Antibiotic Use in Children with Otitis Media Increases Risk for Recurrence
Another reason to wait and see
Clinicians often prescribe antibiotics for treatment of uncomplicated acute otitis media (AOM) in children despite lack of evidence for improved outcomes. To examine the effects of antibiotic treatment on recurrence of AOM, investigators in the Netherlands surveyed parents of 240 children (age range, 6 months to 2 years) about 3 years after the children had participated in a multicenter, randomized, double-blind trial of amoxicillin (40 mg/kg/day in 3 doses) or placebo for treatment of AOM (JW Emerg Med Apr 1 2000). Seventy percent of parents returned questionnaires.
Parents reported at least one episode of AOM since the 6-month posttreatment follow-up visit significantly more often in the amoxicillin group than in the placebo group (63% vs. 43%). Even after adjustment for confounding factors, children in the amoxicillin group had 2.5 times the risk for recurrence. In sensitivity analysis among children who were not prescribed antibiotics during the 6 months after randomized treatment, the adjusted odds ratio for recurrence was 4.4. Ear, nose, and throat surgery was less likely in the amoxicillin group (21% vs. 30%). The authors note that wide confidence intervals limit interpretation of the results and caution that the findings cannot be generalized to children with underlying disease or who live in underresourced conditions.
Comment: One more nail in the coffin for antibiotic use in simple otitis media! This practice increases risk for colonization with resistant pathogens and recurrent infections in individual children and contributes to antibiotic resistance in the general population. In uncomplicated cases, reassure parents that resolution without antibiotics is the rule, not the exception, and try a "wait-and-see prescription," rather than immediately starting unnecessary antibiotics.
Kristi L. Koenig, MD, FACEP
Published in Journal Watch Emergency Medicine August 7, 2009
Citation(s): Bezáková N et al. Recurrence up to 3.5 years after antibiotic treatment of acute otitis media in very young Dutch children: Survey of trial participants. BMJ 2009 Jun 30; 338:b2525. (http://dx.doi.org/10.1136/bmj.b2525)
Dangerous bias - Otitis Media
Your comments in the August 10 issue, concerning otitis media treatment are misleading, and possibly prejudicial. You continue to provide articles of one country (Nederlands), whose definitions and standards may differ from ours – either positively or negatively. But…these reports remain, still, the claims of one country’s research.
This article cited (BMJ) does relate more recurrences with antibiotic usage. However, neither the headline, nor your comments, notes that less surgery was needed for the otitis media treated group.
Additionally, the authors themselves acknowledge "wide confidence intervals" – which may certainly influence the validity of their observations. Nor are any details provided about their “wide confidence intervals.”
The very diagnosis of otitis media is frequently incorrectly described – both here and in the Nederlands - as a red or inflamed TM in a child, instead of a clearly bulging tympanic membrane, which is immotile with pneumatic otoscopy. This review does not refer to diagnostic criteria used.
Even if these authors employ appropriate diagnostic methods and follow-up, the issue of the avoidance of surgery is very significant. That is part of the clinical equation. Does not this significant reason for treatment retain some clinical relevance?
Lastly, your reference of yet another reason to defer antibiotics in “simple otitis media” minimizes the controversy of treatment for children less than 2, at higher risk for mastoiditis. There are "data surfing" young physicians who might apply this factum, in a one-upmanship attempt to be "current", with catastrophic results for young children. Although acknowledging bacterial resistance problems, and the option of not treating children less than 2, current AAP standards and the 18th edition of Nelson by no means foreclose the option of treating these younger children. They also define otitis media by risk factors, rather than "simple otitis media", which can be construed as any otitis media without complications. Finally, their recommended dosage is 80 mg/kg/day - which has some bearing on both treatment success and the acquisition of resistant bacteria.
Even if there is some truth, your expression of "nails in the coffin" for an illness which often IS bacterial, particularly in children less than 2, and which can result in mastoiditis or worse is - in my opinion – facile and unprofessional .
You owe your readers a more nuanced evaluation of data, and I believe that you would do well to review your own critical methods.
Ronald S. Bashian, MD, 19 Aug 2009 12:33 PM EST
Competing interests: None declared