CLINICAL CASES
CLINICAL CASES
Using the Wispr Digital Otoscope
3-year-old with Ear Pain and Fever
A 3-year-old female presented to the pediatric clinic for evaluation of fever and ear pain. Her father reported the child had been up all night with right-sided ear pain. Just prior to her appointment, she had an oral temperature of 104°F and was given a dose of ibuprofen. She had a runny nose for approximately a week, but had not been febrile until that morning. Her medical history was notable for developing hives with amoxicillin. In clinic her temperature was 39.5 C, respiratory rate 28, pulse 120, Pulse Ox 98%. She appeared uncomfortable and had copious yellow crusting and injection to both eyes. Her WiscMed Wispr digital otoscopy exam is shown.
Which of the following antibiotics is the most appropriate management for this child’s condition?
A. Amoxicillin
B. Augmentin
C. Cefdinir
D. Clindamycin
C. Cefdinir
The child’s Wispr exam demonstrates a severely bulging tympanic membrane (TM) with the classic “angry donut” sign diagnostic of acute otitis media (AOM). Note the complete loss of bony landmarks and compare to this normal ear. According to the AAP Practice Guideline, her symptoms would be considered severe solely based on her fever of >39 C. It is also appropriate to consider the impressive appearance of her TM and ear pain (despite not being present for at least 48 hours) as indicative of higher severity. As such, antibiotic therapy is warranted. While high-dose amoxicillin is the first-line therapy for AOM treatment, two additional factors in her presentation must be considered. The child reportedly has an allergy to amoxicillin; therefore, neither amoxicillin nor Augmentin would be appropriate. Additionally, with bilateral purulent conjunctivitis, treatment should cover the β-lactamase–positive H influenzae, a common pathogen in otitis-conjunctivitis syndrome. Macrolides, such as clindamycin, are safe for pen-allergic children but poorly effective against H. influenza. Third-generation cephalosporins such as cefdinir are highly unlikely to be associated with penicillin cross-reactivity to penicillin and provide good coverage against β-lactamase-producing bacteria.
The child was provided a dose of acetaminophen and started on a course of cefdinir. The clinic nurse follow-up call to the family demonstrated significant improvement in both eye and ear complaints within 48 hours.
Key Learning Points and referenced Action Statements from AAP Practice Guideline covered in this case:
- Clinicians should diagnose acute otitis media (AOM) in children who present with moderate to severe bulging of the tympanic membrane (TM) or new onset of otorrhea not due to acute otitis externa.
- The clinician should prescribe antibiotic therapy for AOM (bilateral or unilateral) in children 6 months and older with severe signs or symptoms (ie, moderate or severe otalgia or otalgia for at least 48 hours or temperature 39°C [102.2°F] or higher).
- 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.
- Third generation cephalosporins including cefdinir, cefuroxime, cefpodoxime, and ceftriaxone are highly unlikely to be associated with cross-reactivity with penicillin (likely less than 0.1% for severe reaction).
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