A 5-year old boy, body-weight 15kg, presents with severe unilateral earache 5 days after getting a cold. On examination he is noted to be febrile (temperature 37.8°C) and miserable. There is no discharge from the ear. Otoscopic examination shows a bulging reddened tympanic membrane. There are no other signs of note and his parents inform you that he has no history of ear infections.
According to the prescribing notes in section 12.1.2, BNFC 2009, many cases of acute otitis media, especially those accompanying coryza, are caused by viruses. The main bacterial causes include Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis.
The prescribing notes in section 12.1.2, BNFC 2009, state that most uncomplicated cases of acute otitis media resolve without antibacterial treatment and a simple analgesic, such as paracetamol, may be sufficient to control symptoms. A systemic antibacterial may be started after 72 hours if there is no improvement, or earlier if the condition deteriorates.
At this stage, the boy does not fulfil the criteria for earlier antibacterial treatment because he is over 2 years of age, he has unilateral ear infection with no signs of mastoiditis, he is systemically well with only a mild elevation in body temperature, and risk factors for serious complications are not evident.
The parents should be reassured that an antibiotic is not required immediately because it is unlikely to make much difference to his symptoms, and may cause side-effects such as diarrhoea, vomiting and rash. They must also be advised to reconsult if symptoms worsen, or if there is no improvement after 72 hours.
Further discussion with the parents and a review of the medical records reveal that the boy has frequently relapsing Crohn's disease and is taking azathioprine 30mg daily. Although his Crohn's disease is controlled, he is underweight for his age and is receiving nutritional supplements. His full blood count measured 1 month ago (haemoglobin 12.6 g/dL, white blood cell count 7.7 X 109/L, platelets 278 X 109/L) showed no evidence of myelosuppression. His erythrocyte TPMT (thiopurine methyltransferase) activity was normal (12.5 units/mL red blood cells) before starting azathioprine. He has no history of penicillin allergy.
The boy is taking azathioprine, an immunosuppressive drug, putting him at greater risk of serious complications. For this reason it would be appropriate to give an immediate antibacterial prescription.
Although his pre-treatment TPMT activity was normal, it would be advisable to repeat his full blood count to ensure that he does not have neutropenia. Assuming that his full blood count is satisfactory, standard antibacterial therapy for otitis media would be appropriate. Table 1, section 5.1, BNFC 2009, recommends amoxicillin for 5 days; if there is no improvement after 48 hours, treatment can be switched to co-amoxiclav.
The boy last received vaccinations at the age of 4 years, and is up to date with the Childhood Immunisation Schedule. However he has not received any vaccinations outside the routine Schedule. As the boy has no history of chickenpox or shingles, his blood is tested for anti-varicella antibodies and found to be seronegative.
Ideally, the boy's immunisation requirements should have been assessed before he was started on azathioprine.
The prescribing notes on Active Immunity in section 14.1, BNFC 2009, advise that the immune response to vaccines may be reduced in immunosuppressed children and there is also a risk of generalised infection with live vaccines. Severely immunosuppressed children should not be given live vaccines (such as varicella-zoster vaccine) and specialist advice should be sought for children receiving immunosuppressive drugs.
The boy should avoid close contact with people who have chickenpox or shingles.
To indirectly protect susceptible children against varicella-zoster infection, the prescribing notes on Varicella-Zoster Vaccine in section 14.4, BNFC 2009, advise that this vaccine may be given to seronegative healthy individuals over 1 year of age who come into close contact with susceptible patients such as this boy. Close family members should be assessed, and those who are healthy and seronegative offered vaccination.
The prescribing notes on Varicella-Zoster Immunoglobulin in section 14.5, BNFC 2009, recommend this immunoglobulin in seronegative immunosuppressed children after significant exposure to chickenpox or herpes zoster.
According to the prescribing notes on Influenza Vaccines and Pneumococcal Vaccines in section 14.4, BNFC 2009, children receiving immunosuppressive therapy are at increased risk of pneumococcal infection and influenza. Although the boy is up to date with immunisations for pneumococcal polysaccharide conjugate vaccine, he should be given a single dose of the 23-valent unconjugated pneumococcal polysaccharide vaccine. Influenza vaccine should be offered annually between September and early November to protect against strains of the virus that are prevalent currently. The immune system of children under 13 years may not have been primed by exposure to natural infection with influenza. For this reason, the monograph for Influenza Vaccines, BNFC 2009, recommends that when these children are receiving influenza vaccine for the first time, they should be given 2 doses of the vaccine 4–-6 weeks apart.
The Cautions for vaccines, section 14.1, BNFC 2009, recommend that vaccination may be postponed if the child is suffering from an acute illness or if minor illness is accompanied by fever or systemic upset.
During his last admission to hospital for Crohn's disease, the boy was given Nutrini® Energy by a nasogastric tube. On discharge, the nasogastric tube was removed and he was transferred to 400mL a day of Paediasure® Plus, a paediatric sip feed to supplement his normal diet. Today his parents inform you that he is refusing to take the sip feed because he does not like the milky taste.
According to the tables on Enteral Feeds (A2.1.3.4) and Nutritional Supplements (A2.2.1.2) in Appendix 2, BNFC 2009, Fortijuice® has a similar energy density and protein content to Paediasure® Plus, but without the milky taste. As Fortijuice® is approved by the ACBS in children over 3 years with disease-related malnutrition, it can be prescribed on an FP10 prescription.