Evidence assessment of management of acute otitis media: I. The role of antibiotics in treatment of uncomplicated acute otitis media

Low-fidelity otoscopy simulation and anatomy training: A randomized controlled trial

OBJECTIVES

To evaluate whether the use of low-fidelity otoscopy simulation improved medical students' theoretical knowledge of middle ear anatomy and pathologies compared to traditional teaching methods.

METHODS

This was a randomized controlled trial. Simulation workshops were conducted in April 2019 in the Lyon Sud University medical faculty, France. Students were randomly assigned to the simulation group (n=105) or to the control group (n=95). The students in the control group answered a questionnaire evaluating theoretical knowledge (25 true-false questions) before the simulation tutorial, while the students in the simulation group answered the same questions after the tutorial. Both groups also filled out a satisfaction questionnaire for feedback.

RESULTS

196 of the 200 students who participated in the study completed the knowledge assessment questionnaire. Scores were 32.0% higher in the simulation group than in the control group (mean scores, 12.0/20 vs. 9.1/20; P<0.0001). 184 of the 191 students who completed the satisfaction questionnaire (96.3%) were satisfied or very satisfied with the workshop, and all but one (99.5%) recommended keeping it in the curriculum. In the free comments fields, students highlighted the educational value of learning without the stress of patient discomfort.

CONCLUSION

Otoscopy simulation is an effective training method, improving theoretical knowledge compared with conventional theoretical training.

Preventing unnecessary tympanostomy tube placement in children

OBJECTIVE

In 2013 the American Academy of Otolaryngology published tympanostomy tube guidelines for children; Action Statement 6 recommends against tube placement without middle ear effusion (MEE) at time of assessment. To date, little research has directly evaluated this recommendation in reducing the need for ear tubes. We evaluated the effectiveness of this recommendation and potential risk factors that influence the success of watchful waiting.

METHODS

Retrospective chart review collecting demographics, daycare status, smoking exposure, and time of year of visit. Children aged 6 months to 12 years without MEE on presentation, but with 3 or more episodes of acute otitis media (AOM) in 6 months or 4 or more episodes in 12 months, were assigned to watchful waiting (WW) treatment. These patients were followed every 4 months or returned sooner with additional infections. Any continued AOM, or MEE on follow up leading to tube placement, defined WW failure.

RESULTS

123 patients met criteria, with 81 still in WW to date (66% success rate). 42 children failed WW and received tympanostomy tubes (34% failure rate). There were no statistically significant associations between age, race, gender, smoking exposure, daycare, or month of presentation between children who failed WW compared to children receiving tubes.

CONCLUSIONS

Tympanostomy tube guidelines mitigate unnecessary tube placement in a majority of children with recurrent AOM without MEE. To our knowledge, this is the first study supporting the 2013 recommendations, with a 66% success rate. Additionally, no significant associations between modifying risk factors in those who failed watchful waiting were identified.

Parental acceptability of the watchful waiting approach in pediatric acute otitis media

AIM: To determine parental knowledge about acute otitis media (AOM) and its antibiotic therapy, antibiotic resistance and the willingness to comply with the watchful waiting (WW) approach in primary care settings in southern Israel.

METHODS: The study was conducted in 3 primary care clinics and the pediatric emergency room of Soroka University Medical Center. Questionnaires (20 questions on education background, previous AOM experience, knowledge on antimicrobial resistance and attitude vs the WW approach) were filled by 600 parents (150 at each centers) of children < 6 years of age.

RESULTS: Mothers represented 69% of parents; 2% had an education of < 10 school years, 46% had high-school education and 17% had an academic degree. 69% parents reported previous experience with AOM and 56% thought that antibiotics represent the only treatment for AOM. Knowledge on bacterial resistance to antibiotics was reported by 57% of the parents; 86% parents were willing to accept/probably accept the WW approach for their children. Logistic regression analysis revealed a significant association between parental education and knowledge about bacterial resistance to antibiotics and that previous experience with AOM was significantly associated with reluctance to accept the WW approach. More parents with knowledge on bacterial resistance were willing to accept the WW approach compared with parents without such knowledge. No correlation was found between the education level and willingness to accept the WW approach.

CONCLUSION: A significant correlation was found between previous parental education and experience with AOM and the knowledge about antibiotic use, bacterial resistance and acceptance of the WW approach.

A multi-centre open-label randomised non-inferiority trial comparing watchful waiting to antibiotic treatment for acute otitis media without perforation in low-risk urban Aboriginal and Torres Strait Islander children (the WATCH trial): study protocol for a randomised controlled trial

Background

Treatment guidelines recommend watchful waiting for children older than 2 years with acute otitis media (AOM) without perforation, unless they are at high risk of complications. The high prevalence of chronic suppurative otitis media (CSOM) in remote Aboriginal and Torres Strait Islander communities leads these children to be classified as high risk. Urban Aboriginal and Torres Strait Islander children are at lower risk of complications, but evidence to support the subsequent recommendation for watchful waiting in this population is lacking.

Methods/Design

This non-inferiority multi-centre randomised controlled trial will determine whether watchful waiting is non-inferior to immediate antibiotics for urban Aboriginal and Torres Strait Islander children with AOM without perforation. Children aged 2 − 16 years with AOM who are considered at low risk for complications will be recruited from six participating urban primary health care services across Australia. We will obtain informed consent from each participant or their guardian. The primary outcome is clinical resolution on day 7 (no pain, no fever of at least 38 °C, no bulging eardrum and no complications of AOM such as perforation or mastoiditis) as assessed by general practitioners or nurse practitioners. Participants and outcome assessors will not be blinded to treatment. With a sample size of 198 children in each arm, we have 80 % power to detect a non-inferiority margin of up to 10 % at a significance level of 5 %, assuming clinical improvement of at least 80 % in both groups. Allowing for a 20 % dropout rate, we aim to recruit 495 children.

We will analyse both by intention-to-treat and per protocol. We will assess the cost- effectiveness of watchful waiting compared to immediate antibiotic prescription. We will also report on the implementation of the trial from the perspectives of parents/carers, health professionals and researchers.

Discussion

The trial will provide evidence for the safety and effectiveness of watchful waiting for the management of AOM in Aboriginal and Torres Strait Islander children living in urban settings who are considered to be at low risk of complications.

Trial registration

The trial is registered with Australia New Zealand Clinical Trials Registry (ACTRN12613001068752). Date of registration: 24 September 2013.

Long-term follow-up of otitis media with effusion in children: comparisons between a ventilation tube group and a non-ventilation tube group

OBJECTIVE

The objective of this study was to investigate the long-term outcomes in children with otitis media with effusion who received either medical treatment or ventilation tubes.

METHODS

We retrospectively analyzed the medical records of 89 bilateral cases of otitis media with effusion in children who were recommended to receive ventilation tube insertion and were followed up for more than 5 years. Tympanic membrane was inspected by otoscopic examination. Hearing was evaluated with pure tone audiometry. The mean duration of follow-up was 8.4 years (range, 5.2-15.7 years). Twenty-three children were treated without surgery, while 22 were treated once by ventilation tube insertion and 44 were treated more than once by ventilation tube insertion.

RESULTS

At the fifth year of follow-up, both groups of children who underwent ventilation tube insertion had more frequent tympanic membrane abnormalities than the medication group (8.7% in those treated without surgery, 72.7% in those treated once by ventilation tube insertion, and 88.6% in those treated more than once by ventilation tube insertion). Common tympanic membrane abnormalities were retraction (27.0%) and tympanosclerotic plaque (23.6%), regardless of the treatment modality. At the fifth year follow-up, the average air-conduction threshold was 10.0 dB (± 6.5 dB) in patients treated without surgery, 15.9 dB (± 11.2dB) in patients treated once by ventilation tube insertion, and 17.8 dB (± 7.6 dB) in those treated more than once by ventilation tube insertion. The audiological difference was significant when we compared the hearing level of children treated by medication without surgery to the two ventilation tube groups.

CONCLUSION

Though ventilation tube insertion can resolve hearing loss quickly, there were more tympanic membrane abnormalities and a decline in hearing levels in our ventilation tube insertion group vs. the observation group measured 5 years later. Physicians should therefore be cautious when applying a ventilation tube in patients with otitis media with effusion and should explain the risks to patients who are a candidate for repeated ventilation tube insertion.

Pneumococcus

Pneumococcus is one of the most common bacterial pathogens encountered in medicine. This article summarizes the risk factors, pathogenesis, treatment, and prevention of the spectrum of disease caused by pneumococcus with particular emphasis on antibiotic resistance as well as immunization. This information is useful for physicians caring for patients both as inpatients and outpatients as well as for those concerned with public health and disease prevention.

Earache

Earache, a common emergency department presentation, may be caused by a variety of conditions, some distant from the ear. This article discusses the diagnosis and treatment of acute otitis media, otitis media with effusion, otitis externa, otitis media with ruptured tympanic membrane or tympanostomy tubes, malignant otitis externa, mastoiditis and petrositis, traumatic ruptured tympanic membrane, cerumen impactions, and foreign bodies in the ears.

The diagnosis and management of acute otitis media

This evidence-based clinical practice guideline is a revision of the 2004 acute otitis media (AOM) guideline from the American Academy of Pediatrics (AAP) and American Academy of Family Physicians. It provides recommendations to primary care clinicians for the management of children from 6 months through 12 years of age with uncomplicated AOM. In 2009, the AAP convened a committee composed of primary care physicians and experts in the fields of pediatrics, family practice, otolaryngology, epidemiology, infectious disease, emergency medicine, and guideline methodology. The subcommittee partnered with the Agency for Healthcare Research and Quality and the Southern California Evidence-Based Practice Center to develop a comprehensive review of the new literature related to AOM since the initial evidence report of 2000. The resulting evidence report and other sources of data were used to formulate the practice guideline recommendations. The focus of this practice guideline is the appropriate diagnosis and initial treatment of a child presenting with AOM. The guideline provides a specific, stringent definition of AOM. It addresses pain management, initial observation versus antibiotic treatment, appropriate choices of antibiotic agents, and preventive measures. It also addresses recurrent AOM, which was not included in the 2004 guideline. Decisions were made on the basis of a systematic grading of the quality of evidence and benefit-harm relationships. The practice guideline underwent comprehensive peer review before formal approval by the AAP. This clinical practice guideline is not intended as a sole source of guidance in the management of children with AOM. Rather, it is intended to assist primary care clinicians by providing a framework for clinical decision-making. It is not intended to replace clinical judgment or establish a protocol for all children with this condition. These recommendations may not provide the only appropriate approach to the management of this problem.

Hearing 25 years after surgical treatment of otitis media with effusion in early childhood

OBJECTIVE

To determine the long-term hearing following surgical treatment of chronic OME in early childhood (myringotomy or ventilation tube) and to determine the impact of the occurrence and the extension of specific eardrum pathology on the hearing level.

PATIENTS AND METHODS

In 1977-1978, 224 consecutive children (91 girls and 133 boys) with chronic bilateral OME were enrolled and treated by adenoidectomy, bilateral myringotomy and insertion of a ventilation tube on the right side only. In 2002, a follow-up examination included otomicroscopy and audiometry. Hearing thresholds were compared to an age- and gender-matched normative data set. For the determination of the impact of specific eardrum pathology on the hearing, multiple linear regression modelling was used in adjustment for age and concomitant eardrum pathologies.

RESULTS

Long-term hearing after chronic OME and associated treatment is not different from age and gender-matched normal hearing. Treatment modality (myringotomy or ventilation tube) has no impact on the long-term hearing level. The regression analyses showed that the presence of myringosclerosis is associated with an overall hearing loss in myringotomised ears (4-5 dB), but not in tubed ears, for which only high frequencies were affected. Conversely, tensa atrophy is associated with an overall hearing loss in tubed ears (3-4 dB), but not in myringotomised ears, for which only high frequencies were affected.

CONCLUSIONS

Hearing 25 years after surgical treatment of chronic OME is not different from age and gender matched normal hearing. In addition, treatment modality (myringotomy or ventilation tube) has no impact on the long-term hearing level. However, atrophy is associated with a hearing loss in tubed ears, whereas myringosclerosis is associated with a hearing loss in myringotomised ears. The hearing loss associated with pathology is of limited magnitude (up to about 5 dB PTA). Even though pathology does occur more frequently and more extensively in tubed ears, the effect on the hearing at the group level is too small to have an impact. It is important to note, that this may be due to a type 2-error (number of patients too small to show an effect).

Antibiotic use among patients with febrile illness in a low malaria endemicity setting in Uganda

Background

Uganda embraced the World Health Organization guidelines that recommend a universal 'test and treat' strategy for malaria, mainly by use of rapid diagnostic test (RDT) and microscopy. However, little is known how increased parasitological diagnosis for malaria influences antibiotic treatment among patients with febrile illness.

Methods

Data collection was carried out within a feasibility trial of presumptive diagnosis of malaria (control) and two diagnostic interventions (microscopy or RDT) in a district of low transmission intensity. Five primary level health centres (HCs) were randomized to each diagnostic arm (diagnostic method in a defined group of patients). All 52,116 outpatients (presumptive 16,971; microscopy 17,508; and RDT 17,638) aged 5 months to ninety five years presenting with fever (by statement or measured) were included. Information from outpatients and laboratory registers was extracted weekly from March 2010 to July 2011. The proportion of patients who were prescribed antibiotics was calculated among those not tested for malaria, those who tested positive and in those who tested negative.

Results

Seven thousand and forty (41.5%) patients in the presumptive arm were prescribed antibiotics. Of the patients not tested for malaria, 1,537 (23.9%) in microscopy arm and 810 (56.2%) in RDT arm were prescribed antibiotics. Among patients who tested positive for malaria, 845 (25.8%) were prescribed antibiotics in the RDT and 273(17.6%) in the microscopy arm. Among patients who tested negative for malaria, 7809 (61.4%) were prescribed antibiotics in the RDT and 3749 (39.3%) in the microscopy arm. Overall the prescription of antibiotics was more common for children less than five years of age 5,388 (63%) compared to those five years and above 16798 (38.6%).

Conclusion

Prescription of antibiotics in patients with febrile illness is high. Testing positive for malaria reduces antibiotic treatment but testing negative for malaria increases use of antibiotics.

Trial Registration

ClinicalTrials.gov: NCT00565071

Acute otitis media in children

Clinical question:

What is the best treatment for acute otitis media in children?

Results:

Watchful waiting, followed by amoxicillin treatment, if necessary, is the best first-line treatment for acute otitis media in children aged six months or older.

Physician and parent response to the FDA advisory about use of over-the-counter cough and cold medications

OBJECTIVE

The aim of this study was to assess the likely impact of the US Food and Drug Administration (FDA) advisory not to use over-the-counter (OTC) cough and cold products for children aged <2 years on care provided by pediatricians and parents.

METHODS

A mailed survey was completed by 105 community pediatricians (53% response rate), and 1265 parents with children aged <12 years completed a self-administered survey while waiting for an office visit.

RESULTS

All physicians were aware of the advisory; 75% agreed with it. Fifty-nine percent did not recommend OTC cough and cold products for children aged <2 years before the advisory, and 35% were less likely to do so afterward. Seventy-three percent of parents were aware of the advisory, 70% believed these products relieved symptoms, 68% did not believe they were dangerous, and 74% had them at home. After the advisory, 21% of parents were more likely to request an antibiotic from the doctor. Among the parents, 225 only had children aged <2 years and 695 only had children aged 2 to 11 years; of these parental groups, 53% and 10% of parents, respectively, did not use these products before the advisory, an additional 33% and 28%, respectively, were less likely to do so afterward, and 15% and 61%, respectively, would continue use them.

CONCLUSIONS

Pediatricians must be prepared for requests from parents for antibiotics and other remedies for symptom relief for their children with colds. As no effective alternatives are available, maybe nontreatment should be promoted.

Management of children with otitis media: a summary of evidence from recent systematic reviews

Health-care professionals who manage children are regularly confronted with clinical questions regarding the management of the full spectrum of otitis media: acute otitis media; otitis media with effusion; and chronic suppurative otitis media. Given the variety of potential therapies available, the wide spectrum of middle ear disorders, and the lack of consensus about management strategies, clinicians are in a difficult position when managing these children. In this review, we seek to summarise the current best evidence for answering otitis media management questions by collating existing systematic reviews.

[Acute otitis media--rational antibiotic treatment]

Acute otitis media is the most common reason for which antibiotics are prescribed to children. Because use of antibiotics has been implicated in the selection and progression of resistance among upper respiratory tract pathogens a concerted effort has been established to promote their judicious use. To reduce use of antibiotics recently published guidelines recommend observation option (watchful waiting) to children >2 years of age and non severe illness. Amoxicillin at conventional or high-doses remains an appropriate choice for first-line therapy. Appropriate options for second-line therapy include high-dose amoxicillin/clavulanate and ceftriaxon. Tympanocentesis is useful for identifying causative pathogen and may be beneficial for those who have failed second-line therapy. Natural history of untreated otitis media, most common pathogens and their resistance pattern are presented in the paper.

WITHDRAWN: Antibiotics for persistent nasal discharge (rhinosinusitis) in children

BACKGROUND

Nasal discharge (rhinosinusitis) is extremely common in children. It is the result of inflammation of the mucosa of the upper respiratory tract, and is usually due to either infection or allergy. Infections may be caused by bacteria.

OBJECTIVES

To determine the effectiveness of antibiotics versus placebo or standard therapy in treating children with persistent nasal discharge (rhinosinusitis) for at least 10 days.

SEARCH STRATEGY

In this updated review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2005) which includes the ARI Group's specialised trials register; MEDLINE (1966 to April Week 3, 2005) EMBASE (1997 to December 2004), and the references of relevant articles were searched. Authors and pharmaceutical companies were contacted.

SELECTION CRITERIA

All randomised controlled trials that compared antibiotics versus placebo or standard therapy. Trials which included the use of other medications were included if all participants were allowed equal access to such medications or if the additional or alternative therapies were regarded as ineffective. Trials that only combined or compared antibiotics with surgery, or sinus puncture and lavage, were not included in the review.

DATA COLLECTION AND ANALYSIS

Data were extracted by a single author for the following eight outcomes: overall clinical failure (primary outcome), failure to cure, failure to improve, clinical improvement, time to resolution, complications, side-effects and bacteriologic failure. For the dichotomous outcome variables of each individual study, proportional and absolute risk reductions were calculated using a modified intention-to-treat analysis. The summary weighted risk ratio and 95% confidence interval (CI) (fixed effect model) were calculated using the inverse of the variance of each study result for weighting (Cochrane statistical package, RevMan version 4.2).

MAIN RESULTS

A total of six studies involving 562 children compared antibiotics with placebo or standard therapy. All studies were randomised but most were still susceptible to bias. Five of the studies were conducted in emergency, allergy or ENT clinics. Four of the studies required children to have x-ray changes consistent with sinusitis. Only the primary outcome (overall clinical failure) was reported in all studies. Around 40% of all randomised children did not have a clinical success documented when reviewed two to six weeks after randomisation. The control event rate varied from to 22 to 71% (mean 46%). The risk ratio estimated using a fixed effects model was 0.75 (95% CI 0.61 to 0.92). There was no evidence of statistical heterogeneity. Side effects (sufficient to cease treatment) occurred in 4 of 189 control group children (four studies). More children treated with antibiotics had side effects (17 of 330), but this difference was not statistically significant (RR 1.75, 95% CI 0.63 to 4.82).

AUTHORS' CONCLUSIONS

For children with persistent nasal discharge or older children with radiographically confirmed sinusitis, the available evidence suggests that antibiotics will reduce the probability of persistence in the short to medium-term. The benefits appear to be modest and around eight children must be treated in order to achieve one additional cure (number needed to treat (NNT) 8, 95% CI 5 to 29). No long term benefits have been documented. These conclusions are based on a small number of small randomised controlled trials and may require revision as additional data become available.

Age inconsistency in the American Academy of Pediatrics guidelines for acute otitis media

OBJECTIVE

The American Academy of Pediatrics acute otitis media guidelines could reduce antibiotic use. The objective was to compare strategies for diagnosing and treating otitis: (1) a commonly used, 2-criteria strategy, (2) the guidelines' 3-criteria algorithm, and (3) initially watching without antibiotics.

METHODS

A decision analysis was performed with literature-based parameter. The target population was children presenting to primary care physicians with possible otitis media. Main outcomes were antibiotic use, sick days, mild adverse drug events, and number needed to treat/avoided sick day.

RESULTS

For children 2 to <6 months of age, compared with the 2-criteria strategy, guideline use predicted 21% less antibiotic use, 13% more sick days, and 23% fewer adverse drug events; the number needed to treat for the 2-criteria strategy versus the American Academy of Pediatrics strategy was 1.2 children per avoided sick day. For children 6 to <24 months of age, guideline use, compared with the 2-criteria strategy, predicted 26% less antibiotic use, 14% more sick days, and 28% fewer adverse drug events; the number needed to treat for the 2-criteria strategy versus the American Academy of Pediatrics strategy was 1.4 children per avoided sick day. For children >2 years of age, guideline use, compared with the 2-criteria strategy, predicted 67% less antibiotic use, 4% more sick days, and 68% fewer adverse drug events. The number needed to treat for the guideline strategy versus the watch strategy was 6.3 children per avoided sick day; that for the 2-criteria strategy versus the guideline strategy was 12.3. Guideline use for children <2 years implies that our number needed to treat to avoid a sick day is <1.4; for children >2, guideline use implies we are willing to treat at least 6.3 children to avoid a sick day. Thus, the guidelines imply a greater willingness to treat older children, compared with younger children.

CONCLUSIONS

The American Academy of Pediatrics guidelines are inconsistent in their outcomes across age groups. Guideline implementation under age 2 reduces antibiotic use but at a relatively heavy cost of sick days and parental missed work days. This trade-off may be particularly unfavorable for working parents, who might reasonably prefer greater antibiotic use.

Estimating the effect of treatment rate changes when treatment benefits are heterogeneous: antibiotics and otitis media

OBJECTIVE

Contrast methods to assess the health effects of a treatment rate change when treatment benefits are heterogeneous across patients. Antibiotic prescribing for children with otitis media (OM) in Iowa Medicaid is the empirical example.

METHODS

Instrumental variable (IV) and linear probability model (LPM) are used to estimate the effect of antibiotic treatments on cure probabilities for children with OM in Iowa Medicaid. Local area physician supply per capita is the instrument in the IV models. Estimates are contrasted in terms of their ability to make inferences for patients whose treatment choices may be affected by a change in population treatment rates.

RESULTS

The instrument was positively related to the probability of being prescribed an antibiotic. LPM estimates showed a positive effect of antibiotics on OM patient cure probability while IV estimates showed no relationship between antibiotics and patient cure probability.

CONCLUSIONS

Linear probability model estimation yields the average effects of the treatment on patients that were treated. IV estimation yields the average effects for patients whose treatment choices were affected by the instrument. As antibiotic treatment effects are heterogeneous across OM patients, our estimates from these approaches are aligned with clinical evidence and theory. The average estimate for treated patients (higher severity) from the LPM model is greater than estimates for patients whose treatment choices are affected by the instrument (lower severity) from the IV models. Based on our IV estimates it appears that lowering antibiotic use in OM patients in Iowa Medicaid did not result in lost cures.

The spectrum and management of otitis media in Australian indigenous and nonindigenous children: a national study

BACKGROUND

Indigenous children have the highest reported prevalence and severity of otitis media in the world, but whether their clinical management varies accordingly is unknown.

METHODS

Using a representative Australia-wide cluster survey of consecutive primary healthcare consultations, we compared practitioners' investigation, treatment, and referral practices for otitis media in indigenous and nonindigenous children (0-18 years), after adjusting for clustering.

RESULTS

Over 8 years (1998-2006), 7991 practitioners managed 141,693 problems during 119,503 consultations with children, including 2856 (2%) with indigenous children. Ear problems were the fourth most common problems managed overall, with otitis media seen more commonly in indigenous than in nonindigenous children (10% versus 7% consultations, P < 0.001). Indigenous children were significantly more likely to have severe otitis media (chronic and/or suppurative and/or perforation, 8% versus 2%, P < 0.001); discharging ears (4% versus 0.1%, P < 0.001); ear swabs [4%, 95% confidence interval (CI): 2%-6% versus 0.8%, 95% CI: 0.6%-0.9%]; and topical eardrops administered (11%, 95% CI: 7%-15% versus 5%, 95% CI: 4%-5%); but not more likely to receive oral antibiotics (72% versus 76%); have ear syringing (1% versus 0.2%); be referred to an otolaryngologist (6% versus 3%) or audiologist (2% versus 1%); all P > 0.05.

CONCLUSIONS

In the Australian primary healthcare setting, indigenous children are 5 times more likely to be diagnosed with severe otitis media than nonindigenous children, but reported management is not substantially different, which is inconsistent with established national guidelines. This spectrum-management discordance may contribute to continued worse outcomes for indigenous children with otitis media.

WITHDRAWN: Antibiotics for persistent nasal discharge (rhinosinusitis) in children

BACKGROUND

Nasal discharge (rhinosinusitis) is extremely common in children. It is the result of inflammation of the mucosa of the upper respiratory tract, and is usually due to either infection or allergy. Infections may be caused by bacteria.

OBJECTIVES

To determine the effectiveness of antibiotics versus placebo or standard therapy in treating children with persistent nasal discharge (rhinosinusitis) for at least 10 days.

SEARCH STRATEGY

In this updated review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2005) which includes the ARI Group's specialised trials register; MEDLINE (1966 to April Week 3, 2005) EMBASE (1997 to December 2004), and the references of relevant articles were searched. Authors and pharmaceutical companies were contacted.

SELECTION CRITERIA

All randomised controlled trials that compared antibiotics versus placebo or standard therapy. Trials which included the use of other medications were included if all participants were allowed equal access to such medications or if the additional or alternative therapies were regarded as ineffective. Trials that only combined or compared antibiotics with surgery, or sinus puncture and lavage, were not included in the review.

DATA COLLECTION AND ANALYSIS

Data were extracted by a single author for the following eight outcomes: overall clinical failure (primary outcome), failure to cure, failure to improve, clinical improvement, time to resolution, complications, side-effects and bacteriologic failure. For the dichotomous outcome variables of each individual study, proportional and absolute risk reductions were calculated using a modified intention-to-treat analysis. The summary weighted risk ratio and 95% confidence interval (CI) (fixed effect model) were calculated using the inverse of the variance of each study result for weighting (Cochrane statistical package, RevMan version 4.2).

MAIN RESULTS

A total of six studies involving 562 children compared antibiotics with placebo or standard therapy. All studies were randomised but most were still susceptible to bias. Five of the studies were conducted in emergency, allergy or ENT clinics. Four of the studies required children to have x-ray changes consistent with sinusitis. Only the primary outcome (overall clinical failure) was reported in all studies. Around 40% of all randomised children did not have a clinical success documented when reviewed two to six weeks after randomisation. The control event rate varied from to 22 to 71% (mean 46%). The risk ratio estimated using a fixed effects model was 0.75 (95% CI 0.61 to 0.92). There was no evidence of statistical heterogeneity. Side effects (sufficient to cease treatment) occurred in 4 of 189 control group children (four studies). More children treated with antibiotics had side effects (17 of 330), but this difference was not statistically significant (RR 1.75, 95% CI 0.63 to 4.82).

AUTHORS' CONCLUSIONS

For children with persistent nasal discharge or older children with radiographically confirmed sinusitis, the available evidence suggests that antibiotics will reduce the probability of persistence in the short to medium-term. The benefits appear to be modest and around eight children must be treated in order to achieve one additional cure (number needed to treat (NNT) 8, 95% CI 5 to 29). No long term benefits have been documented. These conclusions are based on a small number of small randomised controlled trials and may require revision as additional data become available.

Acute otitis media in children aged less than 2 years: drug treatment issues

The management of acute otitis media (AOM) in childhood has evolved considerably during recent years as a result of the new insights provided by publication (in 2004) of the American Academy of Pediatrics and the American Academy of Family Physicians guidelines for the treatment of AOM. The new treatment guidelines establish a clear hierarchy among the various antibacterials used in the treatment of this disease and also the use of an age-stratified approach to AOM by recommending an observation strategy ('watchful waiting') without the use of antibacterials for some groups of patients with AOM. Infants and young children aged <2 years represent a target population characterized by a high incidence of AOM (and in particular of recurrent disease), lack of anatomic and physiologic maturity of airways, age-related immune humoral and cellular deficiencies, the presence of antibacterial-resistant pathogens, and a less efficient response to antibacterial treatment. Presently, the evidence accumulated in the literature is not sufficient to conclude that the role of antibacterials is only minimal in the management of AOM and that the watchful waiting policy is the most appropriate choice for patients aged <2 years with a certain AOM diagnosis. However, adherence to such a policy in patients with an uncertain or questionable AOM diagnosis and/or mild-to-moderate symptoms, in addition to its implementation in patients aged >2 years, could reduce substantially the use of antibacterials in children and play a major role in the strategy of decreasing antibacterial resistance.

Pediatric acute otitis media: the case for delayed antibiotic treatment

Acute otitis media (AOM) is both a commonly diagnosed condition and a frequent indication for antibiotic use in children. Recent literature suggests that antibiotics are not needed in many children with AOM, as most cases resolve spontaneously without complication. However, a majority of AOM infections in children are still treated with antibiotics. The American Academy of Pediatrics and American Academy of Family Physicians released a guideline for treatment of AOM in children. We review the guideline as well as scientific evidence related to AOM treatment options. We support a set of evidence-based guidelines employing a delayed prescription option for antibiotic therapy in selected children. If used appropriately, these cost-effective guidelines will reduce the amount of antibiotics prescribed, increase parental satisfaction, and may lower rates of antibiotic resistance while producing similar rates of resolution of AOM.

Cost-effectiveness analysis of treatment options for acute otitis media

PURPOSE

This study evaluated the costs and utility of observation and routine antibiotic treatment options for children with acute otitis media.

METHODS

The cost-effectiveness analysis was performed among children aged 6 months to 12 years seen in primary care offices. The interventions studied were watchful waiting as practiced in the Netherlands, delayed prescription, 5 days of amoxicillin, and 7 to 10 days of amoxicillin. The main outcome measure was cost per quality-adjusted life-year (QALY).

RESULTS

In the base case analysis, delayed prescription was the least costly option and 7 to 10 days of amoxicillin was the most effective. The incremental cost utility ratio (ICUR) of 7 to 10 days of amoxicillin compared with delayed prescription was 56,000 dollars per QALY gained. Watchful waiting and 5 days of amoxicillin were inferior options. The results were sensitive to the rate of nonattendance in the delayed prescription strategy: when the rate was less than 23%, watchful waiting was the least costly option and delayed prescription was an inferior option. Probabilistic sensitivity analysis, in which all model variables were simultaneously varied, showed with 95% certainty that compared with delayed prescription, 7 to 10 days of amoxicillin had a 61% probability of having an ICUR of greater than 50,000 dollars per QALY gained, and watchful waiting had a 23% probability of having an ICUR of less than 50,000 dollars per QALY gained.

CONCLUSIONS

Economically, an approach to the treatment of acute otitis media with either an initial period of observation or routine treatment with amoxicillin is reasonable.

Antibiotic prescribing in Australian general practice: How has it changed from 1990–91 to 2002–03?

There is increasing evidence that antibiotics have limited value for many respiratory illnesses. This study investigates changes in overall antibiotic prescribing rates, and rates for specific conditions, by Australian general practitioners (GPs) between 1990-91 and 2002-03. This is a comparative study of two cross-sectional surveys of general practice activity, the Australian Morbidity and Treatment Survey (AMTS) 1990-91 and Bettering Evaluation and Care of Health (BEACH) 2002-03. Both studies used random samples of GPs, each providing data about a cluster of patient encounters. Outcome measures are the antibiotic prescribing rate per 100 encounters or per 100 selected problems managed. Between 1990-91 and 2002-03, the overall antibiotic prescribing rate decreased 24.3% from 18.9 prescriptions per 100 encounters to 14.3 (P<0.001). For children, the decrease for acute upper respiratory tract infection (URTI) was from 39.0 per 100 URTI problems to 24.4 (P<0.001), while the antibiotic prescribing rate increased for acute otitis media, decreased for bronchitis/bronchiolitis, and remained unchanged for other respiratory problems analysed. For adults the antibiotic prescribing rate for URTI decreased from 58.2 per 100 URTI problems to 40.0 (P<0.001), increased significantly for sinusitis and remained unchanged for all other respiratory problems. Antibiotic prescribing decreased significantly between 1990-91 and 2002-03 but the decrease was selective. The decline has been more pronounced among children than adults, and particularly for URTI. While the message of educators may be achieving its goal for URTI, other approaches targeting specific respiratory problems may be required to reduce antibiotic prescribing in these areas.

Emerging therapies for the treatment and prevention of otitis media

Otitis media is one of the most common disorders occurring in children, and there is growing concern that bacteria are quickly becoming resistant to antimicrobials. As a result, global antibiotic treatment is no longer the standard of care and treatment of otitis media has changed dramatically in the last decade. In addition to new antimicrobials currently in development, the effects of the pneumococcal conjugate vaccine are just beginning to be understood. Furthermore, new surgical techniques are for the first time being tested as alternatives for tympanostomy tubes for recurrent acute otitis media. This review discusses current and emerging otitis media therapeutics, with particular attention to acute otitis media. Topics include antimicrobial use, antimicrobial resistance, effects of vaccination and new surgical techniques.

A safety-net antibiotic prescription for otitis media: the effects of a PBRN study on patients and practitioners

Pediatricians can decrease antibiotic use by treating acute otitis media (AOM) with a safety-net antibiotic prescription (SNAP). This study assessed whether the practitioners of the Practice-Based Research Network who participated in the study continued to use the SNAP and report a 60-day follow-up of the study patients. Charts were reviewed of study patients for 60 days following study enrollment. A survey on antibiotic use for AOM was mailed to the 17 study practitioners (SP) and 30 randomly selected community pediatricians (CP). Eight of the SP used the SNAP more than 20 times over the year following the study vs 1 of the CP. Sixty-two percent of patients never received antibiotics. The recurrence/relapse rate was greater in children younger than 2 years old compared to those older, 34% vs 10%. Practitioners who participate in a Practice-Based Research Network study are more likely to use a study intervention than others.

Microbiologic surrogate end points in clinical trials of infectious diseases: example of acute otitis media trials

Clinical outcomes that measure how patients feel, function, or survive are the most important and relevant outcomes of therapy in clinical trials and in clinical practice. Surrogate end points, which do not directly measure clinical benefit to the patient, may function as substitutes for clinical end points in clinical trials. Such surrogates are attractive as they may allow measurement of outcomes earlier in time or with a smaller sample size than with clinical outcomes. Microbiologic biomarkers, such as culture results at a specific time after start of therapy, or pharmacodynamic analyses of the effect of drugs on organisms often are proposed as surrogate end points in clinical trials of therapies for infectious diseases. However, evaluation of biomarkers as surrogate end points poses distinct challenges, and only a few biomarkers have been useful replacements for clinical end points. Evaluation of biomarkers as potential surrogate end points first requires an understanding of the differences among measurements of the cause of a disease, risk factors for outcome, and measurements of treatment effects. We will discuss the definitions of clinical and surrogate end points and the reasons why surrogate end points may not predict the true clinical benefit of therapies. We will use the example of the biomarker of microbiologic outcomes from tympanocenteses performed during therapy as the sole measure of clinical effectiveness in clinical trials of acute otitis media to illustrate the challenges in evaluating biomarkers as surrogate end points.

Development of a practical tool for assessing the severity of acute otitis media

BACKGROUND

Watchful waiting management of nonsevere acute otitis media (AOM) can reduce the use of antibiotics, but it requires a reliable means of assessing clinical severity.

OBJECTIVE

We present the development of a pocket AOM card with which the clinician can rapidly assess total AOM severity.

DESIGN/METHODS

The components of the pocket card consisted of a faces scale, to assess parent perception of severity, and a standard set of tympanic membrane photographs, with which the pediatrician can grade the severity of tympanic membrane inflammation. The components of the pocket card were tested for validity, reliability and responsiveness with the use of data from parents, pediatricians and pediatric otolaryngologists.

STATISTICS

Instruments were assessed for concurrent correlation, sequence validity and reliability against previously published questionnaires with the use of Spearman correlation. Responsiveness was calculated with the use of enrollment, day 12 and day 30 data from a randomized clinical trial.

RESULTS

The components of the pocket AOM card demonstrated excellent sequence validity, concurrent correlation and reliability (r = 0.58-0.99). Total AOM card severity, consisting of the sum of the 2 scales, demonstrated better responsiveness to change than any of the scales taken individually.

CONCLUSIONS

The AOM card combines a parent assessment of symptoms and the clinician assessment of the tympanic membrane to provide an assessment of total AOM severity that can be used to facilitate shared decision making between parent and clinician. The combined score of the AOM card was more responsive to change than any of the instruments used alone. The AOM card provides a useful tool for teaching and research.

Implementing guidelines for the treatment of acute otitis media

The recently published Clinical Practice Guideline for the Diagnosis and Management of Acute Otitis Media represents a sincere effort by the AAP andthe AAFP to provide management guidelines for the practitioner based upon the best scientific evidence available. Despite many years of research and hundreds of clinical studies addressing various aspects of the epidemiology, clinical presentation, and treatment of acute otitis media, important questions remain unaddressed or have been addressed in a less than optimal fashion. These gaps in knowledge and deficiencies in several of the studies that formed the scientific basis for the proposed guidelines are the major reasons behind continued disagreement over certain recommendations. Until more comprehensive and careful analyses can be performed, disagreements are likely to persist. Even so, there is general agreement about most of the recommendations made in these guidelines, and these recommendations will provide a very valuable framework for the practicing physician as he or she cares for children with acute otitis media. To briefly review the major points, first is the critical importance of accurately diagnosing acute otitis media using a combination of clinical findings and observable abnormalities of the tympanic membrane and middle ear space. Particularly important is the differentiation of acute otitis media from otitis media with effusion. Second is the value of treating the pain associated with acute otitis media as a regular component of care, irrespective of any decision concerning antimicrobial treatment. Third is the option, for a select group of older patients with nonsevere disease, of withholding antimicrobial therapy for the first 48 to 72 hours, if close follow-up and active parental involvement can be guaranteed. Fourth is the recommendation that if an antimicrobial agent is used, high-dose amoxicillin (80 to 90 mg/kg/d) is the treatment of choice for most children at the time of initial presentation unless disease is particularly severe or the child has recently failed a previous course of the antibiotic. Finally highlighted is the importance of ongoing education efforts on the part of physicians in advising parents about the things they can do in their households to lessen the risk of future disease.

Study of nasopharyngeal bacterial flora. Second report. Variations in nasopharyngeal bacterial flora in children aged 6 years or younger when administered antimicrobial agents. Part 1

In our first report, we investigated nasopharyngeal bacterial flora related to penicillin-resistant Streptococcus pneumoniae (PRSP) and beta-lactamase-negative ampicillin-resistant Haemophilus influenzae (BLNAR) and their relation to acute upper respiratory tract infection (AURTI). This report analyzes the results of a study of nasopharyngeal bacterial flora before the administration of antimicrobial agents in 172 AURTI patients aged 6 years or younger. In addition to Gram staining, microscopic observation, and culturing, a polymerase chain reaction (PCR) method was used to identify PRSP (gPRSP) and BLNAR (gBLNAR) drug-resistant genes. Of the patients analyzed, 90% had acute otitis media (AOM) and were aged 2 years or younger. The antimicrobial agents administered were amoxicillin (34%), clavulanic acid/amoxicillin (11%), cefditren pivoxil (CDTR-PI) (43%), and others (12%). This was particularly true for patients administered CDTR-PI, among whom there were many who had already suffered one or more episodes of AOM by the age of 1 year or younger, and many in which gPRSP were detected (P < 0.01). There was a significant relation between the degree of nasopharyngeal inflammation indicated by leukocyte infiltration images and the amount of S. pneumoniae and H. influenzae detected, which are the main pathogenic bacteria causing AOM (P < 0.01). In addition to leukocyte infiltration images, there were cases in which shedding of ciliated cells was observed and/or giant monocytic cells. Both nasopharyngeal leukocyte infiltration images and/or shed cell findings observed in infant AURTI cases are important indices for the prompt detection of gPRSP and/or gBLNAR and appropriate doses of antimicrobial agents.

Manejo racional de la antibioterapia en las infecciones otorrinolaringológicas en la infancia: revisión crítica de las mejores pruebas científicas

INTRODUCTION

Upper respiratory tract infections are the more prevalent infections in childhood and it is important to know the use and overuse of antibiotics. The objective of this article is to make a systematic and critical review of the best scientific evidence in bibliography in order to use antibiotics rationally in otorhinolaryngology (ORL) infections.

MATERIAL AND METHODS

Systematic and structured review of the articles regarding antibiotherapy in ORL infections (pharyngitis, tonsillitis, otitis, sinusitis and laryngitis) in childhood published in secondary (Cochrane Collaboration, clinical practice guidelines, health technology assessment database, etc) and primary (bibliographic databases, biomedical journals, books, etc.) publications and critical appraisal by means of methodology of the Evidence-Based Medicine Working Group. We selected the publications with the main scientific evidence in therapeutical articles (clinical trial, systematic review, meta-analysis and clinical practice guideline).

DATA SELECTION

study design, population, intervention, outcomes, main results and applicability in clinical practice.

RESULTS

The main secondary information is found in The Cochrane Library and in Clinical practice guideline clearinghouses. The documents in Cochrane Library are, basically, clinical trials, systematic reviews and/or meta-analysis, mainly about otitis (13 documents), sinusitis/rhinosinusitis (6), pharyngitis/tonsillitis (3) and nasopharyngitis (3). We found 17 guidelines, mainly for otitis (8 guidelines), pharyngitis/tonsillitis (5), sinusitis (3) and laryngitis (1). Also, we found some relevant articles in Pubmed database, complementary to secondary publications.

CONCLUSIONS

There are a high number of quality scientific studies who support an evidence-based decision making in clinical practice about the rational use of antibiotics in ORL infections in childhood, mainly in otitis, tonsillitis and sinusitis. Every decision in this field will have to be based on a systematic appraisal of the best evidence available in the context of the prevailing values and resources available. Doctor's knowledge (mainly in otorhinolaryngologists and pediatricians) of systematic and critical review of the current literature can help to modify prescribing habits about overuse and misuse of antibiotics in ORL infections.

Delayed otogenic hydrocephalus after acute otitis media in pediatric patients: the changing presentation of a serious otologic complication

CONCLUSIONS

The clinical presentation of otogenic dural sinus thrombosis (DST) as a complication of acute otitis media (AOM) can be masked by antibiotic treatment. Morning episodes of vomiting and/or headache, visual impairment and a history of AOM seem to be indicative of otogenic hydrocephalus. We therefore advocate that the MRI scans of patients with similar symptoms should be carefully studied to facilitate the early diagnosis of a potentially life-threatening complication.

OBJECTIVE

To describe the frequency, pathognomonic signs, clinical course and outcome of otogenic hydrocephalus and DST as complications of AOM in pediatric patients.

MATERIAL AND METHODS

We undertook a retrospective chart review of all pediatric patients (age 1-14 years) treated for otitis media and its complications at an academic medical center between 1999 and 2003. The main outcome measures were otologic and ophthalmologic findings and CT and MRI scans at the beginning of treatment and 3 months later.

RESULTS

We report on five cases with otogenic DST following AOM. All but one of them presented initially with diplopia caused by otogenic hydrocephalus. In four cases the otologic complaints had already disappeared by the time of MRI confirmation of the diagnosis. Only one child was referred with severe otologic symptoms. Management included systemic antibiotics, short-term heparin anticoagulation and surgical decompression. In our cases, even after intensive i.v. antibiotic treatment, only surgery led to a significant improvement in the clinical condition.

A randomized, double-blind, placebo-controlled noninferiority trial of amoxicillin for clinically diagnosed acute otitis media in children 6 months to 5 years of age

OBJECTIVES

Debate continues with respect to a "watch and wait" approach versus immediate antibiotic treatment for the initial treatment of acute otitis media. In this double-blind noninferiority trial, we compared clinical improvement rates at 14 days for children (6 months to 5 years of age) with acute otitis media who were randomly assigned to receive amoxicillin or placebo.

METHODS

We enrolled healthy children who presented to clinics or the emergency department with a new episode of acute otitis media during the fall and winter months in Ottawa (from December 1999 to the end of March 2002). The children were randomly assigned to receive amoxicillin (60 mg/kg daily) or placebo for 10 days. Telephone follow-up was performed on each of days 1, 2 and 3 and once between day 10 and day 14. The primary outcome was clinical resolution of symptoms, defined as absence of receipt of an antimicrobial (other than the amoxicillin in the treatment group) at any time during the 14-day period. Secondary outcomes were the presence of pain and fever and the activity level in the first 3 days, recurrence rates, and the presence of middle ear effusion at 1 and 3 months.

RESULTS

According to clinical scoring, 415 of the 512 children who could be evaluated had moderate disease. At 14 days 84.2% of the children receiving placebo and 92.8% of those receiving amoxicillin had clinical resolution of symptoms (absolute difference -8.6%, 95% confidence interval -14.4% to -3.0%). Children who received placebo had more pain and fever in the first 2 days. There were no statistical differences in adverse events between the 2 groups, nor were there any significant differences in recurrence rates or middle ear effusion at 1 and 3 months.

INTERPRETATION

Our results did not support the hypothesis that placebo was noninferior to amoxicillin (i.e., that the 14-day cure rates among children with clinically diagnosed acute otitis media would not be substantially worse in the placebo group than the treatment group). Nevertheless, delaying treatment was associated with resolution of clinical signs and symptoms in most of the children.

The clinical course of acute otitis media in high-risk Australian Aboriginal children: a longitudinal study

BACKGROUND

It is unclear why some children with acute otitis media (AOM) have poor outcomes. Our aim was to describe the clinical course of AOM and the associated bacterial nasopharyngeal colonisation in a high-risk population of Australian Aboriginal children.

METHODS

We examined Aboriginal children younger than eight years who had a clinical diagnosis of AOM. Pneumatic otoscopy and video-otoscopy of the tympanic membrane (TM) and tympanometry was done every weekday if possible. We followed children for either two weeks (AOM without perforation), or three weeks (AOM with perforation), or for longer periods if the infection persisted. Nasopharyngeal swabs were taken at study entry and then weekly.

RESULTS

We enrolled 31 children and conducted a total of 219 assessments. Most children had bulging of the TM or recent middle ear discharge at diagnosis. Persistent signs of suppurative OM (without ear pain) were present in most children 7 days (23/30, 77%), and 14 days (20/26, 77%) later. Episodes of AOM did not usually have a sudden onset or short duration. Six of the 14 children with fresh discharge in their ear canal had an intact or functionally intact TM. Perforation size generally remained very small (<2% of the TM). Healing followed by re-perforation was common. Ninety-three nasophyngeal swabs were taken. Most swabs cultured Streptococcus pneumoniae (82%), Haemophilus influenzae (71%), and Moraxella catarrhalis (95%); 63% of swabs cultured all three pathogens.

CONCLUSION

In this high-risk population, AOM was generally painless and persistent. These infections were associated with persistent bacterial colonisation of the nasopharynx and any benefits of antibiotics were modest at best. Systematic follow up with careful examination and review of treatment are required and clinical resolution cannot be assumed.

Watchful waiting for acute otitis media: are parents and physicians ready?

OBJECTIVE

To assess the current use of initial observation ("watchful waiting") of acute otitis media among community physicians and the acceptability of this option to parents of young children.

SETTING

Sixteen nonoverlapping Massachusetts communities enrolled in a community intervention study on appropriate antibiotic use.

DESIGN

Pediatricians, family physicians, and a random sample of parents of children <6 years old were surveyed. Parents predicted what their satisfaction would be with initial observation of an ear infection without antibiotics if suggested by their physician and concerns they would have regarding this watchful-waiting approach. Physicians reported the frequency with which they use this approach in children > or =2 years and those <2 years old. Separate multivariable models identified factors independently associated with parental satisfaction and with frequency of self-reported use by physicians. All models accounted for clustering of responses within communities.

RESULTS

Two thousand fifty-four (40%) parents and 160 (58%) physicians responded. Of the parents, 34% would be somewhat or extremely satisfied if initial observation was recommended, another 26% would be neutral, and the remaining 40% would be somewhat or extremely dissatisfied. The multivariable model showed lower parental education (odds ratio [OR]: 0.50; 95% confidence interval [CI]: 0.35, 0.71, for high school education or less compared with college graduation) and Medicaid enrollment (OR: 0.77; CI: 0.57, 1.0) was associated with lower predicted satisfaction. Higher antibiotic-related knowledge (OR: 1.2; CI: 1.1, 1.3, per question correct), belief that antibiotic resistance is a serious problem (OR: 2.3; CI: 1.8, 2.8), and reporting feeling included in medical decisions (OR: 1.4; CI: 1.1, 1.7) all were independently associated with higher predicted satisfaction. Thirty-eight percent of physicians treating children > or =2 years old never or almost never reported using initial observation, 39% reported use occasionally, 17% sometimes, and 6% most of the time. In a multivariable model, only more years in practice (OR: 0.96; CI: 0.93, 0.99) was associated with a decreased likelihood of occasional or more-frequent use of watchful waiting (compared with those who never use initial observation). However, a secondary model that combined occasional users with nonusers (compared with those reporting use sometimes or more often) identified several correlates of use of observation: years in practice (OR: 0.95; CI: 0.91, 0.99), family medicine specialization (OR: 4.5; CI: 1.9, 11), belief that antibiotic resistance is a significant problem (OR: 4.3; CI: 1.3, 14.5), and practice in a community receiving a judicious antibiotic-use intervention (OR: 3.5; CI: 1.3, 9.1).

CONCLUSIONS

A majority of physicians reported at least occasionally using initial observation, but few use it frequently. Many parents have concerns regarding this option, but acceptability is increased among those with more education and those who feel included in medical decisions. Substantial change in both parental and provider views would be needed to make initial observation a widely used alternative for acute otitis media.

Randomized, investigator-blinded, multicenter study of gatifloxacin versus amoxicillin/clavulanate treatment of recurrent and nonresponsive otitis media in children

BACKGROUND

Decreased susceptibility of pathogens to currently used agents for recurrent otitis media has provided the impetus for identifying new antimicrobial options.

OBJECTIVE

To compare gatifloxacin with amoxicillin/clavulanate in children with recurrent or nonresponsive acute otitis media (AOM).

METHODS

Included in this multicenter randomized trial were 413 patients, ranging in age from 6 months to 7 years, who had recurrent AOM (at least 3 episodes in the previous 6 months or 4 episodes in the previous 12 months) and/or had failed antibiotic therapy for AOM within 14 days of enrollment. Diagnosis required evidence of acute inflammation and otoscopic findings of middle ear effusion; baseline tympanocentesis was optional and encouraged. Children were randomly assigned (2:1) to 10 days of oral therapy with gatifloxacin suspension (10 mg/kg of body weight once daily) or amoxicillin/clavulanate suspension (45/6.4 mg/kg/d in 2 divided doses).

RESULTS

: Clinical cure was obtained in 90.2% (222 of 246) of patients in the gatifloxacin group and 84.3% (102 of 121) of those in the amoxicillin/clavulanate group (95% confidence interval, -1.9-12.9) 3-10 days after treatment ended. Gatifloxacin was associated with higher clinical cure rates than was amoxicillin/clavulanate in children younger than 2 years of age (92.0% versus 80.0%, respectively). Cure rates by pretreatment pathogen in the gatifloxacin and amoxicillin/clavulanate groups were 92.1% (35 of 38) versus 88.9% (16 of 18) for Streptococcus pneumoniae infections and 88.2% (30 of 34) versus 92.3% (12 of 13) for Haemophilus influenzae infections, respectively. Sustained clinical cures 3-4 weeks after treatment ended were obtained in 74.4% (183 of 246) of patients treated with gatifloxacin and 72.7% (88 of 121) of those treated with amoxicillin/clavulanate. Adverse events considered drug-related occurred with similar frequency in the 2 groups. Six patients (2.2%) in the gatifloxacin group and 2 patients (1.5%) in the amoxicillin/clavulanate group developed transient symptoms of mild or moderate arthralgia.

CONCLUSIONS

In this comparative evaluation of fluoroquinolone therapy in children with AOM, gatifloxacin was similar in clinical efficacy to amoxicillin/clavulanate 45/6.4 mg/kg/d for treatment of recurrent/nonresponsive infections.

Effectiveness of amoxicillin, azithromycin, cefprozil and clarithromycin in the treatment of acute otitis media in children: a population-based study

Population-based studies may give results different from randomized clinical trials assessing the efficacy of antibiotics.

OBJECTIVE

To determine the effectiveness of amoxicillin, azithromycin, cefprozil and clarithromycin in the treatment of acute otitis media (AOM) in children.

METHODS

Using Quebec Health Insurance databases (RAMQ), we selected a cohort of children aged < or = 6 years, with a first episode of AOM between 1999 and 2002. The index AOM was defined as a medical service claim with a diagnosis of AOM and an antibiotic dispensation in the following 72 hours. Failures were defined as a new antibiotic dispensation, a hospitalization or outpatient visit for complications related to AOM in the 30 days after the index AOM. Data were analyzed using logistic regression.

RESULTS

Overall, 12,693 failures occurred among 60,513 first episodes of AOM. Azithromycin was the only antibiotic that was associated with a decreased risk of failure overall, when compared to amoxicillin (OR 0.88, 95% CI: 0.82, 0.94). However in the first 3 days of treatment (n = 680), azithromycin was more associated with treatment failure (OR 1.6, 95% CI: 1.3, 2.0). Compared to amoxicillin, post-therapy failures (n = 9387) were more likely to occur with cefprozil (OR 1.2, 95%CI: 1.2, 1.3) but were less with azithromycin (OR 0.8 95% CI: 0.8, 0.9).

CONCLUSIONS

Azithromycin had the lowest risk of failure 30 days after the onset of treatment but an increased risk of failure during the first few days of treatment. Amoxicillin remains an effective first-line drug for treating first AOM episodes.

Effect of pneumococcal vaccination on quality of life in children with recurrent acute otitis media: a randomized, controlled trial

BACKGROUND

Limited effectiveness of current treatment strategies for recurrent acute otitis media (RAOM) and increasing antibiotic resistance have diverted attention to prevention of AOM by vaccination. Pneumococcal vaccination for AOM seems to have only modest clinical efficacy. Thus far, the effects on health-related quality of life (HRQoL) or functional health status (FHS) have not been studied.

OBJECTIVE

To assess the effect of vaccination on HRQoL or FHS.

METHODS

In a double-blind, randomized, controlled trial, 383 children 1 to 7 years old with RAOM were vaccinated with either heptavalent pneumococcal conjugate vaccine followed by pneumococcal polysaccharide vaccine (pneumococcal group: n = 190) or with hepatitis A or B vaccines (control group: n = 193). Parents completed validated Dutch versions of 8 HRQoL and FHS instruments assessing generic FHS (Rand, Functional Status Questionnaire specific, and Functional Status Questionnaire generic), otitis media-specific FHS (OM-6), otitis media-specific child HRQoL (Numerical Rating Scale for Child), family functioning (Family Functioning Questionnaire), and otitis media-specific caregiver HRQoL (Numerical Rating Scale for Caregiver). Scores were compared at baseline and at 14 and 26 months' follow-up.

RESULTS

At baseline, the average AOM incidence in the pneumococcal and control group was 5.0 (SD: 2.8) and 4.9 (SD: 2.6) episodes per year, respectively, with 38.4% and 36.8% having suffered from > or =6 episodes per year. AOM frequency decreased 4.4 episodes per year in both groups, with a considerable and comparable improvement in HRQoL and FHS. No substantial differences in HRQoL or FHS were found between the pneumococcal and the control group at baseline or at 14 or 26 months' follow-up.

CONCLUSION

Pneumococcal vaccination has no beneficial effect compared with control vaccination on either HRQoL or FHS in children 1 to 7 years old with RAOM.

A willingness-to-pay assessment of parents' preference for shorter duration treatment of acute otitis media in children

OBJECTIVE

To assess parental willingness to pay (WTP) for a shorter course of antibacterial treatment versus conventional antibacterial therapy for acute otitis media (AOM).

METHODS

The study population consisted of 562 parents of children who had been seen and treated by a paediatrician for an episode of AOM between February and November 2002 in Montreal, Quebec, Canada. At the end of the AOM treatment, a questionnaire that included demographic information about the parents and child, details of the child's AOM history, a global wellbeing (i.e. quality of life) assessment, an evaluation of treatment compliance and a scripted WTP question was administered over the telephone. Descriptive analyses were performed in addition to a multivariate analysis to estimate possible predictors of parental WTP.

RESULTS

The children with AOM were representative of the AOM patient population, with 46% being <2 years of age and the majority attending day-care or school. Parents were willing to pay a median of 31.66 Can dollars (2002 values) for a mono-dose (one dose, on 1 day) and 26.63 Can dollars for a tri-dose (one dose daily, for 3 days) antibacterial treatment. Regression analyses demonstrated that the amount parents were willing to pay was positively associated with increasing household income, increasing number of AOM episodes during the previous year and experiencing adverse effects of treatment.

CONCLUSION

Parents of children with AOM were willing to pay more for their child to benefit from a shorter duration of antibacterial treatment than for a standard course. Short duration of treatment appears to be associated with better compliance and parents' perception of better general wellbeing for their child.

Effect of myringotomy on prognosis in pediatric acute otitis media

OBJECTIVE

In children with acute otitis media (AOM), we compared clinical outcomes between groups with and without myringotomy to elucidate the effect of this procedure on long-term clinical course and prognosis.

METHODS

Fifty-nine children (29 male, 30 female) with tympanic membrane bulging or middle ear fluid (MEF) at initial presentation were assigned to one of two treatment groups. Group A received oral antibiotics and also underwent myringotomy at initial enrollment (36 cases), while group B received oral antibiotics without myringotomy (23 cases). Clinical outcomes were evaluated by otolaryngologic specialists using pneumatic otoscopy and tympanometry at 5, 10, 15, 30 days and 12 weeks and then every 2 weeks after the initial treatment. Otitis media with effusion (OME), early recurrence and recurrent AOM were used as the evaluation criteria for the prognosis.

RESULTS

In group A, 6 children (16.7%) showed transition to OME, 11 (30.6%) showed early recurrence of AOM, and 9 (25.0%) developed recurrent AOM. In group B 10, 8, and 3 (43.5%, 34.8%, and 13.0%) showed these respective adverse outcomes. While early recurrence rates and recurrent AOM rates did not differ significantly between groups, progression of OME was significantly less frequent in group A than group B (P = 0.036).

CONCLUSIONS

Lower rates of progression to OME in the group undergoing myringotomy suggested that myringotomy might be effective in preventing this outcome.