#524 - Otitis Media Rx in Kids, Kidney Health 2024, Changing of Seasons

From the Cochrane Library

1)  Antibiotics for Acute Otitis Media in Kids

For a long time, systematic reviews and guidelines have admonished child health clinicians to withhold, or at least delay, antibiotics for uncomplicated acute otitis media in otherwise healthy children. But, somehow, this fails to catch on. A recent study out of Denver Health revealed that an antibiotic was prescribed 98% of the time for children over 2 years with otitis media, with only 4.5% being “SNAPs” (safety-net antibiotic prescriptions, a new term for delayed antibiotics). In this study, non-first-line antibiotics were prescribed 18% of the time, usually to people with private insurance (!). Antibiotics were also commonly prescribed for 10 days, rather than the guideline recommended five days, in urgent cares and for younger children (ages 2-5 years).

The most popular systematic review on this topic from the Cochrane Library was recently updated. This review looked at studies in children with otitis media comparing antibiotics with placebo as well as immediate vs. delayed antibiotics. This was a well-done review that included high-quality studies. In 13 studies (3400 children), fully 60% of subjects were better at 24 hours regardless of treatment group. Antibiotics conferred an advantage with pain reduction after day 3 (number needed to treat (NNT) 20, which improved with more days of follow up). Antibiotics reduced abnormal tympanometry in the short term (NNT ~ 11-16 up to 8 weeks) and tympanic membrane perforation (NNT ~ 33). However, there was no improvement in long-term abnormal tympanometry or recurrent acute otitis media. Adverse events (usually GI or rash related) were common (NNH ~ 14).

Of particular note, three studies (N = 959) showed there was no important difference seen between delayed and immediate antibiotics, except that adverse events were more common in the immediate group.

Finally, a meta-analysis using individual patient data showed that immediate antibiotics were most beneficial for age < 2 years with bilateral otitis media or in children who had both otitis and otorrhea (NNT ~ 3-4 vs. placebo).

John’s Comments:

Delayed antibiotics vary in their effectiveness in different types of upper respiratory infection, but they seem to have an advantage compared to immediate antibiotics for otitis media. Using NSAIDs or acetaminophen can help parents manage symptoms during the delay. In my experience, many parents are ready (and sometimes even happy) to try this out, so I encourage working this into your practice to preserve the usefulness of our antibiotics and to spare children (and parents) the adverse events. When we consider the impact vaccination has had on bacterial disease in children (shifting the microbiology to viruses as the more frequent causative agents), the conclusions from this review could be even stronger.

References:

• Frost HM, Becker LF, Knepper BC, Shihadeh KC, Jenkins TC. Antibiotic Prescribing Patterns for Acute Otitis Media for Children 2 Years and Older. J Pediatr. 2020;220:109-115.e1. Link
• Venekamp RP, Sanders SL, Glasziou PP, Rovers MM. Antibiotics for acute otitis media in children. Cochrane Database of Systematic Reviews. 2023;(11). Link

From the ADA Standards and a Question From a Colleague 

2)  “Kidney Health” 2024

Question:

In patients with diabetes with known chronic kidney disease (CKD) stage 3 or stage 4 but a normal urine microalbuminuria:  1) How can they have that level of kidney disease and have a normal urine micro/creatine ratio and no microalbuminuria and 2) how would my management change either way – if the urine test is normal or if is abnormal?

Answer:

Classically, diabetic nephropathy is associated with proteinuria.  However, as the diabetes epidemic has ballooned, we have learned that not all diabetic nephropathy is associated with proteinuria.  The pathophysiology of proteinuric diabetic nephropathy and non-proteinuric diabetic nephropathy is thought to be a bit different.  However, some of our understanding of this is still limited, especially since most patients with nephropathy do not receive any sort of renal biopsy for classification.

​According to the 2024 ADA standards, non-proteinuric diabetic nephropathy and proteinuric diabetic nephropathy are managed along a continuum (See Figure).  For a patient with diagnosed nephropathy, trending GFR and microalbumin/creatinine ratios is primarily helpful to follow the progression or improvement in a patient's renal function.  Improvements (or stability in some cases) can help indicate therapy is working.  Worsening of albuminuria is still a decline in renal function, even with a similar GFR, and may warrant additional medication therapy including starting or titrating an ACE/ARB, sodium–glucose cotransporter 2 (SGLT-2i) inhibitor, glucagon-like peptide 1 agonist (GLP-1 RA), or a nonsteroidal mineralocorticoid receptor antagonist (nsMRA).  It also indicates a need for tighter glycemic and hypertensive control.

It's also worth considering that not all nephropathy is caused by diabetes and so worsening of GFR in the absence of proteinuria may lead you to more strongly consider additional workup or referral.

As noted above, the ADA recently published their 2024 Standards of Care in Diabetes. Recommendations for Chronic Kidney Disease and Risk Management include:

Screening Recommendations

·         At least annually, assess urinary albumin (e.g., spot urine albumin-to-creatinine ratio [UACR]) and estimated glomerular filtration rate [eGFR] in people with type 1 DM with duration of ≥5 years and in all people with T2D regardless of treatment. B

·         In people with established CKD, spot UACR and eGFR should be monitored 1–4 times per year depending on the stage of the kidney disease (See Figure).  B 

Treatment Recommendations:

·         Optimize glucose management to reduce the risk or slow the progression of CKD. A

·         Optimize blood pressure (BP) control (<130/80) and reduce BP variability to reduce the risk or slow the progression of CKD and reduce cardiovascular (CV) risk. A

·         In nonpregnant patients with DM and HTN, either an ACE inhibitor or an angiotensin receptor blocker (ARB) is recommended for those with moderately increased albuminuria (UACR 30–299 mg/g creatinine) B and is strongly recommended for those with severely increased albuminuria (UACR ≥300 mg/g creatinine) and/or eGFR <60 to prevent the progression of kidney disease and reduce CV events. A

·         Periodically monitor for increased serum creatinine and potassium levels when ACE inhibitors, ARBs, and mineralocorticoid receptor antagonists are used, or for hypokalemia when diuretics are used. B

·         An ACE inhibitor or ARB is not recommended for the primary prevention of CKD in people with diabetes who have normal blood pressure, normal UACR (<30 mg/g creatinine), and normal eGFR. A

·         Do not discontinue renin-angiotensin system blockade for mild to moderate increases in serum creatinine (≤30%) in the absence of signs of extracellular fluid volume depletion. A

·         For those with T2D and CKD, use of a SGLT-2i is recommended to reduce CKD progression and CV events in individuals with eGFR ≥20 and UACR ≥200 (A) and to reduce CKD progression and CV events in individuals with eGFR ≥20 and UACR ranging from normal to 200. B

·         For CV risk reduction in people with T2D and CKD, consider use of a GLP-1 RA or a nsMRA (finerenone) (if eGFR is ≥25). A

·         As people with CKD and albuminuria are at increased risk for cardiovascular events and CKD progression, a nsMRA that has been shown to be effective in clinical trials (finerenone) is recommended to reduce cardiovascular events and CKD progression (if eGFR is ≥25). Potassium levels should be monitored. A

·         In people with CKD who have ≥300 mg/g urinary albumin, a reduction of 30% or greater in mg/g urinary albumin is recommended to slow CKD progression. C

·         For people with non–dialysis-dependent stage G3 or higher CKD, dietary protein intake should be aimed to a target level of 0.8 g/kg body weight per day. A For individuals on dialysis, 1.0–1.2 g/kg/day of dietary protein intake should be considered since protein energy wasting is a major problem in some individuals on dialysis. B

·         Individuals should be referred for evaluation by a nephrologist if they have continuously increasing UACR levels and/or continuously decreasing eGFR and/or if the eGFR is <30. A

·         Promptly refer to a nephrologist for uncertainty about the etiology of kidney disease, difficult management issues, and rapidly progressing kidney disease. B

Mark’s Comments:

We know that “kidney health” is not only of interest to our patients, but to our payers as well.  For those who still resist regularly checking urine albumin-to-creatinine ratios, we hope this information will help clarify why doing so is felt to be so important.  We’ll highlight more from the 2024 Standards of Care for Diabetes in future editions of Take 3.  For assistance in answering this question, I reached out to Jarrod Uhrig, DO, who is a Family Medicine Diabetologist in our department.  Our thanks to him for his input. 

Reference:

• The ADA Professional Practice Committee: 11. Chronic Kidney Disease and Risk Management: Standards of Care in Diabetes—2024.  Diabetes Care 2024: 47 (Supplement 1):S219–S230.  Link

From PeerRxMed ( www.PeerRxMed.org )

3) The Paradox of Change in This Changing of Seasons

“In my own experience of autumn’s losses, I am rarely aware that seeds are being planted.”  Parker Palmer in his book “Let Your Life Speak.”

For the past few years, the transition of seasons has taken on a deeper meaning for me.  During the equinoxes and solstices, I have taken time for a “pause” to reflect on the recent and distant past, ground myself in the present, and look forward to the near and perhaps “farther” future. 

As the winter solstice approaches and we bid autumn farewell, this year I’ve found myself reflecting on both the “losses” as well as some unexpected “gifts” of the last 3 months.  One of the questions I have been pondering that is very relevant for this time of year is:  “What in my life needs to fall away so new life can emerge?”         

As I pondered, I was reminded of a chapter from the book “Let Your Life Speak” by Parker Palmer, a book that I re-read yearly and have gifted to others more than any other.  In the chapter titled “There is a Season,” Palmer writes about the paradox of autumn as being “… a season of great beauty, but also a season of decline ….”  He goes on to say, “In a paradox, opposites do not negate each other – they cohere in a mysterious unity at the heart of reality.  Deeper still, they need each other for health, as my body needs to breathe in as well as breathe out.” 

In such paradox, there exists a dynamic of ‘both/and” rather than “either/or” thinking.  In my own life I have frequently not honored this dynamic, tending to favor one side of the “paradox” over the other.  I seem to be more drawn to “gathering,” “breathing in,” and saying “yes” rather than “letting go, “ “breathing out,” and saying “no,” whether it pertains to more “to dos” at work or just trying to squeeze more in my life without cutting back or stopping anything.  And when we do that enough, what was once a ‘blessing” can soon become “busy” and at some point, a “burden” which if clung to long enough can lead to “burnout.” 

So in this transition of seasons, I’m finding myself focusing more on the “falling away” of fall leading into the dormancy and deep rest of winter, but you may be thinking about what seeds need to be planted.  Regardless of your focus, the symbolism of the transition of seasons provides an incredible opportunity for your own reflection, renewal, and ongoing growth.  Be sure to seize it!   And if you, like me, have some angst about “letting go,” Palmer provides some words of reassurance: “In retrospect … losses that felt irredeemable forced me to discern meanings I needed to know.  On the surface, it seemed that life was lessening, but silently and lavishly the seeds of new hope were always being born.”

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Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org