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AOM observation therapy methods were successful in ED setting
Observation therapy without a prescription substantially reduced antibiotic use in patients with AOM.
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Observation therapy with or without a prescription for antibiotic treatment effectively reduced antibiotic use among children with acute otitis media, aged 2 to 12 years, without compromising parent satisfaction during an emergency department visit, according to researchers from New York.
“Our results go against the popular notion among physicians that even after waiting several hours to be seen, parents only want a prescription for antibiotics,” Jennifer H. Chao, MD, of the department of emergency medicine at the SUNY Downstate Medical Center, New York, told Infectious Diseases in Children.
According to the researchers, this is the first study to directly compare observation therapy among children for acute otitis media with and without a prescription in any health care setting. Despite the fact that many children with acute otitis media are treated in the ED, researchers from most studies of observational therapy have focused on children outside of the pediatric ED.
Urban ED setting
In a prospective, randomized trial, Chao and colleagues randomly assigned 206 children with acute otitis media, aged 2 to 12 years, to observation therapy with or without a prescription for antibiotic treatment.
Parents of children in the observation therapy group (n=100) were told to return to the ED or to their primary care physician if symptoms persisted for two to three days following the initial visit. Parents of children in the observation therapy plus prescription group (n=106) were instructed to fill the prescription only if symptoms persisted for two to three days following the initial ED visit.
The researchers also issued a discharge instruction sheet to parents of both groups of children, which described how to manage earache or fever during the observation period and listed indications for seeking follow-up care or initiation of antibiotics.
At the discretion of the treating physician, parents of children in both groups may have been given ibuprofen or acetaminophen as well as antipyrine plus benzocaine otic drops for the child.
Trained research assistants (blinded to each patient’s assigned group) contacted parents via telephone seven to 10 days following the initial ED visit. The researchers used a standardized survey to assess health status, interim antibiotic or other medication use, parent’s satisfaction with the ED visit and any interim health care visits.
Patients with a diagnosis of acute otitis media were eligible to participate in the study; however, they were excluded if they:
- Had a history of craniofacial abnormalities or an immunodeficiency.
- Were already on antibiotics.
- Were concurrently diagnosed with a bacterial infection that required antibiotic treatment.
- Had an episode of acute otitis media within the last 30 days.
- Had pain not relieved within 30 minutes following administration of analgesics in the ED.
- Had a history of ear pain or fever for more than 48 hours.
- Did not have access to a telephone.
Adherence
Results of the study indicated 87% of parents of children in the observation therapy group reported that they did not give their child antibiotics or visit their primary care physician within the three-day observational period vs. 62% of parents of children in the prescription group (95% CI, 2.01-8.20).
During the seven- to 10-day follow-up, 81% of parents of children without a prescription stated they did not use antibiotics vs. 53% of parents of children with a prescription (95% CI, 1.95-6.87).
“Although both methods were well accepted, there was a greater adherence to delayed antibiotic therapy with the observation therapy group compared with the observation therapy plus prescription group,” the researchers wrote. “Parents given a prescription were more likely to fill the prescription within the first three days following the initial ED visit, contrary to the advice of the physician.”
Data further indicated both groups of parents were either very or extremely satisfied in terms of satisfaction with their ED visit (91% vs. 95%).
Furthermore, there were no reports of adverse events for either group at the seven- to 10-day follow-up, and during the study period, in the 206 cases of AOM, 138 courses of antibiotics were avoided, according to the researchers.
“Observation therapy was well accepted by parents in this urban ED setting, whether they left the ED with or without a prescription,” Chao said. “Although the majority of patients who left the ED with a prescription did not inappropriately fill it, even more patients were spared exposure to antibiotics if they left without a prescription. Hopefully, this will encourage more physicians to use observation therapy without a prescription for acute otitis media, both in the clinic as well as in ED settings.” – by Jennifer Southall
For more information:
- Chao J, Kunkov S, Reyes LB, et al. Comparison of two approaches to observation therapy for acute otitis media in the emergency department. Pediatrics. 2008;doi:10.1542/peds.2007-2278.