Case Study:
A 5-year-old male is brought to the primary care clinic by his mother with a chief complaint of bilateral ear pain with an acute onset that began “yesterday.” The mother states that the child has frequently been crying due to the pain. Ibuprofen has provided minimal relief. This morning, the child refused breakfast and appeared to be “getting worse.”
Vital signs at the clinic reveal HR 110 bpm, 28 respiratory rates, and tympanic temperature of 103.2 degrees F. Weight is 40.5 lbs. The mother reports no known allergies. The child has not been on antibiotics for the last year. The child does not have a history of OM. The child is otherwise healthy without any other known health problems.
Physical examination reveals: Vital signs HR 110 bpm, 28 respiratory rates, and tympanic temperature of 103.2 degrees F. Weight is 40.5 lbs. Bilateral TMs are bulging with severe erythematous. Pneumatic otoscopy reveals absent mobility. Ear canals are normal.
After your questioning and examination, you diagnose this child with bilateral Acute Otitis Media.
According to the current guidelines on medications for a 5-year-old with Acute Otitis Media (AOM), address the following:
| Questions | If No, explain why | If you decide to recommend/ prescribe medication, provide a brief rationale. Give the name of medication along with strength, frequency, dosage, and length of treatment. (provide citations) | What Parent/Patient Education is essential? (you may use bullet format) | What side effects might be expected? (you may use bullet format) |
| Should the APRN prescribe an antibiotic? | Yes | The guidelines recommend antibiotic therapy for children that are six months and older with Acute Otitis Media that are showing symptoms that are severe. The child, in this case, is five years old, and therefore the antibiotic therapy will be most appropriate. The child’s case has been experiencing severe otalgia, and his temperature is above 39 degrees Celsius. It is at 103.2 degrees F.The severity of the vital signs calls for an option for treatment that is more effective for the situation and as recommended by the specialists in Acute Otitis Media in children, and since the child has not received any antibiotics within the last 30 days, the antibiotic that will be recommended will be Amoxicillin (Lieberthal et al., 2013). Since it is the initial treatment, high doses of amoxicillin of 90 mg per kg on a daily basis will be recommended for the patient. Improvement after the administration of this antibiotic is expected to get noticed between 48 to 72 hours after the administration of the antibiotics to the patient. The amoxicillin doses will be administered on the patient for a period of ten days, and it is recommended as the first-line antibiotic therapy. However, Amoxicillin-clavulanate has been considered to be an antibiotic that is better in the treatment of patients with Acute Otitis Media because it has a spectrum that is broader. The reason that it does not get selected for initial antibiotic therapy for this child is that it has effects that are adverse, and that’s why it only gets considered when the child has been unresponsive to the first-line antibiotic treatment (Lieberthal et al., 2013). The observation could have been used instead of antibiotics since the patient’s symptoms have lasted for less than 48 hours. However, antibiotic therapy is necessary because of the severity of the symptoms that the patient is showing. | Pain management, expected outcomes of treatment, risk factors, and how to avoid them, and observation of changes in symptoms. | Nausea, headache, diarrhea, skin rash, itching, vomiting |
| What would the APRN prescribe if this child was allergic to penicillin? | If this child had an allergy for penicillin, the antibiotic therapy that would get recommended by the APRN is 14 mg per kg per day of Cefdinir in two doses that are divided would be recommended. The APRN may also recommend 30 mg per kg on a daily basis of Cefuroxime in two doses that are divided as an alternative in the treatment of Acute Otitis Media in the child in this case (Lieberthal et al., 2013). Until it gets established that a short-course treatment of antibiotic therapy in a patient with AOM is effective, the treatment should be continued for a period of 10 days (Wald & DeMuri, 2018). The normal period of antibiotic therapy is usually between five to ten days when the symptoms are severe as it is an acute phase. However, if the initial antibiotic is working, the treatment can last for a period of up to three days. | Identification of symptoms and signs, possible side effects of medication, dosage, and how to manage the pain (Van Uum et al., 2019). | Vomiting, nausea, skin rash, diarrhea, and itching. | |
| What determines the choice of an antibiotic? | The choice of antibiotic to use for the treatment of Acute Otitis Media is determined by several factors that include; the severity of the symptoms that the patient is experiencing, the medical history of the patient to determine whether he has used antibiotics in the last 30 days, whether the patient’s condition is a recurrence of the same, whether the patient has other underlying conditions that could be affected by the use of certain antibiotics, and whether the child has any known allergies to antibiotic therapy. Also, the resistance of the patient to certain medications, like if he throws up when using the oral medication, can help the doctors decide on the right antibiotic for them. For example, for a patient that is experiencing vomiting that is persistent, alternative ways of administering the antibiotics can be used, which is the administration of ceftriaxone in a dosage of 50mg per kg intramuscularly in one or two points of the anterior thigh. They can also get administered intravenously (Lieberthal et al., 2013). The recommended administration through the injection is once, but in order to minimize the chances of a recurrence happening, more than one dose of ceftriaxone will be required three days after the first dose gets administered. | The patient or parent will be educated on how to identify and manage the side effects of certain antibiotics, and the possible treatment outcomes. | ||
| Will you recommend or prescribe any other medications? | Yes | There are several other medications that I would recommend for the treatment of this child’s condition would be amoxicillin only in the dosage of 80 to 90 mg per kg in two doses that are divided on a daily basis. Another medication recommendation for a child that has a penicillin allergy is Cefpodoxime, 10mg/kg on a daily basis in two doses that are divided (Lieberthal et al., 2013). Ceftriaxone in doses of 50 mg IM or IV daily for one or three doses is recommended. If the child has a penicillin allergy, Clindamycin alone in three-d that are divided, of 30-40 mg per kg, would be recommended. If the penicillin allergy exists and the child is experiencing hypersensitivity, the antibiotic that will get recommended is Azithromycin that gets administered orally in 5-10mg per kg on a daily basis, once a day for a period of five days. My other recommendation could have been a close observation of the patient, and if the symptoms keep getting worse after 48 hours since they started showing, I would then recommend the use of antibiotic therapy. This is because there are some instances when the patient may recover, and making a diagnosis based on symptoms that just began showing could be a mistake, and the patient’s body may end up responding on its own within those hours (Shah-Becker & Carr, 2018). Close observation of the patient helps significantly in coming up with a more accurate diagnosis of what the problem could have been, and it gives the patient a chance to possibly avoid the side effects that come with antibiotic use. | The patient/parent will be educated on the side effects to expect, pain management, and the possible outcomes of the treatment. The patient and parent also need education on the factors of risk that contribute to the recurrence of the condition and why they should avoid them. | Vomiting, itching, skin rash, nausea. diarrhea |
| The child returns in 48 hours with increased pain and fever. What changes will the APRN make in the treatment plan? | If the child returns to the hospital in 48 hours with symptoms including fever and increased pain, several changes will have to be made in the plan of treatment as it is an indication that the antibiotic plan of treatment that was initially used has failed. The APRN will have to conduct a reassessment of the condition of the patient to make a confirmation of the initial diagnosis, and then a second antibiotic can get initiated to help with the condition (Suzuki et al., 2020). The second antibiotic is amoxicillin/clavulanate. In this case, Amoxicillin-clavulanate entailing a dosage of 90 mg per kg on a daily basis of amoxicillin together with 6.4mg per kg of clavulanate in two doses that are divided will be used. The ratio of amoxicillin to clavulanate should be at 14:1. Another option for treatment that comes highly recommended in the event that the initial treatment of antibiotics has been unresponsive in the patient is ceftriaxone that gets administered for a period of three days rather than using the regimen for one day. The APRN can also recommend another option, which is 3 d Clindamycin in doses of 30 to 40 mg per kg in three doses that are divided. This can be administered with or without the third-generation cephalosporin (Lieberthal et al., 2013). The treatment should go on for a period of ten days. If the second antibiotic therapy fails, Clindamycin in three doses of 30 to 40 mg per kg can be used together with the third-generation cephalosporin. Further treatment can be made in consultation with a specialist in Acute Otitis Media in children. The APRN will have to make further consultations if the condition of the patient does not improve even after the alternative antibiotic therapies have been used. A three-day course of Azithromycin can also be used in the treatment of the patient in 20 mg per kg on a daily basis based on the fact that his condition has recurred. If the patient fails to respond to all the options for treatment, and it gets established that he actually has AOM, it means that the condition of the patient has become chronic. In this case, the patient can be recommended for controlled trials that are randomized on the new medication. Another option is surgery to remove the tissue that is infected and have the eardrum perforation repaired. Surgery also helps repair any injury that may have occurred to the tiny bones that get found in the ear (Robb & Williamson, 2016).
| The patient/parent will get educated on what to expect in terms of the possible outcomes of the treatment and information about the available treatment options. They also need education on the factors of risk contributing to the recurrence of the condition (Le Saux et al., 2016). Some of these risk factors include inaccessibility to medical care, overcrowding, exposure to smoke from cigarettes, and living conditions that are poor. | Nausea, vomiting | |
References
Le Saux, N., Robinson, J. L., Canadian Paediatric Society, & Infectious Diseases and Immunization Committee. (2016). Management of acute otitis media in children six months of age and older. Paediatrics & child health, 21(1), 39-44.
Lieberthal, A. S., Carroll, A. E., Chonmaitree, T., Ganiats, T. G., Hoberman, A., Jackson, M. A., … & Schwartz, R. H. (2013). The diagnosis and management of acute otitis media. Pediatrics, 131(3), e964-e999. Retrieved from https://pediatrics.aappublications.org/content/131/3/e964.short
Robb, P. J., & Williamson, I. (2016). Otitis media with effusion in children: current management. Pediatrics and Child Health, 26(1), 9-14.
Shah-Becker, S., & Carr, M. M. (2018). Current management and referral patterns of pediatricians for acute otitis media. International Journal of Pediatric Otorhinolaryngology, 113, 19-21.
Van Uum, R. T., Venekamp, R. P., Schilder, A. G., Damoiseaux, R. A., & Anthierens, S. (2019). Pain management in acute otitis media: a qualitative study of parents’ views and expectations. BMC family practice, 20(1), 18.
Wald, E. R., & DeMuri, G. P. (2018). Antibiotic recommendations for acute otitis media and acute bacterial sinusitis: conundrum no more. The Pediatric Infectious Disease Journal, 37(12), 1255-1257.
Suzuki, H. G., Dewez, J. E., Nijman, R. G., & Yeung, S. (2020). Clinical practice guidelines for acute otitis media in children: a systematic review and appraisal of European national guidelines. BMJ Open, 10(5), e035343.