Otitis Media - Acute (1 of 11)

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

2 3 DIAGNOSIS No Is AOM suspected? ALTERNATIVE DIAGNOSIS

Yes

4 No THERAPY Yes Patient should be Observation DECISION treated w/ Is observation antibiotics1 appropriate?

A Non-pharmacological therapy • Parent education • Pain management B Pharmacological therapy A Non-pharmacological therapy • Analgesics • Parent education • Pain management B Pharmacological therapy • Analgesics • C - 1st-line agent: • FOLLOWUP No - Severe illness: Response within 48- • Penicillins w/ beta-lactamase inhibitors 72 hours? - Non-type 1 allergy to : MIMS• (2nd or 3rd generation) - Type 1 allergy to Penicillin Yes • Antibacterial combinations or macrolides

• Follow-up as appropriate • Continue symptomatic treatment, if necessary

FOLLOWUP © See next page 1Consider local epidemiologic resistance patterns

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

B201 © MIMS Pediatrics 2020 OTITIS MEDIA - ACUTE B Pharmacological therapy Pharmacological • D - Antibiotics - - - Failure w/: of1st-line therapy Severe illness or failure of high dose Amoxicillin/: Amoxicillin/clavulanic dose ofhigh orfailure illness Severe unresponsive tootheragents: unresponsive Type Spneumoniae toPenicillin &Penicillin-resistant 1allergy Type toPenicillin: 1allergy Consider expert referral Considerexpert • • • • • • • • • causes ofillness causes Confi AOM &excluderm other resistance patterns epidemiologic Consider local - Surgery specialist disease Pediatric infectious Penicillins w/ beta-lactamase inhibitor Penicillins w/beta-lactamase (3rd generation) Cephalosporin Advanced macrolide Clindamycin)Advanced (Azithromycin, Lincosamide Lincosamide Lincosamide - Middle ear fl Middleear uid culture &gram - Tympanocentesis - staining REASSESS PATIENTREASSESS E within 48- within 72 hours? 72 hours? Response Response Prevention © 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 No Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing PATIENT TREATED AOM FOR W/ ANTIBIOTICS Otitis Media-Acute(2of11) No Yes B202 MIMS within 48- within 72 hours? Response Response B Pharmacological therapy Pharmacological • Duration ofantibioticDuration therapy Yes E © MIMS Pediatrics 2020 Prevention OTITIS MEDIA - ACUTE • • • • • Factors Risk • Etiology • • • • • Pain Assessment • • Infl Ear &Symptoms ofMiddle Signs ammation • • ofMEE Presence Exam Physical • &Symptoms Signs • • • • History • • confi is Diagnosis ofthefollowing: w/thepresence rmed • Exposure to family members w/ history of AOM or respiratory infections ofAOM orrespiratory w/history members tofamily Exposure Excessive pacifier use Daycare attendance Male Age <2years catarrhalis Haemophilus by pneumoniae isthe infl common most ofAOM followed cause Moraxella uenzae, More common 6to24months inchildren ofage between oftheAccompanied tympanic bulging membrane orotorrhea moderate tosevere by Defi the presence as ofinflned anacuteinfection by ammation inthe which caused may middleear be Children old:Numeric scale ≥8years - Children old:Wong-Baker >3years score - - painscores include:Recommended onchild’sDepends cognitive, &relational behavioral development or activity is apparentOtalgia noticeable by of the discomfort that interference ears causes sleep normal w/ or prevents Apparent ofthe tympanic membrane erythema Air-fl the behind tympanic membrane orairbubbles uid level - Otorrhea - Opacifi oftympanic membrane cation, ordistinctredness cloudiness - tympanic membrane retracted Markedly - landmarks tympanic ofnormal membrane w/loss Bulging - of AOM) predictor mobilityoftympanic membrane Absent (best orlimited - any by of the isindicated Presence following: ofMEE tympanometry confi be can MEE ofthe w/or without pneumatic tympanic otoscopy membrane by visualization direct by rmed - Usually nonspecifi inaninfant), irritability, (pullingofear c &include otalgia fever w/orwithout otorrhea Viral URTI AOM present may orduring before symptoms be palsy Patient or6th cranialnerve may nerve present w/facial also sleep restless fever, otorrhea, irritability,Patient Otalgia, of1ormore ofthe of sudden following: onset may have history ofthe predictor presence ofAOM aloneisapoor History membrane AND Mild tympanic membrane bulging acuteotitisexternal by notcaused otorrhea onset ORnew tympanic membrane bulging Moderate tosevere duration is<3weeks Acute onset - infl ofmiddleear &symptoms &signs (MEE) ammation confi &symptoms, ofsigns ofacuteonset a history ofAOM requires Diagnosis effrmation ofmiddleear usion tion: Face, Legs, Activity, Cry, Consolability (FLACC) pain assessment tool tool painassessment Activity,tion: Face, Cry, Legs, (FLACC) Consolability &nonverbalInfants children ofage w/motororcognitive <3years disorders orthose involving painpercep- stuffi ness) (URTI) tract infection presentSymptoms (eg may be respiratory cough, also of upper discharge nasal or © AStreptococci &group (GAS) 1 ACUTE OTITIS MEDIA (AOM) MEDIA OTITIS ACUTE Otitis Media-Acute(3of11) <48 ofthe tympanic erythema orsevere ofotalgia hours onset 2 DIAGNOSIS

B203 MIMS • • • • Low socioeconomic status socioeconomic Low Supine bottle feeding totobaccoExposure smoke&airpollution breastfeeding oforlimited Lack © MIMS Pediatrics 2020 OTITIS MEDIA - ACUTE • • Treated Previously w/Antibiotics Patients Whohave been • Follow-up) (Ensure Initially Patient Observed WhoMay be • • • • • • • • TreatedPatients WhoShouldbe w/Antibiotics Initially • • • Media Otitis Suppurative Chronic • Myringitis • w/Eff Media Otitis (OME) usion • • • Analgesics Symptomatic  erapy • Pain Management • • • Parent Education Shift tootherShift antibiotics ifchild’s 48-72hoursoftreatment within isunresponsive ordisease worsen symptoms coverage beta-lactamase antibiotics given w/ toAmoxicillin, shouldbe ofrecurrent AOM unresponsive conjunctivitis orw/ahistory 30 w/Amoxicillin the within treated last Children previously w/concurrentdays purulent ORdiagnosed (nootorrhea) illness old, w/ unilateralyears or bilateral uncomplicated AOM, w/ confi≥2 & presenting w/ non-severe diagnosis, rmed Recurrent AOM <39°C) hours & fever for <48 (mild otalgia old, w/ unilateral illness years or bilateral≥2 AOM, w/ non-severe bilateral AOM oldw/severe >2 years nootorrhea <39°C), 6-23 for<48 monthshours &fever (mildotalgia illness old,w/unilateral AOM, &presenting w/non-severe nootorrhea 6-23 months <39°C, old,w/bilateral for<48hours&fever AOM, presenting w/mildotalgia ≥6 months old,w/AOM, w/otorrhea ≥39°C(102.2°F) for>48hoursoriffever isconsidered ismoderate tosevere illness ifotalgia Severe - ≥6 months old,w/either unilateral orbilateral illness AOM, presenting w/severe symptoms <6 months ifw/mild,moderate or severe old,w/AOM, regardless period theduring observation tothedays ifpatient’s given may guardian oranytime An be prescription 2-3 within worsen symptoms - antibiotic without therapy w/observation treated may be certainty, onthe diagnostic Depending patients patient’s selected &assurance offollow-up, age, severity illness Persistent infl tympanic membrane &drainage of exudate w/perforated for>6weeks ammation associated Infl URTI w/viral ammation ofthe tympanic membrane usuallyassociated ofacuteinflsigns ammation Typically ifthere eff ismiddleear diagnosed without orabnormal tympanometry usion onpneumatic otoscopy Eff formild-moderate pain analgesia ective theConsidered mainstay ofpainrelief forAOM Eg Paracetamol (Acetaminophen), Ibuprofen Application orcold compress ofwarm onthe aff pain may ear help alleviate ected (eg sideeff the risks Review antibiotic resistance inthe community)ects, inthe fi especially forantibacterial agents, ofthe need regardless addressed Pain must be hours ofillness rst 24 parent/caregiver onpreventable factors Advise risk © antimicrobial therapy Placebo-controlled that have patients trials shown most improve consequences adverse without without 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 3 Otitis Media-Acute(4of11) ALTERNATIVE DIAGNOSIS 4 THERAPY DECISION

B204 MIMS © MIMS Pediatrics 2020 OTITIS MEDIA - ACUTE • presentation &uncomplicated illness old,mild-moderate Patient ≥6years • presentation &uncomplicated illness old,mild-moderate Patient 2-5years • presentation orcomplicated illness old,severe Patient <2years • ofAntibiotic Duration erapy • • • • Macrolides • Co-trimoxazole • • • • Clindamycin • • • (2nd&3rdGeneration) Cephalosporins • • • (IV/IM) Ceftriaxone • • Amoxicillin/ • • dose) (High acid Amoxicillin/clavulanic • • • • Amoxicillin Amoxicillin/High-dose Antibiotic erapy • • Topical Agents Symptomatic  (Cont’d) erapy Continue antibiotics x5-7days Continue antibiotics x7days Continue antibiotics x10days severity disease duration ofantimicrobialOptimal therapy inAOM patients onpatient’s isuncertain; shoulddepend age & Co-trimoxazole over preferred may resistance be patterns, onlocal Depending checked resistance shouldbe Drug topneumococcus - effiLess Spneumoniae against &Hinflcacy compared toPenicillinuenzae antibiotic toadvanced therapy toPenicillin Iallergy topatients refractory given &those May w/type be Eg Clarithromycin, Azithromycin, Erythromycin toPenicillin 1allergy considered may inpatients be w/type Co-trimoxazole suspected Clindamycin H infl isnotactiveagainst organisms are ifthese used &shouldnotbe orM catarrhalis 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 antibiotic toadvanced therapy toPenicillin Iallergy topatients refractory given &those May w/type be  toPenicillin reaction 1hypersensitivity agents considered ese may inpatients be w/non-type , toPenicillins are cross-reactivity highlyunlikely & todevelop resistant drug against Spneumoniae, Hinfl &Mcatarrhalis uenzae Cefdinir, Cefi are & Cefuroxime the of their preferred agents eff because Cefpodoxime, xime, ectiveness effi superior Has toSpneumoniae compared w/alternative oralantibioticscacy toPenicillin Iallergy w/type those Treatment x3 inpatients recommended days Amoxicillin/clavulanic isalso acidtherapy whohave failed & consideredMay inpatients be unable totakeoralmedications fortreatmentIndicated resistant orcephalosporins tosingletherapy ofinfections w/beta-lactam Eff strains(eg bacterial producing Spneumoniae, Hinfl beta-lactamase against ective & Mcatarrhalis) uenzae alongw/Penicillin-resistant/nonsusceptiblecatarrhalis) Spneumoniae ©  organisms is combination producing (eg coverage provide will for beta-lactamase Amoxicillin orrecurrent therapy illness whopresent orinthose w/severe ofAmoxicillin combined acidare w/Clavulanic forpatients recommended standard High doses whofail where Penicillin-resistantIn areas given are pneumococci common, Amoxicillin shouldbe high-dose pneumococci ofthe most pathogens against Effective ofAOM including &intermediate-resistant susceptible toPenicillins ofallergy concurrent Childshouldbe history purulent &without conjunctivitis-free - administration ofAmoxicillin ofantibiotic intake 30 patients the within last history without forpediatric Recommended todays prior Amoxicillin at suffi isstillconsideredcient the 1st-line doses agent forAOM relief inpatients old temporary May >5years provide Procaine Lidocaine, Eg Benzocaine, 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(5of11)

B205 MIMS © MIMS Pediatrics 2020 H inflH uenzae & M OTITIS MEDIA - ACUTE • • • • • Follow-up forPatients Treated w/Antibiotics • • • • Observation by Managed forPatients Initially Follow-up Strategies • • • • • • • • • placement: tube fortympanostomy Consider referral • • • • • • occurs: any if ofthefollowing specialist disease infectious topediatric Consider referral - Refer to otolaryngologist if hearing loss persists loss ifhearing Refer tootolaryngologist - ifeff performed shouldbe test Hearing usion ispresent 3months post-AOM Persistence isnotanindication forcontinued ofMEE treatment orforanother course ofantibiotics forupto1-3months ifthere cure persists even isbacteriologic can MEE diagnosis after isdone4-8weeks It exam that isrecommended follow-up patients of asymptomatic atFollow-up exam the completion oftreatment isnotnecessary 48-72 hours notimprove within orworsens does only if illness w/directions antibioticUse ofprovisional prescription appointment in48-72hours follow-up Scheduled clinic from topatient call initialvisit 48-72hoursafter Routine follow-up 48-72 hours toclinic condition ortelephone ifworsening call visit ornoimprovementParent at follow-up initiated appropriateClinicians shoulddetermine follow-up ≥4 episodes in a year inayear ≥4 episodes Tympanostomy placement tube 6months ofAOM within considered inchildren or shouldbe w/≥3episodes &Levofl antibiotics include Recommended Amoxicillin/clavulanic acid,Ceftriaxone, oxacin - Prophylactic antibiotic forthe isrecommended prevention ofrecurrent use AOM 6months inthe past w/1 episode inayear 6months ofAOM within or≥4episodes episodes ≥3separate - of therapy forAOM Defi the presence as &infl oftympanic membrane bulging ned ammation completion ofthe after middleear of acute&recurrent AOM Furtherto effprove studies are needed alcohol) sugar in prevention polyol of birch (5-carbon sugar ectiveness - Annual infl vaccine forallchildrenuenza isrecommended ≥6months ofage for the prevention ofAOM - - conjugate Pneumococcal otitismedia pneumococcal vaccine may help inpreventing vaccine-serotype &tobaccoinfections pacifi smoke,&reducing 6months after er use ofage may help prevent AOM w/respiratory topersons exposure avoiding 4-6supinebottlemonths, feeding, for at least Breastfeeding fortympanostomy referred placement tube should be months, 6 inthe last w/1episode year 1 within or4episodes months, 6 ofAOM within Patients w/3episodes orlanguage delay Speech Complications ofAOM outsignifi tympanic membrane (rule Retracted cant likecholesteatoma) pathology in12months ≥4episodes in6months; ≥3 episodes w/eff media Otitis for≥3monthsusion (OME) ≥20dB loss w/bilateral hearing Tympanocentesis stain&culture w/Gram isrecommended - to2nd-lineagents If noresponse ©infl initialdose vaccineuenza forthe after yearly 1sttime,then 1dose receiving tochildrenmonths administered years shouldbe 6 to8 Two interval a4-week by separated doses immunization primary months ofage at for given 12-15 dose w/booster intervals at given 4-week series a3-dose as Recommended S pneumoniae rate & incidence carrier by rate of AOM caused decreased significantly use Introduction of PCV7 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 Otitis Media-Acute(6of11) D R EXPERT REFERRAL E C ECURRENT AOM PREVENTION FOLLOW-UP

B206 MIMS © MIMS Pediatrics 2020 OTITIS MEDIA - ACUTE (TM)] (TM)] Trimethoprim & (SMZ) [ Co-trimoxazole sulfi soxazole) (Erythromycin/ sulfafurazole Erythromycin/ Sulfamethoxazole Drug All dosage recommendations are for children w/ normal renal & hepatic function unless otherwise stated. otherwise unless function &hepatic renal w/ normal children for are recommendations dosage All Products listed above may not be mentioned in the disease management chart but have been 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

© Sulfafurazole/day &6g Erythromycin/day 2g dose: Max onErythromycin based 6-8hrly divided PO ≥2 mth:40-50mg/kg/day onTM 12 hrly based divided 8 mg/kg/day PO 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 ANTIBACTERIAL COMBINATIONS Otitis Media-Acute(7of11) Dosage Guidelines • • • Instructions Special • • • • Reactions Adverse • • • • Instructions Special • • Reactions Adverse

B207 MIMS function Use w/ caution inpatients w/impaired renal orhepatic age of &inpatients <2mth orErythromycin to sulfonamides allergic inpatients reactions Contraindicated w/severe distress gastric todecrease May takew/food macrolides some w/ have loss occurred tinnitus/hearing Dose-related Rarely cardiotoxicity, hepatotoxicity, hematologic effects syndrome) (eg Stevens-Johnson to severe/life-threatening range mild(eg from can reactions rash) Hypersensitivity diarrhea/); antibiotic-associated GI disturbances, GI eff (N/V,ects &other diarrhea discomfort, abdominal impairment hepatic dysfunction orsevere Use w/caution inpatients w/G6PDdeficiency, renal folinate)administration ofCa due tofolicaciddefi (may considerciency anemia megaloblastic disorders especially hematological Use w/extreme caution ornotat allinpatients w/ sulfonamide allergy in patientsContraindicated <2mth ofage &patients w/ Maintain adequate fluid intake eff renal effects, occurred has meningitis Aseptic ects; Rarely hepatic orw/highdoses; forlongperiods if given Rarely hematologic eff which more may common be ects GU eff inthe urine) (crystallization ect necrolysis); toxic epidermal syndrome, Stevens-Johnson (eg mild(eg tosevere/life-threatening from rash) range can reactions Hypersensitivity photosensitivity); effstomatitis); Dermatologic pruritus, (rash, ects glossitis, diarrhea/colitis, antibiotic-associated GI eff (N/V,ects rarely diarrhea, anorexia, Other effOther (candidal ect infections) Remarks © MIMS Pediatrics 2020 OTITIS MEDIA - ACUTE Generation Second Ceftriaxone 50-100 mg/kg/day IM/IV 24hrly x1-3 days 50-100mg/kg/day IM/IV 24hrly 9mg/kg/day PO Ceftriaxone 12hrly 24hrly 8-10mg/kg/day ordivided PO Cefpodoxime Cefi xime Cefdinir 12hrly 20-30mg/kg/day divided  Generation ird Cefuroxime Cefprozil Drug All dosage recommendations are for children w/ normal renal & hepatic function unless otherwise stated. otherwise unless function &hepatic renal w/ normal children for are recommendations dosage All Products listed above may not be mentioned in the disease management chart but have been 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

© 1g/day dose: Max drug-resistant Spneumoniae 3 days treatment ismore eff against ective 400mg/day dose: Max 400mg/day dose: Max 12hrly divided 6-12 mg/kg/day PO 600mg/day dose: Max 12hrly 24hrly14 mg/kg/day ordivided PO 500mg/day dose: Max 1g/day dose: Max 12hrly 15mg/kgPO 6 mth-12yr: hrly IM/IVdivided6-8 mg/kg/day 40-80 1g/day dose: Max hrly POdivided8-12 mg/kg/day 20-40 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 Otitis Media-Acute(8of11) Dosage Guidelines Dosage CEPHALOSPORINS

B208 MIMS • • • • Instructions Special • • • Reactions Adverse colitis of w/history especially disease patients w/renal impairment &GI & chance sensitivity; ofcross to Penicillin, there 10% may be Use w/caution inpatients allergic soln Ca-containing w/IV of Ceftriaxone Avoid administration simultaneous neonates hyperbilirubinemic iscontraindicated in Ceftriaxone distress gastric todecrease taken w/food May be renal effects hepatic & Rarely hematologic, convulsions) CNS effects (encephalopathy, High dosesmaybeassociatedw/ hematuria, inj siteinflammation) (candidal infections,, diarrhea/colitis); Other effects antibiotic-associated rarely occur); GIeff N/V, (diarrhea, ects can anaphylaxis eg reactions severe rash, pruritus, (urticaria, reactions Hypersensitivity Remarks © MIMS Pediatrics 2020 OTITIS MEDIA - ACUTE Erythromycin 30-50 mg/kg/day PO divided 6hrly divided 30-50mg/kg/day PO Erythromycin Josamycin Clarithromycin 15 mg/kg/day PO divided 12hrly divided 15mg/kg/day PO Clarithromycin 24hrly 10mg/kg/day x3days PO Azithromycin 8-12hrly divided 1.5MIU/10kg/day PO Macrolides Advanced 12hrly divided 5-8mg/kg/day PO Spiramycin 4-6x/day divided 25-50mg/kg/day PO Roxithromycin Midecamycin Kitasamycin Drug All dosage recommendations are for children w/ normal renal & hepatic function unless otherwise stated. otherwise unless function &hepatic renal w/ normal children for are recommendations dosage All Products listed above may not be mentioned in the disease management chart but have been 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

© 1g/day dose: Max 24hrly onday250 mgPO 2-5 24hrly onday500 mgPO 1,then or 24hrly x3-days 500mgPO ≥16 yr: x 4days once 5mg/kg/day by daily PO followed 24hrly10 mg/kg/day x1day PO 6-8hrly divided 50 mg/kg/day PO hrly POdivided6-8 mg/kg/day 20-40 6-8hrly divided 30 mg/kg/day PO 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 Otitis Media-Acute(9of11) Dosage Dosage Guidelines MACROLIDES

B209 MIMS • • • • Instructions Special • • • • • • Reactions Adverse metabolized via cytochrome P450system cytochrome via metabolized significant interactions w/drugs &ClarithromycinErythromycin have hypersensitivity in patientsContraindicated w/known dysfunction Use w/caution inpatients w/hepatic distress gastric todecrease May take w/ food discoloration, dysgeusia Clarithromycin may &tongue tooth cause Erythromycin GIdisturbances less cause than &ClarithromycinAzithromycin tend to macrolides w/some occurred have loss tinnitus/hearing Dose-related Rarely cardiotoxicity, hepatotoxicity anaphylaxis) rarely rash, pruritus, (urticaria, are reactions uncommon Hypersensitivity headache) infections, Otherstenosis); eff (candidal ects pyloric stomatitis, infantilehypertrophic diarrhea/colitis, antibiotic-associated &other diarrhea GIdisturbances, GI eff (N/V,ects discomfort, abdominal Remarks © MIMS Pediatrics 2020 OTITIS MEDIA - ACUTE (Amoxycillin) Amoxicillin Inhibitors Beta-lactamase w/ orwithout sulbactam)] 6-8hrly divided 50-100mg/kg/day PO ( & [ sulbactam Ampicillin/ Ampicillin sulbactam Amoxicillin/ clavulanic acid)] (amoxicillin & [Co-amoxiclav clavulanic acid Amoxicillin/ lnayi 20-30mg/kg/ Clindamycin Lincosamide Drug Drug All dosage recommendations are for children w/ normal renal & hepatic function unless otherwise stated. otherwise unless function &hepatic renal w/ normal children for are recommendations dosage All Products listed above may not be mentioned in the disease management chart but have been 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 25-50 mg/kg/day PO divided 12hrly divided 25-50mg/kg/day<30 kg: PO 4gSulbactam/8 gAmoxicillin 24hrly dose: Max infections to150mg/kg/day forsevere increased May be 8hrly infusion IV 60-150mg/kg/day ≤40kg: IV/ orolderweighing 1 yr Inj 5mL8hrly or7.5mL12hrly infant: &nursing <2 yr 2-6yr: Childn 10-20mL8-12hrly >20kg: Childn Susp 8hrly 500mgPO ≥12yr: Childn Tab FC 2g/day dose: Max 12hrly divided 6.4 mg/kg/day PO isgiven 90 mg/kg/day Amoxicillin &clavulanic acid Add Amoxicillin 40-45mg/kg/day that dose: so High Amoxicillin on 8-12hrly based divided 40-45 mg/kg/day PO 8hrly divided 80-90mg/kg/day PO dose: High 8-12hrly divided 40-45 mg/kg/day PO © 6 hrly divided day PO 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 40-100mg/kg/day 8-12hrly Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing 10 mL8hrly Otitis Media-Acute(10of11) Dosage Guidelines • • • • Instructions Special • • Reactions Adverse OTHER ANTIBIOTIC Dosage Discontinue occurs ifdiarrhea syndrome w/gasping associated been this has as in neonates Use Clindamycin-containing w/caution benzoate products sodium impairment Use w/caution inatopic patients &inpatients w/renal or hepatic colitis of w/history especially Use w/ caution inpatients w/GIdisease eff Other eff have occurred; ects (polyarthritis) ect dermatitis);exfoliative Hematologic &vesiculobullous &hepatic eff dermatologic Severe multiforme, (erythema have occurred ects rarely anaphylaxis) urticaria, (rash, reactions N/V,colitis, Hypersensitivity taste); pain,metallic abdominal GI eff antibiotic-related severe pseudomembranous (diarrhea, ects PENICILLINS

B210 MIMS Remarks • • Instructions Special • • • Reactions Adverse w/ renal impairment Use w/caution inpatients Penicillin allergy Avoid in patients w/ convulsions) (encephalopathy, eff w/CNS associated ects may be High doses occurred renal &hepatic eff have ects Rarely hematologic eff ects; fever) infections, eff (candidal ects diarrhea/colitis); Other antibiotic-associated rarely eff N/V, (diarrhea, ects occur); GI can anaphylaxis eg reactions severe pruritus, urticaria, (rash, reactions Hypersensitivity © MIMS Pediatrics 2020 Remarks OTITIS MEDIA - ACUTE 1 (PCV13)] 13-valent conjugate vaccine, polysaccharide [Pneumococcal pneumococcal Vaccine, (PCV10)] 10-valent conjugate vaccine, polysaccharide [Pneumococcal pneumococcal Vaccine, May be given as early as 6wkold as early as given May be Drug All dosage recommendations are for children w/ normal renal & hepatic function unless otherwise stated. otherwise unless function &hepatic renal w/ normal children for are recommendations dosage All Products listed above may not be mentioned in the disease management chart but have been 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 beginning at 2mth beginning at 2mth 3doses intervals series: primary 3-dose Infant IM 0.5 mL/dose least 2mthleast apart at 2doses 1-5yr,Children vaccinated: previously least 2mthapart at 12-23 mth,previouslyunvaccinated:2doses least 2mthinterval 1 mthapartfollowedby3rddoseinthe2ndyrw/at given 7-11 mth,previouslyunvaccinated:1st2doses series primary 3-dose sameas dose at 2mth,1st dose 2mth 2nddose booster later; series: primary 2-dose 12th &preferably &15th mth dose between primary 6mth the at given last least after dose Booster 3 doses at 2 mth intervals beginning at 2mth at beginning 2mth3 doses intervals series: primary 3-dose 0.5 mL/doseIM © at Mayany switch inthe point vaccine: schedule 7-valent w/pneumococcal vaccinated Previously &children Infant Single2-17 yr, dose unvaccinated: previously 2mth at the least from 1stdose 1 dose w/PCV13: 24-71 mth, vaccinated incompletely 2mth at least apart <12mth: 2doses of PCV13 w/2-3doses 12-23 mth, vaccinated incompletely 2mth at least apart <12mth: 2doses PCV13 of w/1dose 12-23 mth, vaccinated incompletely 2 mth apart at least 2doses unvaccinated: 12-23 mth,previously Children 2mth 2nddose atthe least after 2ndyr in 3rd 1mth dose by atgiven least apart followed 1st2doses unvaccinated: 7-11 mth,previously 11-15mth ofage between dose Booster 2 mth later at 2mth, 1stdose 2nddose series: primary 2-dose 12-15mth ofage between dose Booster 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 Please see the end of this section for the reference list. reference the for section this of end the see Please Otitis Media-Acute(11of11) Dosage Guidelines 1 of age of Dosage VACCINES

B211 MIMS 1 of age of • • • • Special Instructions • Adverse Reactions immunosuppressive treatment in patientson immunodeficient patientsor Use w/cautionin w/ acuteseverefebrileillness Defer vaccinationforpatients component hypersensitivity toanyvaccine Contraindicated inpatientsw/ AdministerSCinpatients - muscle ofupperarm aspect ofthighordeltoid Administer inanterolateral fever, lossofappetite Inj sitereactions,irritability, bleeding disorder w/ thrombocytopeniaor Remarks © MIMS Pediatrics 2020