E-drug: Re: Treatment of Acute Otitis Media (AOM) (cont'd)
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[Note from moderator: This is the last posting on this topic unless other
E-druggers want to participate. I apologize in case you feel we took this
too far. But it did move from one topic to another, and treatment of AOM is
actually quite important as it is the most frequent indication in general
practice for prescribing antibiotics and as you will see from the references
(which I hope you will find useful), has been a frequent topic for review
articles during the last 2-3 years. We have also demonstrated the
differences between North America and Europe in the use of antibiotics.
Probably the most important cause of the much higher resistance in USA than
in Northern Europe. Kirsten Myhr]
Reply to "Note from moderator, K Myhr, 1 Jun 1999 14:19:22 GMT"
Antimicrobial therapy in AOM in some studies have suggested that its routine
use is not indicated (2-4). Because the majority of cases of AOM resolve
spontaneously (1), it might appear that antimicrobial therapy is not
necessary. Nonetheless, in the preantibiotic era, complications of AOM such
as mastoiditis were far more common than they are today (5,6); this
difference may be due to the current routine use of antibiotics. A recent
meta-analysis of 5400 children with AOM indicated that antimicrobial therapy
enhanced the primary control by 13.7% despite a spontaneous recovery in 81%
of cases (1). Because it is not possible to determine a priori which cases
of AOM will result in suppurative complications, it is likewise not possible
to determine which cases require antimicrobial therapy and which will
resolve spontaneously. Therefore, it appears prudent to consider all cases
of AOM candidates for antimicrobial therapy in order to minimize the
likelihood of complications. This is clearly an area where more research is
required to identify which patients with AOM require therapy and which would
improve spontaneously without it. Some recommend watchful waiting for 48 to
72 h before initiating antibiotic therapy (4). This approach may be feasible
in children over two years of age if good follow-up can be assured;
therefore, decisions about whether to withhold antibiotic therapy initially
must be made on a patient-by-patient basis.
REFERENCES from Canadian Paediatric Society :
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. van Buchem FL, Dunk JH, van�t Hof MA. Therapy of acute otitis media:
Myringotomy, antibiotics, or neither? A double-blind study in children.
Lancet 1981;ii:883-7.
3. Mygind N, Meistrup-Larsen KI, Thomsen J, et al. Penicillin in acute
otitis media: A double-blind placebo-controlled trial. Clin Otolaryngol
1981;6:5-13.
4. van Buchem FL, Peeters MF, van�t Hof MA. Acute otitis media:
A new treatment strategy. Br Med J 1985;290:1033-7.
5. Gold R. Consensus recommendations for the management of otitis media. Can
J Diagnosis 1989;6:67-76.
6. Berman S. Otitis media in children. N Engl J Med 1995;332:1560-5.
Blaine P. Carmichael, PA-C
bpcarmichael@stic.net
San Antonio, Texas, USA
[Note from moderator: I think the following references are also highly
relevant and represent the most updated review:
- DelMar C, Glasziou P, Hayem M. Are antibiotics indicated as inital
treatment for children with acute otitis media? A meta-analysis. BMJ
1997;314:1526-9
Conclusion: Early use of antibiotics provides only modest benefit for AOM;
to prevent one child from experiencing pain by 2-7 days after presentation,
17 children must be treated with antibiotics early.
- Froom J et al. Antimicrobials for acute otitis media? A review from the
International Primary Care Network. BMJ 1997;315:98-102
Summary points:
Bacterial resistance to antimicrobials is responsible for increasing
morbidity, mortality and costs.
Evidence from randomised, placebo controlled trials that routine use of
antimicrobials decreases the duration and severity of symptoms and prevents
complications is weak.
treatment of AOM differs worldwide, and careful use of antimicrobials in the
Netherlands and Iceland seems to have reduced rates of resistance among
organisms without compromising outcomes.
The management of AOM needs reassessing.
- Pediatr Infect Dis J also carried several articles in 1998; e.g.:
Klein JO. Protecting the therapeutic advantage of antimicrobial agents used
for otitis media. Peadiatr Infect Dis J 1998;17:571-5
I agree that it there is a need for more research to identify the children
that will benefit from antibiotics. This is not the kind of research that
pharmaceutical companies are likely to sponsor and therefore difficult to
get funding for.
In the meantime, the following preventive measures should be taken:
support aggressive encouragement of breast-feeding, avoid tobacco smoke in
the home, encourage day care centres to increase handwashing by staff and
children. Education of parents on the topic: "When your child is sick,
antibiotics are not always the answer".
And this, although it doesn't touch on the issue of no treatment:
Kozyrski AL et al. Treatment of acute otitis media with a shortened course
of antibiotics. A meta-analysis. JAMA 1998;279:1736-42
KM]
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