Otitis Media - Acute (1 of 13)

1 Patient presents w/ symptoms suggestive of acute otitis media (AOM)

DIAGNOSIS No ALTERNATIVE Is AOM DIAGNOSIS suspected?

CONSIDER LOCAL EPIDEMIOLOGIC RESISTANCE PATTERNS

A Non-pharmacological therapy Patient education B Pharmacological therapy Symptomatic therapy Oral antibiotic therapy 1st-line agents: • Amoxicillin or high-dose Amoxicillin Severe illness: • High-dose Amoxicillin/clavulanic acid Non-type 1 allergy to Penicillin: • Cephalosporin (2nd or 3rd generation) Type 1 allergy to Penicillin: • Co-trimoxazole, Erythromycin/sulfafurazole or advanced macrolide

FOLLOW-UP © MIMSSee page 3

Not all products are available or approved for above use in all countries. Speciﬁ c prescribing information may be found in the latest MIMS.

B1 © MIMS 2019 OTITIS MEDIA • Media Otitis Suppurative Chronic • Myringitis • • • w/Eff Media Otitis (OME) usion • Foreign Body • Externa Otitis Diff Diagnoses erential • • ofMEE Presence • • Infl Ear &Symptoms ofMiddle Signs ammation Exam Physical • • • History • • • ofAOM Etiology Symptoms fl todescribe used term General media: Otitis uid in&infl ammation ofthe middleear Persistent infl tympanic membrane & drainage ofexudate w/perforated for >6 wk ammation associated Infl URTI w/viral ammation ofthe tympanic membrane usuallyassociated loss ishearing symptom Main tympanic membrane w/color may isusuallyabsent retracted show change; eardrum Otoscopy bulging Typically ifthere eff ismiddleear diagnosed ofacuteinfl w/osigns usion onpneumatic otoscopy ammation inchildren particularly suspected May pain&shouldbe cause eardrum anormal-appearing similar toAOMMay earache buthas cause Air-fl the behind tympanic membrane uid level - w/rupture oftympanic membrane) purulence isassociated (positive Otorrhea - mobilityoftympanic membrane Absent w/pneumatic pressure orlimited - Opacification oftympanic orcloudiness membrane - landmarks tympanic of normal membrane w/loss Bulging - any by ofthe isindicated Presence following: ofMEE otoscopy confi be can MEE ofthe orpneumatic tympanic otoscopy membrane visualization by direct by rmed or activity is apparentOtalgia noticeable by of the discomfort that interference ears causes sleep normal w/ or prevents Apparent ofthe tympanic membrane erythema Viral URTI AOM present may orduring before symptoms be are usuallynonspecifi &symptoms Signs c ofthe predictor presence ofAOM aloneisapoor History inflammation, &confi effrmation ofmiddleear usion (MEE) ofmiddleear &symptoms signs &symptoms, ofsigns ofacuteonset a history ofAOM requires Diagnosis causes streptococcus & A beta-hemolytic group Moraxellaisolated; is catarrhalis occasionally pneumoniae &Haemophilus inflStreptococcus are the common ofAOM most causes uenzae - dysequilibrium w/orw/ofever, otorrhea unilateral Commonly &include hearing, otalgia, diminished - -

© MIMS of allergic present rhinitis may be also (egSymptoms tractinfection cough, discharge resp ofupper nasal orstuffi throat) sore orexacerbationness, Infl ofthe Eustachian orbrought dysfunction anacuteinfection by about by tube ammation caused may be 1 ACUTE OTITIS MEDIA (AOM) MEDIA OTITIS ACUTE Otitis Media-Acute(2of13) 2 DIAGNOSIS B2 S aureus are other rare © MIMS 2019 OTITIS MEDIA B • EPIDEMIOLOGIC RESISTANCE RESISTANCE EPIDEMIOLOGIC causes ofillness causes Confi AOM &excluderm other Pharmacological therapy Pharmacological C • tootheragents: unresponsive S pneumoniae Type toPenicillin &Penicillin-resistant 1allergy • Type toPenicillin: 1allergy • acid: Amoxicillin/clavulanic ofhigh-dose orfailure illness Severe • Failure of1st-line w/Amoxicillin: therapy therapy antibiotic Oral/parenteral Clindamycin macrolideAdvanced (2ndor3rd generation) Cephalosporin Amoxicillin/clavulanic acid High-dose

REASSESS PATIENTREASSESS CONSIDER LOCAL LOCAL CONSIDER Consider expert referral Consider expert Response w/in w/in Response PATTERNS FOLLOW 48-72 hrs? UP ©No MIMS Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing No Otitis Media-Acute(3of13) ANTIBIOTICS FOR AOM FOR ANTIBIOTICS PATIENT W/ TREATED Response w/in w/in Response Yes 48-72 hrs? B3 Continue antibiotics x5-10days Yes © MIMS 2019 OTITIS MEDIA • • dose) (High Acid Amoxicillin/clavulanic • • • Amoxicillin Amoxicillin/High-dose • Antibiotic erapy • • • Analgesics Symptomatic erapy • • • Use ofAntibiotics • • Use ofAnalgesics • • Patient Education • • Co-trimoxazole • • (2nd&3rdGeneration) Cephalosporins infl organisms (eg H iscombination coverage provide forbeta-lactamase-producing will uenzae Amoxicillin illness therapy whopresent orinthose w/severe ofAmoxicillin combined w/clavulanic acidare forpatients standard recommended whofail High doses where Penicillin-resistantIn areas given are pneumococci common, Amoxicillin shouldbe high-dose pneumococci It iseff ofthe which AOM most including against bacteria cause &intermediate-resistant susceptible ective Amoxicillin at suffi isstillconsideredcient the 1st-line doses agent forAOM Treatment development ofcomplications prevents - ere are nodata antimicrobial initiallywithholding regarding therapy inadultpatients w/AOM Eff formild-moderate pain analgesia ective theConsidered mainstay ofpainrelief forAOM indicated be may Opioids occasionally - (egEg Ibuprofen) Paracetamol, NSAIDs improvement 2-3days ofanalgesics after orworsening young patients orif thereEducate the patientis no that cases, antibiotics are only in severe recommended (eg sideeff the risks Review antibiotic resistance inthe community)ects, antibiotics donotimprove prognosis Patient madeaware that shouldbe cases, inmost inthe esp 1st24hrsofillness forantibacterial agents, ofthe need regardless addressed Pain must be until ofanalgesics paindecreases use theDiscuss regular smokingcessationPatient isadvised ofAOM prognosis long-term good regarding Patient reassured shouldbe Use may be limited by local resistance patterns local by Use limited may be toPenicillin 1allergy considered may inpatients be w/type Co-trimoxazole effi superior Has - to Spneumoniae compared w/alternative oralantibioticscacy x3 days recommended inpatients Also Amoxicillin/clavulanate whofail - considered may inpatients be (IV/IM) (eg unable totakeoralmedications vomiting) Ceftriaxone toPenicillin reaction 1hypersensitivity agents considered ese may inpatients be w/non-type - drug-resistant Spneumoniae, Hinfl &Mcatarrhalis uenzae Cefdinir, of their are the & Cefuroxime eff Cefprozil agentspreferred because Cefpodoxime, against ectiveness alongw/Penicillin-resistantcatarrhalis Spneumoniae)

© MIMS Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing A NON-PHARMACOLOGICAL THERAPY B PHARMACOLOGICAL THERAPY Otitis Media-Acute(4of13) B4 © MIMS & M 2019 OTITIS MEDIA • • • • • • • • • occurs: any if ofthefollowing referral Consider expert • ofAntibiotic Duration erapy • • • Clindamycin • • • Macrolides Advanced • • Erythromycin/sulfafurazole Antibiotic (Cont’d) erapy - Refer to otolaryngologist if hearing loss persists loss ifhearing Refer tootolaryngologist - ifeff performed shouldbe test Hearing usion ispresent 3mths AOM post Persistence isnotanindication forcontinued ofMEE treatment orforanother course ofantibiotics - cure forupto1mth persist can in50%ofpatientsMEE &upto3mths ifthere in10%ofpatients even isbacteriologic orw/inthe next4-6 wks isdonein3-4 wks It exam that isrecommended follow-up patients of asymptomatic atFollow-up exam the completion oftreatment isnotnecessary appropriateClinicians shoulddetermine follow-up tympanic membrane Retracted in12mths ≥4episodes in6mths, ≥3 episodes w/eff media Otitis for≥3mthsusion (OME) ≥20dB loss w/bilateral hearing Tympanocentesis stain&culture w/Gram isrecommended - to2nd-lineagents If noresponse May continue antibiotics x5-7days &upto10 days inmild-moderate illness ifsevere - duration ofantimicrobialOptimal therapy inAOM patients isuncertain Clindamycin Hinfl isnotactiveagainst are suspected ifthese used &shouldnotbe orMcatarrhalis uenzae treatment Clindamycin eff may be toother Penicillin-resistant against notresponding ective infection pneumococcal stain&culture forGram tympanocentesis isnotpossible complete consideredMay inapatient be antibiotic persistent previous therapy AOM after whohas &inwhom drug-resistant against Spneumoniae activity agents ese have decreased Active the against major pathogens that AOM cause Eg orClarithromycin Azithromycin Co-trimoxazole over preferred may resistance be patterns, onlocal Depending toPenicillin 1allergy consideredMay inpatients be w/type © MIMS Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not B Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing PHARMACOLOGICAL THERAPY (CONT’D) Otitis Media-Acute(5of13) C EXPERT REFERRAL FOLLOW-UP B5 © MIMS 2019 OTITIS MEDIA Dibekacin aayi 1-2gdailyIM Kanamycin 80 mg/2 mLIM/IV Gentamicin (TM)] Trimethoprim & (SMZ) [Sulfamethoxazole Co-trimoxazole Drug Drug Products listed above may not be mentioned in the disease management chart but have been have but chart management disease the in mentioned be not may above listed Products placed here based on indications listed in regional manufacturers’ product information. product manufacturers’ regional in listed indications on based here placed & non-elderly adults w/ normal renal & hepatic function unless otherwise stated. otherwise unless function &hepatic renal w/ normal adults & non-elderly All dosage recommendations are for non-pregnant & non-breastfeeding women, women, &non-breastfeeding non-pregnant for are recommendations dosage All © MIMS 100 mg dailyIM divided 12 hrly divided >50kg 8 hrly xwt TM PO 12 hrlyTM PO SMZ/160 mg 800 mg Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Dosage Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing Dosage ANTIBACTERIAL COMBINATIONS Otitis Media-Acute(6of13) Dosage Guidelines AMINOGLYCOSIDES • • • • Instructions Special • • Reactions Adverse folinic acid), &inpatients w/G6PDdeficiency defi (may consideradministrationof folate ciency dysfunction, hepatic severe Use w/cautioninpatientsrenalimpairment, anemia duetofolicaciddefi megaloblastic disorders esp ciency Use w/ extreme caution ornotat allinpatients w/hematological inpatientsContraindicated allergic tosulfonamides Maintain adequate fluid intake occurred has meningitis Aseptic renal Rarely eff hepatic, orw/highdoses; for longperiods ects; Rarely hematologic eff which more may common be ifgiven ects Urogenital syndrome); eff inthe urine) (crystallization ect (eg Stevens-Johnson (eg tosevere/life-threatening rash) range mild from can reactions Hypersensitivity photosensitivity); effDermatologic glossitis); diarrhea/colitis, pruritus, (rash, ects GI eff (N/V, ects rarely antibiotic-associated diarrhea, anorexia, • • Instructions Special • Reactions Adverse cochlear impairment or vestibular patients renal dysfunction, w/preexisting Parkinson’s), (egmuscle myasthenia weakness gravis, w/ Use w/caution inpatients w/conditions associated - Consider monitoring of serum concentrations ofserum Consider monitoring &/orpeak - drugs receiving orhavealso other received ototoxic/nephrotoxic orwhoare orforlongperiods who are receiving highdoses w/renaldehydrated those impairment, inpatients patients, &nephrotoxicity likely areOtotoxicity most ingeriatric, reactions Hypersensitivity &muscular paralysis); depression inresp resulting blockade Neuromuscular effadministered); (neuromuscular ects when have other been also nephrotoxic drugs usually nephrotoxicity, reported been acuterenal has failure vertigo); Renal eff dizziness, loss, (reversible ects effOtotoxic ototoxicity inhearing resulting (irreversible ects

serum concentrations/MICserum ratio patients inthese B6 Remarks Remarks © MIMS 2019 OTITIS MEDIA (Cephradine) Cefradine Cefazolin (Cephalexin) Cefalexin Cefadroxil First Generation sulfi soxazole) (Erythromycin/ sulfafurazole Erythromycin/ Drug Drug Products listed above may not be mentioned in the disease management chart but have been have but chart management disease the in mentioned be not may above listed Products placed here based on indications listed in regional manufacturers’ product information. product manufacturers’ regional in listed indications on based here placed & non-elderly adults w/ normal renal & hepatic function unless otherwise stated. otherwise unless function &hepatic renal w/ normal adults & non-elderly All dosage recommendations are for non-pregnant & non-breastfeeding women, women, &non-breastfeeding non-pregnant for are recommendations dosage All © MIMS divided 6 hrly divided 1-4 gPO 8-12 hrly 1 gIM 6 hrly 250-500 mg PO divided 12 hrly divided 24 hrly or 1-2 gPO PO 6 hrly PO Sulfafurazole & 1200 mg Erythromycin 400 mg Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not ANTIBACTERIAL COMBINATIONS (CONT’D) Dosage Dosage Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing Otitis Media-Acute(7of13) Dosage Guidelines CEPHALOSPORINS • • • Instructions Special • • • Reactions Adverse • • • Instructions Special • • Reactions Adverse Use w/ caution inpatients w/renal impairment 10% chance ofcross-sensitivity Use w/ caution inpatients allergic toPenicillin, there may be distress gastric todecrease taken w/food May be cephalosporins N-methylthiotetrazole sidechain-containing (NMTT) w/o bleeding) frequently &occur most w/ reported have been &/or hypoprothrombinemia(w/or (APTT), time thromboplastin partial activated prolonged prothrombinProlonged time(PT), have occurred convulsions);Rarely hematologic eff &renalHepatic effects; ects eff w/CNS associated may be High doses (encephalopathy,ects infections) effOther diarrhea/colitis); antibiotic-associated (candidalect GIeff anaphylaxis); eg reactions N/V, (diarrhea, ects rarely severe rash, pruritus, (urticaria, reactions Hypersensitivity Use w/caution inpatients w/renal orhepatic dysfunction sulfonamides allergic in patients to reactions Contraindicated w/severe May takew/foodtodecreasegastricdistress macrolides w/some have loss occurred tinnitus/hearing cardiotoxicity, Hematologic eff hepatotoxicity; Dose-related ects; Rarely syndrome); (eg Stevens-Johnson severe/life-threatening range mild(eg to from can reactions rash) Hypersensitivity (candidal infections) diarrhea/colitis); disturbances, antibiotic-associated GI eff (N/V,ects diarrhea discomfort, abdominal & other GI B7 Remarks Remarks Other effOther ect © MIMS 2019 OTITIS MEDIA Carbocisteine 24 hrly 1-2gIM/IV 24 hrly 400 mgPO Ceftriaxone 8-12 hrly 1gIM/IV Ceftibuten 12 hrly 100-200 mgPO Ceftazidime Cefpodoxime 12 hrly 500 mgPO 8 hrly 100-200 mgPO Cefi xime 8 hrly 100-200 mgPO Cefetamet Cefditoren Cefdinir 12 hrly 250-500 mgPO Generation ird Cefuroxime 8 hrly 100-200 mgPO Cefprozil 8 hrly 250-500 mgPO Cefotiam Cefaclor Generation Second Drug Drug Products listed above may not be mentioned in the disease management chart but have been have but chart management disease the in mentioned be not may above listed Products placed here based on indications listed in regional manufacturers’ product information. product manufacturers’ regional in listed indications on based here placed 8hrly 500 mgPO media: otitis Cough-induced 400 mg/day dose: Max 12 hrly 100 mg PO 24 hrly 500 mg PO 12 hrly 250-500 mg PO 1200 mg/day dose: Max 12 hrly 375-500 mg PO & non-elderly adults w/ normal renal & hepatic function unless otherwise stated. otherwise unless function &hepatic renal w/ normal adults & non-elderly All dosage recommendations are for non-pregnant & non-breastfeeding women, women, &non-breastfeeding non-pregnant for are recommendations dosage All © MIMS Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing Dosage Dosage COUGH &COLDPREPARATION CEPHALOSPORINS (CONT’D) Otitis Media-Acute(8of13) Dosage Guidelines • • Instructions Special • Reactions Adverse • • • Instructions Special • • • Reactions Adverse Use w/ caution in patients w/ history of peptic ulcer ofpeptic Use w/ caution inpatients w/history Avoid ulcer inpatients w/peptic GIbleeding GIdisturbances, skinrash, Headache, Use w/caution inpatients w/renal impairment 10%chancebe sensitivity ofcross Use w/caution inpatients allergic toPenicillin, there may distress gastric todecrease taken w/food May be chain-containing cephalosporins frequentlymost w/N-methylthiotetrazole side (NMTT) &occur reported have been binemia (w/orw/obleeding) &/orhypoprothrom- time(APTT), thromboplastin partial activated prolonged prothrombinProlonged time(PT), Hepatic &renal eff have occurred ects (encephalopathy, convulsions); Rarely hematologic eff ects; eff w/CNS associated may be High doses ects (candidal infections) effOther diarrhea/colitis); antibiotic-associated ect GIeff anaphylaxis); eg reactions N/V, (diarrhea, ects rarely severe rash, pruritus, (urticaria, reactions Hypersensitivity B8 Remarks Remarks © MIMS 2019 OTITIS MEDIA Josamycin 800-1200 mg/day PO divided 6-8 hrly divided 800-1200 mg/day PO Josamycin linked chemically w/adoubleester) linked Ampicillin/sulbactam, are the 2drugs (Sultamicillin: of Pro-drug Ampicillin/sulbactam Ampicillin/cloxacillin Ampicillin Amoxicillin/sulbactam Amoxicillin/dicloxacillin clavulanate) (Co-amoxiclav, Amoxicillin/ Amoxicillin/clavulanic acid Amoxicillin (Amoxycillin) Aminopenicillins w/ or w/o Beta-Lactamase Inhibitors w/ orw/oBeta-Lactamase Aminopenicillins Clarithromycin 24 hrly x3 days 500 mgPO Azithromycin Macrolides Advanced 8 hrly 1.5MIUPO Spiramycin 12 hrly 150 mgPO 6-8 hrly divided 600-1200 mg/day PO Roxithromycin 6 hrly 250-500 mgPO Midecamycin Kitasamycin Drug Drug Products listed above may not be mentioned in the disease management chart but have been have but chart management disease the in mentioned be not may above listed Products placed here based on indications listed in regional manufacturers’ product information. product manufacturers’ regional in listed indications on based here placed 500-1000 mg PO 24 hrly 500-1000 mgPO release: Extended 12 hrly 250-500 mg PO 24 hrly x4 days 250 mg PO by 24 hrly x1day500 mg PO followed 8 hrly 500 mg PO 12 hrly 3 MIUPO 24 hrly 300 mg PO & non-elderly adults w/ normal renal & hepatic function unless otherwise stated. otherwise unless function &hepatic renal w/ normal adults & non-elderly All dosage recommendations are for non-pregnant & non-breastfeeding women, women, &non-breastfeeding non-pregnant for are recommendations dosage All © MIMS Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing Dosage Otitis Media-Acute(9of13) 375-750 mg PO 12 hrly 375-750 mg PO 6hrly 500 mgPO 6 hrly 1gPO dose: High 6 hrly 250-500 mg PO Amoxicillin 24hrly 4gSulbactam/8 g dose: Max infections day insevere upto150mg/kg/ increased May be 8 hrly infusion IM/IV/IV 1.5-3gdeep Inj TabFC 8hrly 500mgPO 6-8hrly 375-750 mgPO 250 mg/day PO isgiven Amoxicillin/day &clavulanic acid Add that Amoxicillin so 4g dose: High 12 hrly 1 gPO 8-12 hrly 625 mg PO 8 hrly 375-750 mg PO 8 hrly 1gPO dose: High 8 hrly 500 mg PO Dosage Guidelines MACROLIDES PENICILLINS Dosage B9 • • Instructions Special • • • Reactions Adverse dysfunction Use w/caution inpatients w/hepatic distress gastric todecrease May take w/food Erythromycin GIdisturbances less cause than &ClarithromycinAzithromycin tend to macrolides w/some occurred has loss tinnitus/hearing Dose-related Rarely cardiotoxicity, hepatotoxicity; rarely rash, anaphylaxis); pruritus, (urticaria, are reactions uncommon Hypersensitivity diarrhea/colitis); antibiotic-associated &other diarrhea GIdisturbances, GI eff (N/V,ects discomfort, abdominal Other effOther (candidal ect infections) • • Instructions Special • • Reactions Adverse Remarks w/ renal impairment Use w/ caution inpatients Penicillin allergy Avoid inpatients w/ convulsions) eff (encephalopathy,ects w/CNS associated may be Highdoses have occurred; Renal &hepatic eff ects Rarely hematologic eff ects; infections) eff (fever,ect candidal diarrhea/colitis);Other antibiotic-associated N/V,(diarrhea, rarely GIeffanaphylaxis); ects eg reactions severe pruritus, urticaria, (rash, reactions Hypersensitivity Remarks © MIMS 2019 OTITIS MEDIA Ciprofl oxacin Bacampicillin Penicillin Spectrum w/Extended 300,000-900,000uIM benzylpenicillin Procaine 6-8 hrly 125-250 mgPO Phenoxymethylpenicillin K Penicillins Sensitive Beta-Lactamase Dicloxacillin Cloxacillin 6-8 hrly 2gIV Penicillins Antistaphylococcal Reactions Adverse Piperacillin/tazobactam Inhibitor Penicillin w/Beta-Lactamase Antipseudomonal Sitafl oxacin Prulifl oxacin Ofl oxacin Levofl oxacin Drug Drug Products listed above may not be mentioned in the disease management chart but have been have but chart management disease the in mentioned be not may above listed Products placed here based on indications listed in regional manufacturers’ product information. product manufacturers’ regional in listed indications on based here placed & non-elderly adults w/ normal renal & hepatic function unless otherwise stated. otherwise unless function &hepatic renal w/ normal adults & non-elderly All dosage recommendations are for non-pregnant & non-breastfeeding women, women, &non-breastfeeding non-pregnant for are recommendations dosage All © MIMS Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing 125-750 mg PO 12 hrly 125-750 mg PO 12 hrly 400-800 mg PO 12-24 hrly 6 hrly 500 mg PO 6 hrly 500 mg PO 50 mg PO 12 hrly 50 mg PO 12 hrly 200 mg PO 8-12 hrly 300-600 mg PO 24 hrly 250-500 mg PO Otitis Media-Acute(10of13) PENICILLINS (CONT’D) Dosage Guidelines Dosage Dosage QUINOLONES B10 • • Reactions Adverse • • Instructions Special • • • • • Instructions Special • renal eff ects Rarely hematologic eff hepatic & ects; syndrome) Stevens-Johnson (eg to severe/life-threatening range mild(eg from can reactions rash) Hypersensitivity photosensitivity); drowsiness); restlessness, disorders, effCNS sleep dizziness, (headache, ects diarrhea/colitis); antibiotic-associated rarely diarrhea, pain, dyspepsia, GI eff (N/V,ects abdominal diarrhea, impairment Use w/caution inpatients w/renal Avoid inpatients w/Penicillin allergy (encephalopathy, convulsions) eff w/CNS associated may be doses ects hepatic eff High have occurred; ects Rarely hematologic eff Renal & ects; infections) colitis); effOther (candidalect diarrhea/ rarely antibiotic-associated GIeffanaphylaxis); N/V, (diarrhea, ects eg reactions severe pruritus, urticaria, (rash, reactions Hypersensitivity in those w/G6PDdefiin those ciency w/ impaired & renal orhepatic function inpatients disorders, ofCNS or history Use w/ caution inpatients w/epilepsy tanning beds Avoid tostrong sunlight exposure or Fe orbuffered Didanosinepreparations or supplements containing Zn dietary Al-orMg-containingafter antacids, or3hr 2hr before Administer at least prolong the QT interval have quinolones Some the potential to Dermatologic effDermatologic pruritus, (rash, ects Remarks Remarks © MIMS 2019 OTITIS MEDIA icmcn600 mg-2g/day IM Lincomycin 600 mg-1.8g/day PO Clindamycin Lincosamides 12 hrly 100 mg PO Doxycycline Drug Drug Products listed above may not be mentioned in the disease management chart but have been have but chart management disease the in mentioned be not may above listed Products divided 12 hrly divided 6-8 hrly divided 100 mg/day dose: Maintenance placed here based on indications listed in regional manufacturers’ product information. product manufacturers’ regional in listed indications on based here placed & non-elderly adults w/ normal renal & hepatic function unless otherwise stated. otherwise unless function &hepatic renal w/ normal adults & non-elderly All dosage recommendations are for non-pregnant & non-breastfeeding women, women, &non-breastfeeding non-pregnant for are recommendations dosage All © MIMS Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Dosage Dosage Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing

Otitis Media-Acute(11of13) Dosage Guidelines OTHER ANTIBIOTICS TETRACYCLINE • • Instructions Special • • Reactions Adverse • • • • Instructions Special • • Reactions Adverse Discontinue occurs ifdiarrhea impairment inpatients w/renal w/atopy &inthose colitis, or hepatic of w/history esp Use w/ caution inpatients w/GIdisease (polyarthritis) multiforme, dermatitis); exfoliative &vesiculobullous eff dermatologic Severe (erythema have occurred ects anaphylaxis) rarely urticaria, (rash, reactions Hypersensitivity taste); N/V, colitis, pseudomembranous pain,metallic abdominal GI eff antibiotic-related severe (diarrhea, ects Use w/caution inpatients w/renal orhepatic impairment (SLE) lupuserythematosus w/ systemic Avoid inchildren &pregnant women; avoid ≤8yr inpatients tobed retiring Take w/plenty offluid whilesitting orstanding&before Avoid tosunlight ortanningbeds longexposure have reactions occurred hypersensitivity intracranial disturbances; pressure &visual w/headache hepatotoxicity,Rarely renal dysfunction, hematologic eff ects, women) infants/pregnant discoloration interference inyoung ofteeth, growth w/bone effOther (photosensitivity); (candidal infections, ects taken w/aninsuffi effcient amountDermatologic ofliqd); ect ulceration when esophageal occurred has dysphagia, colitis, GI eff (N/V,ects diarrhea/ antibiotic-associated diarrhea, Hematologic &hepaticHematologic eff effOther have occurred; ects ect B11 Remarks Remarks © MIMS 2019 OTITIS MEDIA hydrocortisone B/ Neomycin/polymyxin lidocaine furaltadone/fl udrocortisone/ B/ Neomycin/polymyxin fl udrocortisone/lidocaine B/ Neomycin/polymyxin fl acetonide uocinolone B/ Neomycin/polymyxin dexamethasone B/ Neomycin/polymyxin Ofl oxacin Oxymetazoline Oxymetazoline Xylometazoline Drug Drug Drug NASAL DECONGESTANTS &OTHERNASALPREPARATIONS Products listed above may not be mentioned in the disease management chart but have been have but chart management disease the in mentioned be not may above listed Products placed here based on indications listed in regional manufacturers’ product information. product manufacturers’ regional in listed indications on based here placed 0.3% ear drops 0.3% ear & non-elderly adults w/ normal renal & hepatic function unless otherwise stated. otherwise unless function &hepatic renal w/ normal adults & non-elderly 0.05% nasal spray 0.05% nasal .%nslsry1-2sprays each spray 0.1% nasal All dosage recommendations are for non-pregnant & non-breastfeeding women, women, &non-breastfeeding non-pregnant for are recommendations dosage All © MIMS Available Strength Available Strength Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not EAR ANTISEPTICS W/CORTICOSTEROIDS EAR ANTISEPTICS Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing EAR ANTI-INFECTIVES&ANTISEPTICS Otitis Media-Acute(12of13) 6-10 drops12 hrly nostril 12 hrly nostril 2-3 sprays each nostril 6-8 hrly nostril Dosage Guidelines 3-4 drops 6-8 hrly3-4 drops 6-12 hrly4-5 drops 6 hrly4-5 drops 6-12 hrly3-4 drops 12 hrly1-5 drops Dosage Dosage Dosage B12 • Instructions Special • Reactions Adverse • Reactions Adverse • • • Instructions Special • • Reactions Adverse perforated is Use w/caution ifthe drum ear occur can ototoxicity reactions; Hypersensitivity Occasionally taste perversion; pruritus perversion; taste Occasionally injury, prostatic hypertrophy or infection hyperthyroidism, nasal DM, cerebral disease, arteriosclerosis, arterial coronary failure, heart hypertension, Use w/ caution inpatients w/asthma, glaucomanarrow-angle inpatientsContraindicated w/ >3-7 days use forextended Not recommended eff (nausea) ect GI headache); drowsiness, dizziness, eff CNS irregularities); (fever,ects effCV BP, (increase ects cardiac frequently or>3-7 days rebound congestion may occur ifused mucosa; ofnasal dryness sneezing, effLocal Transientects: irritation, Remarks Remarks Remarks © MIMS 2019 OTITIS MEDIA adsorbed) adsorbed) (13-valent, conjugate vaccine polysaccharide Pneumococcal Drug Products listed above may not be mentioned in the disease management chart but have been have but chart management disease the in mentioned be not may above listed Products placed here based on indications listed in regional manufacturers’ product information. product manufacturers’ regional in listed indications on based here placed & non-elderly adults w/ normal renal & hepatic function unless otherwise stated. otherwise unless function &hepatic renal w/ normal adults & non-elderly All dosage recommendations are for non-pregnant & non-breastfeeding women, women, &non-breastfeeding non-pregnant for are recommendations dosage All

© MIMS single dose 0.5 mLIMas Adult >50yr: Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Dosage VACCINES, ANTISERA&IMMUNOLOGICALS Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing Please see the end of this section for reference list. reference for section this of end the see Please Otitis Media-Acute(13of13) Dosage Guidelines • • • • Instructions Special • Reactions Adverse Delay febrile illness vaccination inacute,moderate orsevere notinjDo inthe area gluteal coagulation disorder, impaired immune responsiveness orany Use w/caution inpatients w/thrombocytopenia Avoid todiphtheria inpatients toxoid w/hypersensitivity fever) rash, sleep, restless (drowsiness, eff vomiting);Other eff diarrhea, appetite, (decreased ects ects effLocal induration GI ortenderness); (inj siteerythema, ects B13 Remarks © MIMS 2019