NUR 635 Topic 11 DQ 1

Sample Answer for NUR 635 Topic 11 DQ 1 Included After Question

Jack is a 3-year-old male who presents with ear pain and fever for 36 hours. Jack weighs 32 pounds. On visual inspection, you notice middle ear effusion and a budging tympanic membrane. Based on the patient’s presentation, Jack is diagnosed with acute otitis media (AOM). Use the guidelines and relevant literature in your topic Resources to discuss the following: 

  • Describe the diagnostic factors associated acute otitis media (AOM).
  • Briefly describe the bacteria associated with bacterial ear infections. Include which bacteria are associated with the highest prevalence and how these bacteria are classified (e.g., gram-negative, gram-positive, etc.)
  • Explain the factors associated when deciding to use antibiotic therapy versus observation.
  • Determine a treatment strategy for Jack; if choosing a pharmacologic approach include the drug, dose, frequency, and treatment length, and explain your rationale for choosing this medication, including spectrum of coverage and mechanism of action. 
  • Determine monitoring, side effects, and drug-drug interactions associated with each medication.
  • How would you address Jack’s pain associated with AOM?
  • In the event Jack presented with a bacterial eye infection in addition the ear infection, how would change your treatment plan? Explain your rationale.

American Association of Colleges of Nursing Core Competencies for Professional Nursing Education

This assignment aligns to AACN Core Competencies 1.2, 2.2, 2.5. 4.2, 6.4, 9.2

A Sample Answer For the Assignment: NUR 635 Topic 11 DQ 1

Title: NUR 635 Topic 11 DQ 1

Describe the diagnostic factors associated with acute otitis media (AOM).

Acute otitis media (AOM) is infection (bacterial or viral), inflammation, and fluid in the middle ear (Rosenthal & Burchum, 2021).  Diagnostic criteria for AOM include sudden onset of signs and symptoms, middle ear effusion, and middle ear inflammation (Rosenthal & Burchum, 2021).  Signs of a middle ear effusion are a bulging tympanic membrane with little mobility or a ruptured tympanic membrane with purulent drainage (Rosenthal & Burchum, 2021).  Inflammation is indicated by pain and erythema of the tympanic membrane (Rosenthal & Burchum, 2021).  AOM is often preceded by a viral respiratory infection, causing inflammation, swelling, and subsequent eustachian tube blockage (Rosenthal & Burchum, 2021). 

Briefly describe the bacteria associated with bacterial ear infections. Include which bacteria are associated with the highest prevalence and how these bacteria are classified (e.g., gram-negative, gram-positive, etc.)

The most common bacterial causes of AOM are Haemophilus influenzae, Moraxella catarrhalis, and Streptococcus pneumoniae (Rosenthal & Burchum, 2021).  Haemophilus influenzae is the most common cause of bacterial AOM, accounting for 52% of cases (Rosenthal & Burchum, 2021).  Haemophilus influenzae is a gram-negative coccobacillus (Centers for Disease Control and Prevention [CDC], 2022a).  Moraxella catarrhalis is a gram-negative diplococcus commonly found in the respiratory tract (Murphy, 2023).  Moraxella catarrhalis is the second most common cause of AOM (Rosenthal & Burchum, 2021).   Finally, Streptococcus pneumoniae is a gram-positive, lancet-shaped anaerobic bacteria and is the third most common cause of AOM (CDC, 2022b; Rosenthal & Burchum, 2021). 

Explain the factors associated with deciding to use antibiotic therapy versus observation.

Children should not automatically be prescribed antibiotics for AOM.  The patients who should get antibiotics when AOM is suspected or diagnosed with AOM are infants less than six months of age, patients who are immune compromised, and patients with craniofacial abnormalities such as a cleft palate.  AOM symptoms usually resolve in three days with or without antibiotics (Pelton & Tahtinen, 2023).  Similarly, about 80% of AOM cases resolve without treatment within a week (Rosenthal & Burchum, 2021).  When children are diagnosed with AOM, they should be treated for pain if it is present and monitored for 48 to 72 hours with a definitive follow-up appointment (Pelton & Tahtinen, 2023).   

Determine a treatment strategy for Jack; if choosing a pharmacologic approach, include the drug, dose, frequency, and treatment length, and explain your rationale for choosing this medication, including spectrum of coverage and mechanism of action.

Jack’s treatment plan includes initial observation for the first 48-72 hours.  A follow-up appointment will be made two to three days after the initial visit.  Jack’s parents will be instructed to treat his pain with over-the-counter acetaminophen and ibuprofen (see dosages and recommendations below in the following question).  If Jack’s symptoms do not improve by the follow-up appointment, Jack will be prescribed the following antibiotic:

Amoxicillin 45 mg/kg oral suspension by mouth BID for 10 days

Amoxicillin is the first line of therapy due to the common bacterial causes of AOM susceptibility to the drug (Lieberthal et al., 2013).  Amoxicillin is a broad-spectrum penicillin that covers a variety of gram-positive bacteria and some gram-negative coverage (Bobak et al., 2022; Rosenthal & Burchum, 2021).  Amoxicillin covers most streptococcus species (Bobak et al., 2022).  According to the American Academy of Pediatrics (2013), Amoxicillin is the preferred treatment if the patient “has not received amoxicillin in the past 30 days or the child does not have concurrent purulent conjunctivitis or the child is not allergic to penicillin” (p. e980).

Determine monitoring, side effects, and drug-drug interactions associated with each medication.

Amoxicillin

Monitoring: Monitor for a hypersensitivity reaction, including a rash.  If a rash develops, patients can have a skin test to check for a type-I hypersensitivity reaction (Bobak et al., 2022).  The antibiotic class of penicillin is the most common cause of allergic drug reactions (Rosenthal & Burchum, 2021).  Otherwise, laboratory monitoring is not indicated for short-term therapy with amoxicillin (Bobak et al., 2022).   

Side effects: Amoxicillin is usually well tolerated.  However, amoxicillin’s most common side effects are nausea, vomiting, and diarrhea (Bobak et al., 2022; Rosenthal & Burchum, 2021).    

Drug-drug interactions: Amoxicillin use with probenecid may cause increased levels of amoxicillin (Evans et al., 2023).  Oral anticoagulants with amoxicillin may increase bleeding time (Evans et al., 2023).  Finally, the use of amoxicillin with oral contraceptives may decrease the efficacy of the contraceptives (Evans et al., 2023). 

How would you address Jack’s pain associated with AOM?

Jack can be prescribed acetaminophen and ibuprofen on an alternating schedule for pain control.  The recommendation for each medication is as follows:

            Acetaminophen 160 mg PO Q6 hours as needed for pain

            Ibuprofen 100 mg PO Q 6 hours as needed for pain

Giving clear instructions on over-the-counter dosing for weight-based pediatric medications is especially important.  Patient education visual charts show a table of age, weight, and doses for acetaminophen and ibuprofen.  Examples of acetaminophen and ibuprofen dosing from the American Academy of Pediatrics are shown below:

In the event Jack presented with a bacterial eye infection in addition to the ear infection, how would you change your treatment plan? Explain your rationale.

Amoxicillin is the first-line treatment in AOM.  However, the presence of conjunctivitis indicates a more aggressive dual therapy treatment.  According to the American Academy of Pediatrics (2013), “clinicians should prescribe an antibiotic with additional β-lactamase coverage for AOM and… has concurrent purulent conjunctivitis” (p. e980).  The combination therapy includes high-dose amoxicillin-clavulanate at 90 mg/kg/day of amoxicillin and 6.4 mg/kg/day of clavulanate in two divided doses (Lieberthal et al., 2013). 

Jack weighs 32 pounds or 14.5 Kg.  The treatment plan is as follows:

Amoxicillin 45 mg/kg oral suspension PO BID for 10 days

Clavulanate 3.2 mg/kg oral suspension PO BID for 10 days

References

Bobak, A. J., Khanna, N. R., & Vijhani, P. (2022, August 8). Amoxicillin. StatPearls.https://www.ncbi.nlm.nih.gov/books/NBK482250/

Centers for Disease Control and Prevention. (2022a, March 4). Haemophilus influenzae. Centers

for Disease Control and Prevention. https://www.cdc.gov/hi-disease/clinicians.html#:~:text=Haemophilus%20influenzae%20is%20a%20pleomorphic,that%20have%20distinct%20capsular%20polysaccharides.

Centers for Disease Control and Prevention. (2022b, January 27). Streptococcus pneumoniae:

Information for clinicians. Centers for Disease Control and Prevention.

https://www.cdc.gov/pneumococcal/clinicians/streptococcus-pneumoniae.html

Evans, J., Hanoodi, M., & Wittler, M. (2023, August 16). Amoxicillin clavulanate. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK538164/

Lieberthal, A. S., Carroll, A. E., Chonmaitree, T., Ganiats, T. G., Hoberman, A., Jackson, M. A., Joffe, M. D., Miller, D. T., Rosenfeld, R. M., Sevilla, X. D., Schwartz, R. H., Thomas, P. A., & Tunkel, D. E. (2013). The Diagnosis and Management of Acute Otitis Media. Pediatrics (Evanston), 131(3), e964-e999. https://doi.org/10.1542/peds.2012-3488

Murphy, T. (2023, August 9). Moraxella catarrhalis infections. UpToDate. https://www.uptodate.com/contents/moraxella-catarrhalis-infections

Pelton, S. I., & Tahtinen, P. (2023, September 8). Acute otitis media in children: Treatment. UpToDate. https://www.uptodate.com/contents/acute-otitis-media-in-children-treatment

Rosenthal, L. D., & Burchum, J.R. (2021). Lehne’s pharmacotherapeutics for advanced

practice nurses and physician assistants (2nd ed.). Elsevier. ISBN: 9780323554954

A Sample Answer 2 For the Assignment: NUR 635 Topic 11 DQ 1

Title: NUR 635 Topic 11 DQ 1

1. Diagnostic Factors Associated with Acute Otitis Media (AOM):

Acute otitis media is primarily diagnosed based on clinical presentation and otoscopic findings. Jack’s symptoms, including ear pain and fever, align with the typical clinical presentation of AOM. Otoscopic examination reveals a bulging tympanic membrane and middle ear effusion, confirming the diagnosis. The presence of otalgia and the characteristic visual indicators are crucial diagnostic factors (McCance & Huether, 2018).

2. Bacteria Associated with Bacterial Ear Infections:

The bacteria commonly associated with AOM include Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. Streptococcus pneumoniae, a gram-positive bacterium, is particularly prevalent in AOM cases. Haemophilus influenzae can be either gram-negative or gram-positive. Moraxella catarrhalis is a gram-negative bacterium. The classification of bacteria based on Gram staining informs treatment decisions, as antibiotics may have differing efficacies against gram-positive and gram-negative organisms (Brook, 2017).

3. Factors in Choosing Antibiotic Therapy vs. Observation:

The decision to use antibiotics or adopt an observation approach depends on various factors. For Jack, a 3-year-old with ear pain and fever, initiating antibiotic therapy is appropriate. Antibiotics are recommended for younger children with severe symptoms or uncertain diagnoses. The decision involves weighing the benefits of early treatment against the potential risks and considering the patient’s overall health.

4. Treatment Strategy for Jack:

Considering Jack’s age and the common pathogens involved in AOM, amoxicillin is a suitable first-line antibiotic. Amoxicillin covers many bacteria, including Streptococcus pneumoniae and Haemophilus influenzae. The recommended 80-90 mg/kg/day dose in two divided doses ensures adequate coverage. The 5–7-day treatment length is effective in resolving the infection. This choice is based on the drug’s efficacy, safety profile, and the prevalence of the bacteria associated with AOM. Rosenthal, L. D., & Burchum, J. R. (2020)

Monitoring, Side Effects, and Drug-Drug Interactions:

Monitoring: Regular follow-up to assess symptom improvement and ensure resolution.

Side Effects: Monitoring for common side effects like diarrhea and rash is essential. Additionally, vigilance for signs of allergic reactions is crucial.

Drug-Drug Interactions: Amoxicillin generally has limited interactions, but caution is advised when used concurrently with probenecid.

5. Addressing Jack’s Pain:

To alleviate Jack’s pain, analgesics such as acetaminophen or ibuprofen can be administered based on weight and age-appropriate dosing. Topical otic analgesic drops may also provide localized relief.

6. Bacterial Eye Infection in Addition to AOM:

If Jack were to present with a bacterial eye infection alongside AOM, the treatment plan may be adjusted. Topical antibiotics, such as polymyxin-bacitracin, could be added for the eye infection. The choice of systemic antibiotics may be re-evaluated based on the specific bacteria causing both infections. Care coordination between the ear and eye specialists may be necessary for comprehensive management.

American Academy of Pediatrics. (2013). Clinical practice guideline: The diagnosis and management of acute otitis media.

Lieberthal, A. S., et al. (2013). The diagnosis and management of acute otitis media. Pediatrics, 131(3), e964-e999.

McCance, K. L., & Huether, S. E. (2018). Pathophysiology – e-book (8th ed.).

Rosenthal, L. D., & Burchum, J. R. (2020). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants – e-book (2nd ed.). Elsevier Health Sciences.

Brook, I. (2017). Microbiology of acute otitis media in children. The Laryngoscope, 127(11), 2535-2540.