch and wait approach that is shown to significantly reduce the risk of antibiotic complications.

The ethical concerns of implementing any treatment to children, let alone one with as many unknowns as antibiotic or wait-and-see treatment for AOM are much greater than they would be with an adult. The patient is not capable of making decisions so the parents must be brought into the conversation, complicating the typical doctor-patient relationship. Parents are likely to react negatively to any risk that they are not familiar with and so will be previously inclined toward either antibiotics or observation. 

Informed consent and confidentiality, in this case, are deferred to the parents, making the child subject to whatever is decided for him or her. In many cases, the wishes of the parents may not align with the correct medical decision out of fear or prejudice and could cause harm to the child. This is not the same as treating an adult patient who takes their own health into their hands when they make decisions for their treatment that contradicts doctor recommendations. This same issue can also arise with certain populations who lack the education or language skills to communicate effectively with the doctor about medical concerns. The ethical dilemma is, as always with children, at what point does the doctor seek legal intervention for the safety of a child.  

References

AAP/AAFP (2004.) Clinical practice guideline: Diagnosis and management of acute otitis media. Retrieved May 17, 2008, from http://aappolicy.aappublications.org/cgi/content/full/pediatrics 113/5/1451 

Block, S. L. (1997). Causative pathogens, antibiotic resistance and therapeutic considerations in acute otitis media. Pediatric Infectious Disease Journal, 16, 449–456. 

Kelley, P. E., Friedman, N., Johnson, C. (2007). Ear, nose, and throat. In W. W. Hay, M. J. Levin, J. M. Sondheimer, & R. R. Deterding (Eds.), Current pediatric diagnosis and treatment (18th ed., pp. 459–492). New York: Lange Medical Books/McGraw-Hill. 

McCracken, G. H. (1998). Treatment of acute otitis media in an era of increasing microbial resistance. Pediatric Infectious Disease Journal, 17, 576–579. 

Carper, B. (1978). Fundamental Patterns of Knowing in Nursing. Advances in Nursing Science 1(1) p13-23

Fry S. (1989). Towards a Theory of Nursing Ethics. Advances in Nursing Science 11(4) p 9-22

Mills L. (2008). Management of Otitis Media. Nurse Prescribing. 6(5) p 197-200