Acute otitis media or AOM is one of the most common infections encountered by children, parents, guardians, school administrators, and health care workers such as physicians and nurses (American Academy of Pediatrics, 2004 p.1451). It is also one of the most common ear infection for which antibacterial agents are prescribed (American Academy of Pediatrics, 2004, p.1451). In fact, in 1996 alone there were approximately 24 million prescriptions for antibiotic suspensions written for treatment of AOM (McCracken, 1998, p.576). AOM is a disruptive medical condition and its symptoms include fever, pain, decreased appetite, effusion and inflammation (Kelley, Friedman, & Johnson, 2007, p.460). Aside from the therapeutic considerations associated with AOM, another major concern is the antibiotic resistance of some bacterial pathogens. In the context of nursing care, it is important to recognize appropriate sources of evidence and use it to improve nursing practice.
Types of Sources of Evidence
There are three major types of evidence taken from research and these are:
- primary research evidence;
- evidence summary;
- evidence-based guidelines.
Primary research evidence is a type of evidence gleaned from primary research such as experiments conducted by research professionals. Evidence summary is a type of evidence taken from primary research and as the name suggests is a summary of information taken from after research findings had been evaluated for accuracy and reliability. Finally, evidence-based guidelines are guidelines for health care practice created from information taken from the results of primary evidence or evidence summary.
In this particular study there are four sources that will be evaluated. The proponent of this study will classify these sources in order to determine its appropriateness when it comes to the development of improved nursing practices. The first resource is an article from the American Academy of Pediatrics and it is an evidence-based guideline. The second resource that will be evaluated is an article prepared Stan Block entitled Causative Pathogens, Antibiotic Resistance and Therapeutic Considerations in Acute otitis media. This one is an example of evidence summary because there was no experiment that was conducted and no primary research was accomplished. For example, Block cited data taken from the Pittsburgh Otitis Media Research Center (Block, 1997).
The third resource that will be evaluated is an article prepared by George McCracken entitled Treatment of Acute Otitis Media in an Era of Increasing Microbial Resistance. This resource is another example of evidence summary. McCracken collated the research results from experiments conducted between 1970 and 1993. The fourth evidence that will be evaluated is an article prepared by Kelley, Friedman and Johnson. This resource is another example of evidence summary particularly with regards to the etiology and pathophysiology of AOM.
Appropriateness of sources of Evidence
The sources mentioned can be considered as appropriate for this particular nursing situation. The evidence-based guideline from American Academy of Pediatrics is appropriate because it is a helpful tool when it comes to the development of clinical practice guideline on the management of AOM. For example, it provides recommendations when it comes to the accurate diagnosis of AOM and suggests that the clinician should confirm “a history of acute onset, identify signs of middle-ear effusion, and evaluate for the presence of signs and symptoms of middle-ear inflammation” (American Academy of Pediatrics, 2004, 1452). Therefore, nursing practitioners are made aware of the necessary steps needed to arrive at an accurate diagnosis of AOM.
The appropriateness of McCracken’s article can be appreciated as a source of knowledge when it comes to the selection of an antibiotic regimen for AOM treatment. Although the majority of the information contained therein is for the use of a physician, a nursing practitioner can use the same information in order to be familiar with treatment strategies, particularly those that pertain to the use of antimicrobial therapy.
The same thing can be said about the appropriateness of the article written by Kelley, Friedman and Johnson. The article is also another source of knowledge with regards to the selection of antibiotic regimen for AOM; however, it also contains other helpful information that can help nurses. The said article provides helpful information when it comes to examination techniques and procedures. Once again, most of the information found in this article was written with the physician in mind; however, the nursing practitioner can use the same information in order to learn more about AOM. Thus, the nurse can assist the physician more effectively and efficiently.
Stan Block’s article is appropriate because it does not only provide relevant information when it comes to AOM as a common pediatric infection, the article also sheds light on the increase in the prevalence of antibiotic resistant microbes that causes AOM. Although physicians must be aware of the implications of the medical findings highlighted in this article, a nursing practitioner can also benefit from studying this resource. It can be argued that a nurse familiar with the information in this article can be more effective when it comes to dealing with AOM.
The evidence-based guideline from American Academy of Pediatrics provides a compelling argument that watchful waiting is an appropriate approach when it comes to the treatment and management of AOM. However, the same article issues a warning that watchful waiting must used on limited basis and used only if the patient is healthy and between the age of 6 months to 2 years (American Academy of Pediatrics, 2004, p.1452). This article also stated that watchful waiting can only be used if there is no clear diagnosis and if there were no severe symptoms.
The evidence summary from the article written by McCracken suggested that watchful waiting is a prudent choice considering that “about 60% of children with acute otitis media will have spontaneous resolution of infection” (McCracken, 1998, p.580). In this article watchful waiting is also justified due to the increasing microbial resistance of the pathogen.
The article written by Kelley, Friedman, and Johnson also supports the use of watchful waiting as one of the key management strategies for AOM. The authors said that there are times when AOM was over-diagnosed. The authors said that chronic otitis media with effusion is sometimes mistaken for acute otitis media. The authors also clarified that there is pressure from parents to relieve the pain. But watchful waiting is important because it prevents the misuse of antibiotics. But before this rule can be implemented, physicians will continue to use antibiotic treatment even if diagnosis is not yet certain. As a result the wrong diagnosis of AOM and the frequent use of antibacterial treatment have created drug resistance.
The same argument can be seen in the article prepared by Stan Block. There is mounting evidence when it comes to the connection between misdiagnosis, the immediate application of antibacterial treatment and the drug resistance. Therefore, Stan Block’s article advocates watchful waiting as a more effective strategy to deal with AOM.
Application of Findings
Based on information supplied from the articles and the insights that can be gleaned from reading the same it can be argued that watchful waiting as well as the use of antimicrobial treatment strategies are two of the most important techniques in the treatment and management of AOM. Thus, it is important to fully understand the pathophysiology of AOM in order to prevent misdiagnosis and the use of antibacterial treatment.
Watchful waiting is effective if the nursing practitioner is able to differentiate between the symptoms of AOM and the symptoms due to fever and other medical problems that have nothing to do with AOM. Watchful waiting can only be utilized if parents are made aware of the benefits of the said practice. If parents and guardians are not made aware of the importance of watchful waiting, then, they will exert pressure so that health workers will do something to relieve the symptoms even if diagnosis is still not certain.
The application of insights gleaned from evidence-based research can cause conflict with clinicians and parents or guardians. It has to be pointed out that certain healthcare facility and most physicians follow the idea that the preference of parents and legal guardians must be considered in the treatment of a child. Since AOM usually affects children it is important to consider the fact that parents and guardians are aware of the medical condition called AOM and other forms of ear infection. Thus, they may demand for the application of antibacterial treatment even if there is still no clear diagnosis. This is an example of an ethical issue that can arise as a result of the conflict between the beliefs of parents and recent findings based on research.
The treatment and management of AOM is made difficult by the fact that vulnerable populations involve infants and children. Thus, it is difficult to have an accurate diagnosis. For example, fever can cause inflammation and it can be mistaken as a symptom of for AOM. Another difficulty is the fact that parents wanted to provide instant relief for their child. As a result it is a challenge to institute watchful waiting.
Aside from the application of principles gleaned from the study of AOM, it is also important to develop appropriate strategies when it comes to performing research that involves children. It is imperative to secure informed consent when clinicians use the information collected from observing a child. There must be clear communication between clinicians and the parents of children with AOM before the research process can commence.
Evidence-based research for the treatment and management of AOM must be used to improve nursing practice in the clinic. It is important to use insights and information gleaned from evidence-based research in order to increase the efficiency of health care provides. But at the same time health workers must realize that ethical and other issues may arise if one will attempt to change an established practice. It is therefore important to explain to the parents, guardians and patients the importance of a particular strategy or technique so that they will allow clinicians to do their work unimpeded.
American Academy of Pediatrics. (2004). Diagnosis and management of acute otitis media. Pediatrics, 113(1), 1451-1465.
Block, S. (1997). Causative pathogens, antibiotic resistance and therapeutic considerations in acute otitis media. The Pediatric Infectious Disease, 16(4), 449-456.
Kelley, P., Friedman, N., & Johnson, N. (2007). Ear, nose and throat. In W. Hay & M. Levin (Eds.), Current pediatric diagnosis and treatment (459-492). New York: McGraw-Hill.
McCracken, G. (1998). Treatment of acute otitis media in an era of increasing microbial resistance. The Pediatric Infectious Disease, 17(6), 576-579.