E-drug: Re: NoFreeLunch /treatment of AOM (cont'd)
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Bacteria cause the majority of cases of AOM, and the most frequent etiological
agents are Streptococcus pneumoniae, nontypeable Haemophilus influenzae,
Moraxella catarrhalis, group A streptococcus and Staphylococcus aureus. Viruses
continue to cause a substantial minority of cases (2), and antibiotic therapy
would not be expected to affect the outcome. With the increasing prevalence of
beta-lactamase-producing (penicillin-resistant) strains of H influenzae and M
catarrhalis, alarms have been sounded about the wisdom of routinely using
aminopenicillins (such as amoxicillin) as the standard first-line antimicrobial
for uncomplicated AOM. Despite theoretical concerns about the diminishing
usefulness of amoxicillin, it continues to be as effective as any other oral
antimicrobial agent for childhood AOM. In fact, it works as well as extended
spectrum, penicillinase-resistant oral agents for otitis media caused by either
penicillin-susceptible or -resistant bacteria (1). Most comparative trials of
antimicrobial therapy in AOM have failed to demonstrate a difference in
effectiveness between amoxicillin and any other agent. Furthermore, the
newer, broader spectrum, penicillinase-stable antimicrobial agents are
substantially more expensive than amoxicillin (Table 1), and their use may
be associated with relatively high rates of side effects and may increase
the pressure for selection of multiply antibiotic-resistant strains of
bacteria. Therefore, because of its excellent �track record� (for infections
due to penicillin-susceptible and -resistant bacteria), low cost, safety and
acceptability to patients, amoxicillin remains the drug of choice for
uncomplicated AOM.
REFERENCES
1. Rosenfeld RM, Vertrees JE, Carr J, et al. Clinical efficacy of antimicrobial
drugs for acute otitis media: Metaanalysis of 5400 children from
thirty-three randomized trials. J Pediatr 1994;124:355-67.
2. Carroll K, Reimer L. Microbiology and laboratory diagnosis of
upper respiratory tract infections. Clin Infect Dis 1996;23:442-8.
Blaine P. Carmichael, PA-C
bpcarmichael@stic.net
[Note from moderator: 80% of AOM should not be treated with antibiotics in
the first place (1). Number of patients receiving antibiotic treatment
differs substantially between countries, from 31% in the Netherlands to 98%
in Australia and USA. Even if several studies show that many children do not
benefit from treatment with anitbiotics, CDC and others in USA continue to
recommend such treatment. Fortunately I come from a country with a
restrictive antibiotic policy abd therefore with few resistance problems. A
study in press concludes that one reason is our use of Penicillin V as
antibiotic of first choice for ARI etc. (search Medline for authors
Hjortdahl P and/or Lindbaek M). We use Penicillin V as first choice and
treat for 5 days. Only in frequent and recurrent cases do we recommend
amoxycillin, in resistant cases which may be caused by
beta-lactamaseproducing H influenzae we recommend moxycillin+ clavulanic
acid.(In Norway only on the market as a mixture for children). A recent
intervention study from an acute care unit in a city in Norway showed that
before intervention 85% received a prescription, after intervention with
information to doctors and patients (including advice to the parents to wait
for a day or two before starting treatment), 68% received a prescription.
Only 70% of the prescriptions were filled in both periods. In a prescription
survey in another county, 44% of patients with AOM received a prescription
(Straand J et al. Drug prescribing for children in general practice. A
report from the M�re & Romsdal Prescription Study. Acta Paediatr
1998;87:218-24). Kirsten Myhr]
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