Treatment of acute otitis media in children

Comparison of registered and published outcomes in randomized controlled trials: a systematic review

BACKGROUND

Clinical trial registries can improve the validity of trial results by facilitating comparisons between prospectively planned and reported outcomes. Previous reports on the frequency of planned and reported outcome inconsistencies have reported widely discrepant results. It is unknown whether these discrepancies are due to differences between the included trials, or to methodological differences between studies. We aimed to systematically review the prevalence and nature of discrepancies between registered and published outcomes among clinical trials.

METHODS

We searched MEDLINE via PubMed, EMBASE, and CINAHL, and checked references of included publications to identify studies that compared trial outcomes as documented in a publicly accessible clinical trials registry with published trial outcomes. Two authors independently selected eligible studies and performed data extraction. We present summary data rather than pooled analyses owing to methodological heterogeneity among the included studies.

RESULTS

Twenty-seven studies were eligible for inclusion. The overall risk of bias among included studies was moderate to high. These studies assessed outcome agreement for a median of 65 individual trials (interquartile range [IQR] 25-110). The median proportion of trials with an identified discrepancy between the registered and published primary outcome was 31%; substantial variability in the prevalence of these primary outcome discrepancies was observed among the included studies (range 0% (0/66) to 100% (1/1), IQR 17-45%). We found less variability within the subset of studies that assessed the agreement between prospectively registered outcomes and published outcomes, among which the median observed discrepancy rate was 41% (range 30% (13/43) to 100% (1/1), IQR 33-48%). The nature of observed primary outcome discrepancies also varied substantially between included studies. Among the studies providing detailed descriptions of these outcome discrepancies, a median of 13 % of trials introduced a new, unregistered outcome in the published manuscript (IQR 5-16%).

CONCLUSIONS

Discrepancies between registered and published outcomes of clinical trials are common regardless of funding mechanism or the journals in which they are published. Consistent reporting of prospectively defined outcomes and consistent utilization of registry data during the peer review process may improve the validity of clinical trial publications.

Contemporary concepts in management of acute otitis media in children

Acute otitis media (AOM) is a common disease of childhood. AOM is most appropriately diagnosed by careful otoscopy with an understanding of clinical signs and symptoms. The distinction between AOM and chronic otitis media with effusion should be emphasized. Treatment should include pain management, and initial antibiotic treatment should be given to those most likely to benefit, including young children, children with severe symptoms, and those with otorrhea and/or bilateral AOM. Tympanostomy tube placement may be helpful for those who experience frequent episodes of AOM or fail medical therapy. Recent practice guidelines may assist the clinician with such decisions.

Systemic antibiotic use among children and adolescents in Germany: a population-based study

The aim of the study was to comprehensively describe antibiotic use among children and young adolescents in Germany. Outpatient prescriptions of systemic antibiotics to children (<15 years) were analysed using data from four German statutory health insurances for the years 2004 to 2006. Annual prevalence of antibiotic prescriptions was determined using the average number of insured children during the respective year as reference population. Annual antibiotic prescription rates were calculated per 1,000 person years. Both figures were stratified by age (0-4, 5-9 and 10-14 years) and sex. Frequent indications for prescribing were analysed. Annual prevalence of antibiotic prescriptions rose from 35.68 % [95 % confidence intervals (CI), 35.62-35.75] in 2004 to 37.79 % [95 % CI, 37.72-37.86] in 2006. Prescription rates slightly increased by 6.01 % from 668.54 [95 % CI, 667.34-669.72] antibiotic prescriptions per 1,000 person years in 2004 to 708.71 [95 % CI, 707.47-709.95] in 2006. In 2006, prescriptions of broad-spectrum penicillins (25.09 %), second-generation cephalosporins (18.11 %) and narrow-spectrum penicillins (16.45 %) were most frequent. The most common indication for antibiotic prescribing was tonsillitis followed by bronchitis, otitis media, acute upper respiratory infections and scarlet fever.

CONCLUSION

In contrast to other northern European countries, paediatric prescription rates are high in Germany. This and the frequent prescribing of broad spectrum agents for the treatment of mostly viral self-limiting conditions indicate limited adherence to evidence-based practice guidelines in antibiotic prescribing in the German outpatient setting.

Treatment of acute otitis media in young children

Although acute otitis media (AOM) is one of the most common pediatric problems, the debate over treatment, especially in young children, continues. The 2004 Guideline on treatment of AOM stated that observation without antimicrobial therapy was an option for selected children 6-24 months of age with AOM. Two recent randomized trials sought to determine the necessity of antimicrobial treatment in young children; both studies found modest, statistically significant, positive effects of treatment. However, these studies provoked a flurry of discussion in the literature and the issue remains unsettled. That prevention is preferable to treatment is not controversial. Eliminating or modifying risk factors and use of vaccines, both bacterial and viral, may help decrease the number of AOM episodes. The discussion on treatment of AOM in young children must also take into account side effects of treatment and effect of treatment on possible long-lasting sequelae of AOM, such as developmental outcomes.