MCQ Quiz: Management of Otitis Media

The management of otitis media, particularly Acute Otitis Media (AOM), is a cornerstone of pediatric ambulatory care and a frequent reason for antibiotic prescriptions in children. For PharmD students, a thorough understanding of the pathophysiology, common pathogens, and evidence-based treatment guidelines is essential for promoting appropriate antibiotic stewardship and ensuring optimal patient outcomes. This quiz focuses on the pharmacotherapy of AOM, including first-line and alternative treatments, dosing considerations, management of treatment failure, and the role of observation versus immediate antibiotic therapy. Test your knowledge on how to effectively and safely manage this common pediatric condition.

1. Which of the following is the most common bacterial pathogen responsible for Acute Otitis Media (AOM) in children?

• a) Moraxella catarrhalis
• b) Streptococcus pneumoniae
• c) Staphylococcus aureus
• d) Pseudomonas aeruginosa

Answer: b) Streptococcus pneumoniae

2. According to American Academy of Pediatrics (AAP) guidelines, what is the recommended first-line antibiotic for a 3-year-old child with non-severe AOM and no penicillin allergy?

• a) Azithromycin
• b) Cefdinir
• c) Amoxicillin
• d) Trimethoprim-sulfamethoxazole

Answer: c) Amoxicillin

3. High-dose amoxicillin (80-90 mg/kg/day) is recommended for AOM primarily to cover which pathogen?

• a) Beta-lactamase producing H. influenzae
• b) Drug-resistant Streptococcus pneumoniae (DRSP)
• c) Moraxella catarrhalis
• d) Methicillin-resistant Staphylococcus aureus (MRSA)

Answer: b) Drug-resistant Streptococcus pneumoniae (DRSP)

4. A 4-year-old child is diagnosed with AOM and has been treated with amoxicillin for the past 20 days for a separate infection. Which of the following is the most appropriate initial therapy?

• a) Standard-dose amoxicillin
• b) Amoxicillin-clavulanate
• c) Azithromycin
• d) Ceftriaxone injection

Answer: b) Amoxicillin-clavulanate

5. “Watchful waiting” or observation for 48-72 hours without antibiotics is an appropriate strategy for which of the following patients with AOM?

• a) A 4-month-old infant with a high fever and bulging eardrum.
• b) A 7-year-old child with unilateral, non-severe AOM.
• c) Any child with a perforated tympanic membrane.
• d) A 1-year-old with bilateral AOM.

Answer: b) A 7-year-old child with unilateral, non-severe AOM.

6. A child with AOM also presents with concurrent purulent conjunctivitis (otitis-conjunctivitis syndrome). This is most commonly caused by which pathogen?

• a) Streptococcus pyogenes
• b) Chlamydia trachomatis
• c) Nontypeable Haemophilus influenzae
• d) Mycoplasma pneumoniae

Answer: c) Nontypeable Haemophilus influenzae

7. Due to the pathogen commonly associated with otitis-conjunctivitis syndrome, what is the preferred antibiotic treatment?

• a) Amoxicillin
• b) Amoxicillin-clavulanate
• c) Penicillin VK
• d) Erythromycin

Answer: b) Amoxicillin-clavulanate

8. What is the standard duration of antibiotic therapy for AOM in a 5-year-old child?

• a) 3 days
• b) 5-7 days
• c) 10 days
• d) 14 days

Answer: b) 5-7 days

9. For a 20-month-old child with severe AOM, what is the recommended duration of antibiotic therapy?

• a) 3 days
• b) 5 days
• c) 7 days
• d) 10 days

Answer: d) 10 days

10. A child experiences treatment failure after 48-72 hours on high-dose amoxicillin for AOM. What is the most appropriate next step?

• a) Switch to azithromycin.
• b) Switch to high-dose amoxicillin-clavulanate.
• c) Continue amoxicillin for another 5 days.
• d) Discontinue antibiotics and observe.

Answer: b) Switch to high-dose amoxicillin-clavulanate.

11. A child with a documented non-severe, non-type I hypersensitivity reaction (e.g., rash) to penicillin is diagnosed with AOM. Which antibiotic is a suitable alternative?

• a) Amoxicillin
• b) Ampicillin
• c) Cefdinir
• d) Levofloxacin

Answer: c) Cefdinir

12. For a child with a severe, type I hypersensitivity reaction (e.g., anaphylaxis) to penicillin, which antibiotic class should generally be avoided?

• a) Macrolides
• b) Tetracyclines
• c) Cephalosporins
• d) Fluoroquinolones

Answer: c) Cephalosporins

13. Which of the following is a primary goal in managing the pain associated with AOM?

• a) To prescribe opioid analgesics to all pediatric patients.
• b) To use topical antibiotic drops for immediate pain relief.
• c) To provide effective analgesia with medications like acetaminophen or ibuprofen.
• d) To wait for the prescribed oral antibiotic to relieve the pain.

Answer: c) To provide effective analgesia with medications like acetaminophen or ibuprofen.

14. What is Otitis Media with Effusion (OME)?

• a) An active bacterial infection of the middle ear with inflammation.
• b) The presence of fluid in the middle ear without signs or symptoms of an acute infection.
• c) An infection of the outer ear canal.
• d) A viral infection of the eardrum.

Answer: b) The presence of fluid in the middle ear without signs or symptoms of an acute infection.

15. The management of uncomplicated Otitis Media with Effusion (OME) typically involves:

• a) Immediate antibiotic treatment for 10 days.
• b) A 3-month period of observation.
• c) Surgical placement of tympanostomy tubes.
• d) A course of oral corticosteroids.

Answer: b) A 3-month period of observation.

16. Which vaccine has significantly reduced the incidence of AOM caused by Streptococcus pneumoniae?

• a) Measles, Mumps, Rubella (MMR) vaccine
• b) Haemophilus influenzae type b (Hib) vaccine
• c) Diphtheria, Tetanus, and acellular Pertussis (DTaP) vaccine
• d) Pneumococcal conjugate vaccine (PCV13/PCV15)

Answer: d) Pneumococcal conjugate vaccine (PCV13/PCV15)

17. What is the primary role of clavulanate when combined with amoxicillin?

• a) It enhances the analgesic effect of amoxicillin.
• b) It inhibits bacterial beta-lactamase enzymes.
• c) It improves the taste of the suspension.
• d) It increases the absorption of amoxicillin.

Answer: b) It inhibits bacterial beta-lactamase enzymes.

18. A 1-year-old child weighing 10 kg is prescribed amoxicillin suspension (400 mg/5 mL) at a dose of 90 mg/kg/day, divided every 12 hours. What volume should be administered for each dose?

• a) 2.8 mL
• b) 5.6 mL
• c) 11.25 mL
• d) 1.25 mL

Answer: b) 5.6 mL

19. Which of the following is NOT a risk factor for Acute Otitis Media?

• a) Attending daycare
• b) Exposure to tobacco smoke
• c) Breastfeeding
• d) Family history of ear infections

Answer: c) Breastfeeding

20. A child who has had three episodes of AOM in the last six months is defined as having:

• a) Chronic Otitis Media
• b) Otitis Media with Effusion
• c) Recurrent Acute Otitis Media
• d) Treatment-resistant AOM

Answer: c) Recurrent Acute Otitis Media

21. A common side effect of amoxicillin-clavulanate that can be minimized by taking it with food is:

• a) Rash
• b) Drowsiness
• c) Diarrhea
• d) Constipation

Answer: c) Diarrhea

22. An appropriate counseling point for a parent whose child is starting antibiotics for AOM is:

• a) “You can stop the medication as soon as your child feels better.”
• b) “Symptoms should start to improve within 48 to 72 hours.”
• c) “This medication will prevent all future ear infections.”
• d) “Skip a dose if your child experiences any stomach upset.”

Answer: b) “Symptoms should start to improve within 48 to 72 hours.”

23. Why is azithromycin not a preferred first-line agent for AOM despite its convenient dosing?

• a) It is not effective against H. influenzae.
• b) It has poor activity against S. pneumoniae.
• c) It has a high rate of resistance among common AOM pathogens.
• d) It is only available as an injection.

Answer: c) It has a high rate of resistance among common AOM pathogens.

24. The placement of tympanostomy tubes is a surgical intervention primarily indicated for:

• a) The first episode of uncomplicated AOM.
• b) Recurrent AOM or chronic OME with associated hearing loss.
• c) All cases of otitis externa.
• d) Pain relief in AOM.

Answer: b) Recurrent AOM or chronic OME with associated hearing loss.

25. Ceftriaxone is administered via which route for the treatment of AOM?

• a) Oral
• b) Topical
• c) Intramuscular or Intravenous
• d) Intranasal

Answer: c) Intramuscular or Intravenous

26. A key diagnostic feature of AOM is:

• a) The presence of fluid in the middle ear (effusion).
• b) A red tympanic membrane.
• c) A bulging tympanic membrane.
• d) Ear pain (otalgia).

Answer: c) A bulging tympanic membrane.

27. What is the rationale for using the 90 mg/kg/day dose of amoxicillin for AOM?

• a) It is the only dose available.
• b) It achieves concentrations in the middle ear fluid that are above the MIC for resistant S. pneumoniae.
• c) It has fewer side effects than the lower dose.
• d) It is required by law for all pediatric prescriptions.

Answer: b) It achieves concentrations in the middle ear fluid that are above the MIC for resistant S. pneumoniae.

28. Topical analgesic eardrops containing benzocaine can provide symptomatic relief but should be used cautiously and not in patients with:

• a) A high fever.
• b) A perforated tympanic membrane.
• c) A history of asthma.
• d) A penicillin allergy.

Answer: b) A perforated tympanic membrane.

29. What is a potential complication of untreated or inadequately treated AOM?

• a) Asthma
• b) Mastoiditis
• c) Diabetes
• d) Eczema

Answer: b) Mastoiditis

30. Which third-generation cephalosporin is a common oral option for AOM in a child with a non-severe penicillin allergy?

• a) Cephalexin
• b) Cefaclor
• c) Cefdinir
• d) Cefepime

Answer: c) Cefdinir

31. A definitive diagnosis of AOM requires visualization of the tympanic membrane and confirmation of:

• a) Middle ear effusion and acute inflammation.
• b) Cerumen impaction.
• c) A foreign body in the ear canal.
• d) Normal mobility of the eardrum.

Answer: a) Middle ear effusion and acute inflammation.

32. For a child who vomits a dose of amoxicillin within 15 minutes of administration, the general recommendation is to:

• a) Skip the dose and wait until the next scheduled time.
• b) Administer half of the original dose immediately.
• c) Re-administer the full dose.
• d) Contact the physician to switch to an injectable antibiotic.

Answer: c) Re-administer the full dose.

33. The amoxicillin/clavulanate formulation with a 14:1 ratio (e.g., Augmentin ES-600) is designed to:

• a) Provide a lower dose of clavulanate to reduce the risk of diarrhea.
• b) Provide a higher dose of amoxicillin relative to clavulanate.
• c) Be administered only once a day.
• d) Be used exclusively in adults.

Answer: b) Provide a higher dose of amoxicillin relative to clavulanate.

34. The primary viral pathogens that can precede AOM are:

• a) Hepatitis A and B
• b) Human Immunodeficiency Virus (HIV)
• c) Herpes Simplex Virus (HSV)
• d) Respiratory Syncytial Virus (RSV), influenza, and rhinovirus

Answer: d) Respiratory Syncytial Virus (RSV), influenza, and rhinovirus

35. A child is considered to have severe AOM if they have:

• a) Any ear pain.
• b) Mild redness of the eardrum.
• c) Moderate to severe otalgia or a fever ≥ 39°C (102.2°F).
• d) Fluid in the ear for more than one month.

Answer: c) Moderate to severe otalgia or a fever ≥ 39°C (102.2°F).

36. Clindamycin is a treatment option for AOM after multiple treatment failures, but its spectrum of activity does not reliably cover:

• a) Streptococcus pneumoniae
• b) MRSA
• c) Haemophilus influenzae
• d) Anaerobic bacteria

Answer: c) Haemophilus influenzae

37. How does the anatomy of the Eustachian tube in young children contribute to the risk of AOM?

• a) It is longer and more vertical than in adults.
• b) It is shorter, wider, and more horizontal, which impairs drainage.
• c) It is narrower and less flexible.
• d) It is completely closed until puberty.

Answer: b) It is shorter, wider, and more horizontal, which impairs drainage.

38. What is a key counseling point when a parent picks up an amoxicillin suspension that requires reconstitution?

• a) “Store this medication in the freezer.”
• b) “Shake the bottle well before each use and store it in the refrigerator.”
• c) “This medication is good for one year after mixing.”
• d) “You can mix it with hot water to dissolve it faster.”

Answer: b) “Shake the bottle well before each use and store it in the refrigerator.”

39. Prophylactic antibiotics for the prevention of recurrent AOM are:

• a) The first-line strategy for all children with more than one ear infection.
• b) No longer routinely recommended due to concerns about antibiotic resistance.
• c) Administered only during the winter months.
• d) Always a macrolide antibiotic.

Answer: b) No longer routinely recommended due to concerns about antibiotic resistance.

40. What is the role of decongestants and antihistamines in the management of AOM?

• a) They are proven to shorten the duration of the infection.
• b) They are recommended as first-line therapy to reduce fluid.
• c) They are not recommended as they have shown no benefit and may cause side effects.
• d) They are used to prevent AOM in all children with a cold.

Answer: c) They are not recommended as they have shown no benefit and may cause side effects.

41. A child with tympanostomy tubes develops ear drainage (otorrhea). What is the preferred treatment?

• a) Oral amoxicillin
• b) Oral amoxicillin-clavulanate
• c) Topical antibiotic eardrops (e.g., ofloxacin or ciprofloxacin/dexamethasone)
• d) Observation without treatment

Answer: c) Topical antibiotic eardrops (e.g., ofloxacin or ciprofloxacin/dexamethasone)

42. The “wait-and-see” prescription (WASP) approach for AOM involves:

• a) Giving the parent a prescription for an antibiotic and instructing them to fill it only if the child does not improve in 48-72 hours.
• b) Telling the parent to wait and see if another pharmacy has the antibiotic in stock.
• c) Prescribing a subtherapeutic dose of antibiotics.
• d) Waiting to see the patient in the clinic again in one week.

Answer: a) Giving the parent a prescription for an antibiotic and instructing them to fill it only if the child does not improve in 48-72 hours.

43. Which of these is a sign of a bulging tympanic membrane?

• a) A shiny, translucent appearance.
• b) A concave or retracted shape.
• c) A visible perforation.
• d) Loss of landmarks and convex, outward-pushed appearance.

Answer: d) Loss of landmarks and convex, outward-pushed appearance.

44. What is the maximum recommended dose of amoxicillin for AOM?

• a) 1000 mg per dose
• b) 2000 mg per day
• c) It should not exceed 4000 mg per day.
• d) There is no maximum dose.

Answer: c) It should not exceed 4000 mg per day.

45. Which of the following is an important factor when deciding whether to treat AOM with antibiotics?

• a) The child’s gender.
• b) The child’s age and the certainty of the diagnosis.
• c) The time of day the child was diagnosed.
• d) The parent’s occupation.

Answer: b) The child’s age and the certainty of the diagnosis.

46. Otitis externa, or “swimmer’s ear,” is an infection of the:

• a) Middle ear
• b) Inner ear
• c) Mastoid bone
• d) External auditory canal

Answer: d) External auditory canal

47. A 2-year-old is switched to ceftriaxone after failing two previous courses of oral antibiotics for AOM. How is ceftriaxone typically dosed for this indication?

• a) A single oral dose.
• b) A once-daily intramuscular injection for 1-3 days.
• c) A 10-day course of oral tablets.
• d) Topical ear drops applied twice daily.

Answer: b) A once-daily intramuscular injection for 1-3 days.

48. Why is it important to ask about recent antibiotic use when selecting therapy for AOM?

• a) To ensure the child is not getting too many flavors of medicine.
• b) To assess the likelihood of infection with a drug-resistant pathogen.
• c) To check for compliance with previous therapies.
• d) It is not an important factor.

Answer: b) To assess the likelihood of infection with a drug-resistant pathogen.

49. An important non-pharmacological measure to reduce the risk of AOM in infants is:

• a) Feeding the infant in a supine (lying flat) position.
• b) Avoiding all pacifier use.
• c) Ensuring the infant is up-to-date with recommended immunizations.
• d) Exposing the infant to other children as early as possible.

Answer: c) Ensuring the infant is up-to-date with recommended immunizations.

50. What is the best way to confirm middle ear effusion?

• a) Asking the parent if the child’s hearing seems normal.
• b) Performing a pneumatic otoscopy or tympanometry.
• c) Looking at the color of the eardrum.
• d) Checking for fever.

Answer: b) Performing a pneumatic otoscopy or tympanometry.