Management of Acute Otitis Media Without Antibiotics Has Not Increased

From Medscape Medical News

Laurie Barclay, MD

January 25, 2010 — The management of acute otitis media (AOM) without antibiotics has not increased after publication of the 2004 American Academy of Pediatrics (AAP) and the American Academy of Family Physicians (AAFP) clinical practice guideline on AOM allowing "watchful waiting," according to the results of a study reported Online First January 25 and to be published in the February issue of Pediatrics.

"Observation without initial antibiotic therapy was accepted as an option for ...AOM management in the 2004 American Academy of Pediatrics and American Academy of Family Physicians clinical practice guideline," write Andrew Coco, MD, MS, from Lancaster General Research Institute in Lancaster, Pennsylvania, and colleagues. "The guideline also recommended amoxicillin as the first-line treatment for most children, and analgesic treatment to reduce pain if it was present. Our objective was to compare the management of AOM after publication of the 2004 guideline."

Using the National Ambulatory Medical Care Survey from 2002 to 2006, the investigators analyzed data from 1114 children aged 6 months to 12 years who were diagnosed with AOM in US physicians' offices. They also made comparisons for the 30-month periods before and after the guideline was released in 2004. The main endpoint of the study was the rate of encounters with no reported antibiotic-prescribing, and secondary endpoints were predictors of encounters at which no antibiotic-prescribing was reported and rates of antibiotic- and analgesic-prescribing.

After guideline publication, the rate of AOM encounters at which no antibiotic prescribing was reported did not change significantly (11% - 16%; P = .103).
Absence of ear pain, absence of reported fever, and receipt of an analgesic prescription independently predicted encounters at which no antibiotic-prescribing was reported.

Changes after guideline publication were increased rate of amoxicillin-prescribing (40% - 49%; P = .039), decreased rate of amoxicillin/clavulanate-prescribing (23% - 16%; P = .043), increased rate of cefdinir-prescribing (7% - 14%; P = .004), decreased rate of prescribing other cephalosporins (12% - 6%; P = .025), and increased rate of analgesic-prescribing (14% - 24%; P = .038).

"Although management of AOM without antibiotics has not increased after the publication of the 2004 American Academy of Pediatrics and American Academy of Family Physicians clinical practice guideline, children who did not receive antibiotics were more likely to have mild infections," the study authors write. "In accordance with the guideline, the prescribing of amoxicillin and analgesics has increased. Contrary to the guideline, the prescribing of amoxicillin/clavulanate has decreased, whereas the prescribing of cefdinir has increased."

Limitations of this study include retrospective nature of the data, inclusion of data immediately after the release of the guideline (which may not have allowed sufficient time for adopting the guideline recommendations), exclusion of telephone and email contact information, and inability to distinguish between the prescribing of high-dose vs standard-dose amoxicillin.

"It is encouraging that after the publication of the guideline, amoxicillin-prescribing has increased and the pain associated with AOM is more frequently being treated," the study authors conclude.

In an accompanying editorial, Robert M. Siegel, MD, from Cincinnati Children's Hospital Medical Center in Cincinnati, Ohio, notes that educating patients and families regarding antibiotic use and ensuring that the child's ear pain is adequately managed will lead to decreased antibiotic use and better patient satisfaction.

"Today's patients and families are more medically sophisticated than the last generation, because they have greater access to information through the Internet and its educational resources such as wikis and blogs," Dr. Siegel writes. "Health care providers should embrace and encourage this empowerment and involve patients in shared decision-making regarding whether to use antibiotics for otitis media. With the assurance of a pediatrician that prescribed analgesics will probably remove their child's pain, patients will appreciate being asked to participate in the decision as to when to fill an antibiotic prescription for AOM."

The study authors have disclosed no relevant financial relationships. Dr. Siegel is a member of the Scientific Advisory Board of Atkins Nutritionals, Inc.

Pediatrics. Published online January 25, 2010.