A new way to treat ear infections

A new way to treat ear infections in children called "individualized care" is described in the May 2013 issue of Pediatric Infectious Diseases Journal. It explains how to reduce the frequency of repeated ear infections nearly 500% and how to reduce the need for ear tube surgery by 600% in your practice.

Dr. Janet Casey at Legacy Pediatrics in Rochester, N.Y.; Anthony Almudevar, Ph.D., of the University of Rochester; and I conducted the prospective, longitudinal multiyear study with the support of the National Institutes of Health’s National Institute for Deafness and Communication Disorders and the Thrasher Research Fund (Pediatr. Infect. Dis. J. 2013 Jan. 21 [Epub ahead of print]).

The study compared three groups: children who were in the Legacy Pediatrics practice and received individualized care; control children in the Legacy practice who did not participate because their parents declined participation (they did not want venipunctures or ear taps); and community controls drawn from a different pediatric practice in the suburbs of Rochester that used the diagnostic criteria of the American Academy of Pediatrics and treated all children empirically with high-dose amoxicillin as endorsed by the former and new AAP treatment guidelines (Pediatrics 2013;131:e964-99).

The new treatment paradigm of individualized care included a tympanocentesis procedure, also called an ear tap, to determine precisely the bacteria causing the ear infection. Treatment was started with high-dose amoxicillin/clavulanate. The sample of fluid then was taken to my laboratory at the Rochester General Hospital Research Institute, where the bacteria isolated were tested against a panel of antibiotics to determine whether to continue with amoxicillin/clavulanate or switch to a more effective antibiotic for the child based on culture susceptibility. By doing the ear tap and antibiotic testing, the frequency of repeated ear infections was reduced by 250%, compared with the Legacy practice controls who did not participate, and by 460%, compared with the community controls.

The most common reason for children to receive ear tubes is repeated ear infections, so when the frequency of ear infections was reduced so too was the frequency of ear tube surgery. The new treatment approach resulted in 260% fewer ear tube surgeries in the individualized care group, compared with the Legacy Pediatrics controls, and 620% fewer surgeries than the community controls.

Allowing the child to receive an ear tap was a requirement for the study. Dr. Casey and I found a way to do the procedure painlessly by instilling 8% Novocain in the ear canal as drops to anesthetize the tympanic membrane. After 15 minutes there was no pain when the tap was done. We used a papoose to hold the child still.

The ear-tap procedure not only allowed individualized care with the astonishing results reported, it also allowed more rapid healing of the ear since removal of the pus and bacteria from behind the ear allowed the antibiotics to work better and the immune system to clear the infection more effectively.

The article discusses reasons for the remarkable difference in results with the individualized care approach. First, Dr. Casey and I have undergone special training from ear, nose, and throat (ENT) doctors in the diagnosis of ear infections.

In earlier studies, a group of experts in otitis media diagnosis joined together in a continuing medical education course sponsored by Outcomes Management Education Workshops to use video exams to test whether pediatricians, family physicians, and urgent care physicians knew how to correctly distinguish true acute otitis media (AOM) from otitis media with effusion (OME) and variations of normal in the tympanic membrane exam. We found that all three specialty groups and residents in training in all three specialties and nurse practitioners and physician assistants overdiagnosed AOM about half the time.

Second, the selection of antibiotic proved to be key. Dr. Casey and I have the only otitis media research center in the United States providing tympanocentesis data at the current time. We have found that amoxicillin kills the bacteria causing AOM infections in children in the Rochester area only about 30% of the time. By knowing the bacteria, an evidence-based antibiotic can be chosen.

I expect that readers of this column will believe they diagnose AOM correctly nearly all the time and that it is the other physician who overdiagnoses. I expect that readers will be reluctant to not adhere to the AAP guideline recommendation of using amoxicillin as the treatment of first choice. Most of all, I expect readers to be reluctant to undertake training on how to do the ear tap procedure. Change is always resisted by the majority, and only with time does it occur if the evidence is strong and there is growing adoption.

Nevertheless, I encourage all to find an opportunity to attend a CME course on AOM diagnosis and I hope that resident training programs will incorporate more effective teaching on AOM diagnosis. I recommend high-dose amoxicillin/clavulanate as the treatment of choice for AOM; if it is not tolerated, then one of the preferred cephalosporins endorsed by the AAP guideline should be chosen.

I recommend that resident training programs include tympanocentesis as part of the curriculum. Why are residents taught how to do a spinal tap, arterial artery puncture, and lung tap but not an ear tap? I also recommend that practicing pediatricians gain the skill to perform tympanocentesis as well. I recognize that some just won’t have the hand/eye coordination or steady hand needed, so it’s not for everyone. However, especially in group practices, a few trained providers could become an internal referral resource for getting the procedure done.

Arguments about malpractice are a smokescreen. The risks of tympanocentesis are no greater than venipuncture in trained and skilled hands. It is included as a standard procedure for pediatricians in our state without any additional malpractice insurance costs. And Dr. Casey and I have effectively managed to get the procedure done when a patient needs it without blowing our schedules off the map and raising the ire of patients and staff. It just takes a commitment.

It would be convenient to refer to an ENT doctor for a tympanocentesis, but most ENT doctors have not been trained to do the procedure while the child is awake and prefer to have the child asleep. Also, try to get a child in for an appointment with an ENT with no notice on the same day! Moreover, ENT doctors have been trained that if an ear tap is needed then it is advisable to go ahead and put in an ear tube.

Because of the success of this research, our center received a renewal of support from NIH in 2012 to continue the study through 2017. Several pediatric practices in Rochester are part of the research – Long Pond Pediatrics, Westfall Pediatrics, Sunrise Pediatrics, Lewis Pediatrics, and Pathway Pediatrics – as well as Dr. Margo Benoit of the department of otolaryngology at the University of Rochester and Dr. Frank Salamone and Dr. Kevin Kozara of the Rochester Otolaryngology Group, which is affiliated with Rochester General Hospital.

Dr. Pichichero, a specialist in pediatric infectious diseases, is director of the Rochester (N.Y.) General Hospital Research Institute. He is also a pediatrician at Legacy Pediatrics in Rochester. He said he had no relevant financial conflicts of interest to disclose.

A new way to treat ear infections in children called "individualized care" is described in the May 2013 issue of Pediatric Infectious Diseases Journal. It explains how to reduce the frequency of repeated ear infections nearly 500% and how to reduce the need for ear tube surgery by 600% in your practice.

Dr. Janet Casey at Legacy Pediatrics in Rochester, N.Y.; Anthony Almudevar, Ph.D., of the University of Rochester; and I conducted the prospective, longitudinal multiyear study with the support of the National Institutes of Health’s National Institute for Deafness and Communication Disorders and the Thrasher Research Fund (Pediatr. Infect. Dis. J. 2013 Jan. 21 [Epub ahead of print]).

The study compared three groups: children who were in the Legacy Pediatrics practice and received individualized care; control children in the Legacy practice who did not participate because their parents declined participation (they did not want venipunctures or ear taps); and community controls drawn from a different pediatric practice in the suburbs of Rochester that used the diagnostic criteria of the American Academy of Pediatrics and treated all children empirically with high-dose amoxicillin as endorsed by the former and new AAP treatment guidelines (Pediatrics 2013;131:e964-99).

The new treatment paradigm of individualized care included a tympanocentesis procedure, also called an ear tap, to determine precisely the bacteria causing the ear infection. Treatment was started with high-dose amoxicillin/clavulanate. The sample of fluid then was taken to my laboratory at the Rochester General Hospital Research Institute, where the bacteria isolated were tested against a panel of antibiotics to determine whether to continue with amoxicillin/clavulanate or switch to a more effective antibiotic for the child based on culture susceptibility. By doing the ear tap and antibiotic testing, the frequency of repeated ear infections was reduced by 250%, compared with the Legacy practice controls who did not participate, and by 460%, compared with the community controls.

The most common reason for children to receive ear tubes is repeated ear infections, so when the frequency of ear infections was reduced so too was the frequency of ear tube surgery. The new treatment approach resulted in 260% fewer ear tube surgeries in the individualized care group, compared with the Legacy Pediatrics controls, and 620% fewer surgeries than the community controls.

Allowing the child to receive an ear tap was a requirement for the study. Dr. Casey and I found a way to do the procedure painlessly by instilling 8% Novocain in the ear canal as drops to anesthetize the tympanic membrane. After 15 minutes there was no pain when the tap was done. We used a papoose to hold the child still.

The ear-tap procedure not only allowed individualized care with the astonishing results reported, it also allowed more rapid healing of the ear since removal of the pus and bacteria from behind the ear allowed the antibiotics to work better and the immune system to clear the infection more effectively.

The article discusses reasons for the remarkable difference in results with the individualized care approach. First, Dr. Casey and I have undergone special training from ear, nose, and throat (ENT) doctors in the diagnosis of ear infections.

In earlier studies, a group of experts in otitis media diagnosis joined together in a continuing medical education course sponsored by Outcomes Management Education Workshops to use video exams to test whether pediatricians, family physicians, and urgent care physicians knew how to correctly distinguish true acute otitis media (AOM) from otitis media with effusion (OME) and variations of normal in the tympanic membrane exam. We found that all three specialty groups and residents in training in all three specialties and nurse practitioners and physician assistants overdiagnosed AOM about half the time.

Second, the selection of antibiotic proved to be key. Dr. Casey and I have the only otitis media research center in the United States providing tympanocentesis data at the current time. We have found that amoxicillin kills the bacteria causing AOM infections in children in the Rochester area only about 30% of the time. By knowing the bacteria, an evidence-based antibiotic can be chosen.

I expect that readers of this column will believe they diagnose AOM correctly nearly all the time and that it is the other physician who overdiagnoses. I expect that readers will be reluctant to not adhere to the AAP guideline recommendation of using amoxicillin as the treatment of first choice. Most of all, I expect readers to be reluctant to undertake training on how to do the ear tap procedure. Change is always resisted by the majority, and only with time does it occur if the evidence is strong and there is growing adoption.

Nevertheless, I encourage all to find an opportunity to attend a CME course on AOM diagnosis and I hope that resident training programs will incorporate more effective teaching on AOM diagnosis. I recommend high-dose amoxicillin/clavulanate as the treatment of choice for AOM; if it is not tolerated, then one of the preferred cephalosporins endorsed by the AAP guideline should be chosen.

I recommend that resident training programs include tympanocentesis as part of the curriculum. Why are residents taught how to do a spinal tap, arterial artery puncture, and lung tap but not an ear tap? I also recommend that practicing pediatricians gain the skill to perform tympanocentesis as well. I recognize that some just won’t have the hand/eye coordination or steady hand needed, so it’s not for everyone. However, especially in group practices, a few trained providers could become an internal referral resource for getting the procedure done.

Arguments about malpractice are a smokescreen. The risks of tympanocentesis are no greater than venipuncture in trained and skilled hands. It is included as a standard procedure for pediatricians in our state without any additional malpractice insurance costs. And Dr. Casey and I have effectively managed to get the procedure done when a patient needs it without blowing our schedules off the map and raising the ire of patients and staff. It just takes a commitment.

It would be convenient to refer to an ENT doctor for a tympanocentesis, but most ENT doctors have not been trained to do the procedure while the child is awake and prefer to have the child asleep. Also, try to get a child in for an appointment with an ENT with no notice on the same day! Moreover, ENT doctors have been trained that if an ear tap is needed then it is advisable to go ahead and put in an ear tube.

Because of the success of this research, our center received a renewal of support from NIH in 2012 to continue the study through 2017. Several pediatric practices in Rochester are part of the research – Long Pond Pediatrics, Westfall Pediatrics, Sunrise Pediatrics, Lewis Pediatrics, and Pathway Pediatrics – as well as Dr. Margo Benoit of the department of otolaryngology at the University of Rochester and Dr. Frank Salamone and Dr. Kevin Kozara of the Rochester Otolaryngology Group, which is affiliated with Rochester General Hospital.

Dr. Pichichero, a specialist in pediatric infectious diseases, is director of the Rochester (N.Y.) General Hospital Research Institute. He is also a pediatrician at Legacy Pediatrics in Rochester. He said he had no relevant financial conflicts of interest to disclose.

A new way to treat ear infections in children called "individualized care" is described in the May 2013 issue of Pediatric Infectious Diseases Journal. It explains how to reduce the frequency of repeated ear infections nearly 500% and how to reduce the need for ear tube surgery by 600% in your practice.

Dr. Janet Casey at Legacy Pediatrics in Rochester, N.Y.; Anthony Almudevar, Ph.D., of the University of Rochester; and I conducted the prospective, longitudinal multiyear study with the support of the National Institutes of Health’s National Institute for Deafness and Communication Disorders and the Thrasher Research Fund (Pediatr. Infect. Dis. J. 2013 Jan. 21 [Epub ahead of print]).

The study compared three groups: children who were in the Legacy Pediatrics practice and received individualized care; control children in the Legacy practice who did not participate because their parents declined participation (they did not want venipunctures or ear taps); and community controls drawn from a different pediatric practice in the suburbs of Rochester that used the diagnostic criteria of the American Academy of Pediatrics and treated all children empirically with high-dose amoxicillin as endorsed by the former and new AAP treatment guidelines (Pediatrics 2013;131:e964-99).

The new treatment paradigm of individualized care included a tympanocentesis procedure, also called an ear tap, to determine precisely the bacteria causing the ear infection. Treatment was started with high-dose amoxicillin/clavulanate. The sample of fluid then was taken to my laboratory at the Rochester General Hospital Research Institute, where the bacteria isolated were tested against a panel of antibiotics to determine whether to continue with amoxicillin/clavulanate or switch to a more effective antibiotic for the child based on culture susceptibility. By doing the ear tap and antibiotic testing, the frequency of repeated ear infections was reduced by 250%, compared with the Legacy practice controls who did not participate, and by 460%, compared with the community controls.

The most common reason for children to receive ear tubes is repeated ear infections, so when the frequency of ear infections was reduced so too was the frequency of ear tube surgery. The new treatment approach resulted in 260% fewer ear tube surgeries in the individualized care group, compared with the Legacy Pediatrics controls, and 620% fewer surgeries than the community controls.

Allowing the child to receive an ear tap was a requirement for the study. Dr. Casey and I found a way to do the procedure painlessly by instilling 8% Novocain in the ear canal as drops to anesthetize the tympanic membrane. After 15 minutes there was no pain when the tap was done. We used a papoose to hold the child still.

The ear-tap procedure not only allowed individualized care with the astonishing results reported, it also allowed more rapid healing of the ear since removal of the pus and bacteria from behind the ear allowed the antibiotics to work better and the immune system to clear the infection more effectively.

The article discusses reasons for the remarkable difference in results with the individualized care approach. First, Dr. Casey and I have undergone special training from ear, nose, and throat (ENT) doctors in the diagnosis of ear infections.

In earlier studies, a group of experts in otitis media diagnosis joined together in a continuing medical education course sponsored by Outcomes Management Education Workshops to use video exams to test whether pediatricians, family physicians, and urgent care physicians knew how to correctly distinguish true acute otitis media (AOM) from otitis media with effusion (OME) and variations of normal in the tympanic membrane exam. We found that all three specialty groups and residents in training in all three specialties and nurse practitioners and physician assistants overdiagnosed AOM about half the time.

Second, the selection of antibiotic proved to be key. Dr. Casey and I have the only otitis media research center in the United States providing tympanocentesis data at the current time. We have found that amoxicillin kills the bacteria causing AOM infections in children in the Rochester area only about 30% of the time. By knowing the bacteria, an evidence-based antibiotic can be chosen.

I expect that readers of this column will believe they diagnose AOM correctly nearly all the time and that it is the other physician who overdiagnoses. I expect that readers will be reluctant to not adhere to the AAP guideline recommendation of using amoxicillin as the treatment of first choice. Most of all, I expect readers to be reluctant to undertake training on how to do the ear tap procedure. Change is always resisted by the majority, and only with time does it occur if the evidence is strong and there is growing adoption.

Nevertheless, I encourage all to find an opportunity to attend a CME course on AOM diagnosis and I hope that resident training programs will incorporate more effective teaching on AOM diagnosis. I recommend high-dose amoxicillin/clavulanate as the treatment of choice for AOM; if it is not tolerated, then one of the preferred cephalosporins endorsed by the AAP guideline should be chosen.

I recommend that resident training programs include tympanocentesis as part of the curriculum. Why are residents taught how to do a spinal tap, arterial artery puncture, and lung tap but not an ear tap? I also recommend that practicing pediatricians gain the skill to perform tympanocentesis as well. I recognize that some just won’t have the hand/eye coordination or steady hand needed, so it’s not for everyone. However, especially in group practices, a few trained providers could become an internal referral resource for getting the procedure done.

Arguments about malpractice are a smokescreen. The risks of tympanocentesis are no greater than venipuncture in trained and skilled hands. It is included as a standard procedure for pediatricians in our state without any additional malpractice insurance costs. And Dr. Casey and I have effectively managed to get the procedure done when a patient needs it without blowing our schedules off the map and raising the ire of patients and staff. It just takes a commitment.

It would be convenient to refer to an ENT doctor for a tympanocentesis, but most ENT doctors have not been trained to do the procedure while the child is awake and prefer to have the child asleep. Also, try to get a child in for an appointment with an ENT with no notice on the same day! Moreover, ENT doctors have been trained that if an ear tap is needed then it is advisable to go ahead and put in an ear tube.

Because of the success of this research, our center received a renewal of support from NIH in 2012 to continue the study through 2017. Several pediatric practices in Rochester are part of the research – Long Pond Pediatrics, Westfall Pediatrics, Sunrise Pediatrics, Lewis Pediatrics, and Pathway Pediatrics – as well as Dr. Margo Benoit of the department of otolaryngology at the University of Rochester and Dr. Frank Salamone and Dr. Kevin Kozara of the Rochester Otolaryngology Group, which is affiliated with Rochester General Hospital.

Dr. Pichichero, a specialist in pediatric infectious diseases, is director of the Rochester (N.Y.) General Hospital Research Institute. He is also a pediatrician at Legacy Pediatrics in Rochester. He said he had no relevant financial conflicts of interest to disclose.