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When antibiotics are necessary for childhood ear infections

Robin Wulffson MD's picture
ear infection, otitis media, antibiotics, amoxicillin, watchful waiting

An ear infection (otitis media) is an extremely common form of childhood ailment. About 50% of children will suffer from one before one year of age and 75% will experience one by age three. To address the situation, the American Academy of Pediatrics (AAP) has released a new set of guidelines that have the goal of educating both pediatricians and parents regarding the proper management. The information is designed to advise whether antibiotics, pain killers, or simply watchful waiting is appropriate. The new guideline once again stresses that in a number of cases antibiotics should not be given for an infection.

The report notes that historically in the United States all diagnosed otitis media infections have been historically treated with antibiotics, making it by far the most common condition for which antibacterial agents are prescribed for US children. However, in other developed nations, most notably The Netherlands, antibiotics are not routinely prescribed for uncomplicated infections. It notes that physicians need to be cognizant of the increased resistance among many of the pathogens (bacteria and viruses) that cause AOM.

In 2004, the AAP and the American Academy of Family Physicians (AAFP) jointly issued a well-publicized clinical practice guideline on the management of otitis media in children aged six months through 12 years. The guideline recommended an observation option in selected children with otitis media on the basis of their age, severity of symptoms, and certainty of diagnosis; furthermore, it made specific antibiotic recommendations on the basis of illness severity and treatment response. It also reiterated the fact that infections caused by a virus would not respond to antibiotics. The guideline also made a strong recommendation that the management of the infection should include an assessment of pain and the appropriate analgesic (pain killer) treatment if pain is present. The guideline also recommended amoxicillin as the first-line treatment for most children.
The guideline noted that observation without initial antibiotic therapy was accepted as an option by many physicians for otitis media by many clinicians after the guideline was released. The goal of the new study was to compare management of otitis media after publication of the 2004 guideline.

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The researchers accessed data from the National Ambulatory Medical Care Survey, 2002–2006 (1,114 children aged six months to 12 years who were diagnosed with acute otitis media), which occurred in US physicians’ offices. The time comparisons were the 30 month periods before and after the guideline. The main outcome measure was the percentage of children who received no antibiotic treatment. The secondary outcome measures were the identification of factors associated with encounters at which no antibiotic-prescribing was reported and antibiotic- and analgesic-prescribing rates.

The researchers found that the rate of otitis media encounters at which no antibiotic-prescribing was reported did not change after guideline publication (11%–16%). Independent predictors of an encounter at which no antibiotic-prescribing was reported were the absence of ear pain, absence of reported fever, and receipt of an analgesic prescription. After guideline publication, the rate of amoxicillin-prescribing increased (40%–49%), the rate of Augmentin (amoxicillin/clavulanate)-prescribing decreased (23%–16%), the rate of (Omnicef) cefdinir-prescribing increased (7%–14%), and the rate of analgesic-prescribing increased (14%–24%).

The researchers concluded that, although management of AOM without antibiotics has not increased after the publication of the 2004 clinical practice guideline, children who did not receive antibiotics were more likely to have mild infections. They added that, 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.

Take home message:
This study reiterates that antibiotics are not necessary for an infection. One factor driving the use of antibiotics is a parent’s insistence that they be given. With watchful waiting, antibiotics can be given if symptoms persist and/or a culture proves the presence of a bacterial origin.

Reference: Pediatrics