Voiceover: Welcome to NP certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question, so you can better understand how to arrive at the correct test answer.
So, if you're ready, let's jump right in.
Margaret Fitzgerald: Esteban is an 18-month-old child who presents with his father for a sick visit. The child, who is typically healthy and up to date with immunizations and without drug allergies, has had URI-like symptoms the past 6 days with a congested cough and clear-to-yellow nasal discharge. Per parental report, Esteban is drinking fluids without difficulty and has a slightly reduced appetite and reports a single episode of post-tussive vomiting 3 days ago.
For the past 36 hours, his father reports increased crankiness and intermittent fever to 102.6°F (39.2°C), with the father stating, “This is how he acted a few months ago when he had an ear infection." Physical exam confirms the diagnosis of bilateral acute otitis media. When prescribing an antimicrobial for this child, which of the following represents the first line treatment option?
A: Oral azithromycin.
B: Oral cefpodoxime.
C: IM ceftriaxone.
D: Oral amoxicillin.
The correct answer is D: Oral amoxicillin. Where do we start with this question? Clearly, since we're being asked to treat this child, this is a plan/intervention question. A bit of background information: nearly two-thirds of all children will have at least one acute otitis media episode by their second birthday, and one-third will have three or more episodes of acute otitis media.
This is a clinical diagnosis arrived at with the history of present illness and physical exam. In other words, as it is with any clinical diagnosis, no special testing is needed. The disease's pathophysiology consists of middle ear inflammation triggered most often by infection caused by viral or bacterial. Causative organisms include Streptococcus pneumoniae, the most common organism when AOM is bacterial in origin.
Haemophilus influenzae and Moraxella catarrhalis, which are pretty much the number two, number three bacterial organisms. Very close, about 29% of all AOM will be either H. influenzae or M. catarrhalis. And about 49%, when it's bacterial in origin, will be S. pneumoniae. And then of course, remember not all AOMs are caused by bacteria. There are a number of respiratory tract viruses that can result in acute otitis media.
Streptococcus pneumoniae is the microorganism that most often causes the AOM where the child is uncomfortable, feverish, cranky, crying-that type of a scenario. It's also the form of AOM that's less likely to resolve without an antimicrobial. The other two bugs oftentimes will resolve, the H. influenzae and M. catarrhalis, without an antimicrobial being given. You might also recall these are the same bacterial organisms implicated in ABRS, acute bacterial rhinosinusitis-and I mention that because recognizing patterns in causative pathogens in infectious disease, then looking at the antimicrobials effective against these bugs, is going to be enormously helpful in organizing your learning. So, to look at the question, empiric antimicrobial therapy is based on best evidence, and this is going to guide the choice of antibiotic. In other words, we are being directed to prescribe an antibiotic.
Now in acute otitis media, in otherwise healthy children, there is the option of doing watch and wait therapy. And I'm going to let you take some time and look that up. And I've done both watch and wait and also prescribe antimicrobials with acute otitis media. Why watch and wait in some kids? Because one more time, regardless of the causative organisms, AOM often spontaneously resolves even when it is bacterial in origin.
But let's go back and take a look at the question and walk through the treatment options. Esteban is an 18-month-old child who presents with his father for a sick visit. The child, who is typically healthy and up to date with immunizations and has no drug allergies, has had URI-like symptoms for the past 6 days with a congested cough and clear to yellow nasal discharge. Per parental report, Esteban is drinking fluids without difficulty and has a slightly decreased appetite and had a single episode of post-tussive vomiting 3 days ago. For the past 36 hours, his father reports increased crankiness and intermittent fever to 102.6°F, or 39.2°C, with a father stating, “This is how he acted a few months ago when he had an ear infection.” Physical exam confirms the diagnosis of bilateral acute otitis media.
Yeah. I want to stop for a moment here. And I'm also doing another podcast on diagnosing acute otitis media. But what we're given here is we're told what the diagnosis is, we're not going to argue with the diagnosis. But I do want to point a few things out to you here. Note, the dad says the child's only been feverish for the past 36 hours.
And that was around the time he started to get cranky. So, that probably tells us before that, he's been sick-ish for about 6 days, but he got sick more over the last 36 hours. Also, I want you to know he's taking fluids without any difficulty, so that's telling us his GI status is intact. And don't be one bit concerned about the post-tussive vomiting 3 days ago.
Kids do this all the time. They've got junk draining out of their nose into the back of their throat. They don't know how to clear their throat and they cough, cough, cough to get this nasal discharge out. And they could cough to the point where they vomit. He's done it one time, that doesn't mean GI function is not intact.
Okay, so let's get back here. When prescribing an antimicrobial for this child, which of the following represents the first-line treatment option? A: Oral azithromycin. This is incorrect. The macrolides are a class of antimicrobial that includes erythro-, clarithro-, and azithromycin and are not preferred medications in AOM, nor in abscess for that matter, because of their poor activity against Streptococcus pneumoniae, that is the most common causative organism for severe AOM, and for AOM that does not get better without an antibiotic.
So, we always want to go for an antimicrobial in a case like this with good S. pneumoniae coverage, the macrolides don't fit the bill. B: Oral cefpodoxime. This has the 'cef' prefix. And so, this is a cephalosporin. This antimicrobial will have activity against the AOM causative bacterial organisms. But it's actually not recommended as a first-line medication.
However, it is considered an acceptable alternative in penicillin allergy that is not characterized by anaphylaxis. C: IM ceftriaxone. Okay, again 'cef’ prefix-another cephalosporin. And again this will provide activity against the AOM pathogen. At the same time remember one of the rules of prescribing never inject what you can give PO. This child is taking fluids, eating, though appetite is reduced.
Hey, who's appetite doesn't tend to be a little bit reduced when you don’t feel great regardless of the person's age. Plus, this kid's a toddler. Sometimes the toddlers go on these amazing hunger strikes when they don't feel good. As long as they're taking fluids, they can sustain themselves for a few days without a lot of solids. D: Oral amoxicillin.
Of course, this is the correct answer. When given in sufficient dose, the amoxicillin will provide great activity against S. pneumoniae. Granted, H. influenzae and M. cattharalis can produce beta-lactamase that could destroy the amoxicillin, at the same time, these bacterial organisms have high spontaneous resolution rate without using an antibiotic and evidence-based practice supports amoxicillin as the first-line drug in the treatment of acute otitis media.
Key takeaway: choosing the correct antimicrobial means knowing the causative bugs and the right drugs, backed by best evidence.
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