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Sharpening diagnostic skills for AOM key to achieving judicious use of antimicrobials
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In 2004, the American Academy of Pediatrics and the American Academy of Family Practitioners developed and published a guideline for the diagnosis and management of acute otitis media.
The intent of the guideline was to highlight the importance of pain control for children with acute otitis media (AOM) and to curb the overuse of antibiotics. The strategy that the guideline employed to reduce the use of antibiotics relies on the so-called “observation option” or watchful waiting. In this strategy, under some circumstances, the practitioner is encouraged to postpone treating the child with AOM immediately; instead, they are encouraged to wait and see if the patient improves spontaneously over the next several days. If they fail to improve, then antibiotic treatment is endorsed.
The current enthusiasm for watchful waiting as an approach to children with AOM is a response, at least in part, to the escalation of antibiotic resistance among the pathogens that cause the common bacterial infections of childhood. The notion of watchful waiting arises from reports of several meta-analyses that have summarized the randomized controlled clinical trials of antimicrobial drug therapy for AOM in children. These meta-analyses support the conclusion that antibiotics are only modestly beneficial compared with placebo for children with AOM and that there has been no demonstrable superiority of any antibiotic compared to amoxicillin in the treatment of this condition. Unfortunately, the evidence is not sufficient to support this conclusion.
Without going into detail, many of the studies included in these meta-analyses are imperfect studies with several substantial shortcomings. The most common problem is the inclusion in many of these studies of children who do not actually have AOM but rather have otitis media with effusion (OME), a condition in which non-infected fluid is in the middle ear cavity. As might be predicted, if a substantial number of children included in the studies actually have OME rather than AOM, it would not be surprising that there would be either modest differences or no differences in outcome between children receiving antimicrobial and those receiving placebo. Although authors of the guideline advocated for improvement in diagnostic skills, which would permit the differentiation of AOM from OME in most cases, they nonetheless endorsed an observation option.
Treatment algorithm
The table below summarizes the algorithm that was offered by the guideline with regard to the antibiotic management of AOM in a schema based on age of the patient, severity of the clinical presentation and certainty of the diagnosis.
An episode of AOM was considered to be severe if the patient presented with temperature greater than 39.0°C and if otalgia was moderate or severe. All remaining cases were considered to be non-severe. A diagnosis was deemed to be uncertain if the clinician was not able to adequately visualize the tympanic membrane. This might happen when the tympanic membrane was obscured by cerumen or blood or if the canal was narrow and circuitous.
The option to observe the patient was offered in three circumstances: 1) in children older than 2 years with acertain diagnosis but who are classified as non-severe; 2) children 6-24 months with an uncertain diagnosis who are classified as non-severe, and 3) children older than 24 months of age with an uncertain diagnosis. In contrast, antimicrobials were advised for children younger than 2 years with a certain diagnosis, but also for infants less than 6 months of age if the diagnosis was uncertain and for those 6 to 24 months of age if they had high fever and the diagnosis was uncertain. Accordingly, the guideline puts us in the awkward position of treating children with an uncertain diagnosis and withholding antibiotics from children in whom the diagnosis is certain (albeit not severe).
Coco and colleagues recently published an article titled: Management of AOM after publication of the 2004 AAP and AAFP clinical practice guideline. They analyzed the National Ambulatory Medical Care Survey for 2002 to 2006 in U.S. physician offices. They compared the practices of clinicians for the 30 months before and after the publication of the guideline with respect to the encounter rate of patient visits at which antibiotics were not prescribed for children with the diagnosis of AOM. The results showed that this encounter rate did not change after publication of the guideline. However, after the guideline was published, the rate at which amoxicillin was prescribed increased (40% to 49%; P = .039), the rate of prescriptions for amoxicillin clavulanate decreased (43% to 16% P=.043), the rate of prescribing cefdinir increased (7% to 14%; P = .004) and the rate of prescribing of analgesics increased (14% to 24%; P = .038).
A recent study by Halasa and colleagues showed both a decrease in the diagnosis of AOM and the use of antibiotics in otitis media, suggesting that the decrease in use was secondary to improvements of diagnosis rather than to increased employment of a watchful waiting strategy.
Sharpening diagnostic skills in the evaluation of middle ear pathology is the optimum approach to achieving the judicious use of antimicrobials. In fact, given that AOM is the most frequent organic disease cared for by the practicing pediatrician and the most common indication for the prescription of antimicrobials, proficiency in examining the ears of young children should be a required competency for board certification in Pediatrics. This might be accomplished through a combination of assessment tools including video images and simulation models.
What of the other reported outcomes in the study by Coco et al? The guideline recommends the use of amoxicillin clavulanate when patients do not respond to amoxicillin or in cases of AOM in which several risk factors co-exist to indicate the high likelihood that infection of the middle ear cavity is caused by resistant bacterial species, ie, penicillin-resistant Streptococcus pneumoniae or beta-lactamase positive Haemophilus influenzae. This is a recommendation with which I strongly agree.
Applying pharmacokinetic and pharmacodynamic principles to the selection of antimicrobial agents for the common microbiologic agents that cause AOM demonstrates that high dose amoxicillin clavulanate has greater in vitro activity against both of these bacterial species than cefdinir. Cefdinir, a pleasant tasting third-generation cephalosporin, has adequate activity against penicillin-sensitive S. pneumoniae but is quite weak against intermediate or highly resistant isolates of S. pneumoniae. Even when cefdinir was administered at a dose of 25 mg/kg, microbiologic failures among children with AOM yielded resistant S. pneumoniae. Accordingly, it is disappointing that practitioners are using more cefdinir and less amoxicillin-clavulanate.
Finally, what about analgesics for children with AOM? Using analgesics is a very reasonable recommendation, as, even when antimicrobials are appropriately used, relief of pain (which will not be modified by the use of antibiotics for at least 24 to 48 hours) is indicated.
For more information:
- AAP Subcommittee on Management of Acute Otitis Media. Pediatrics. 2004;113:1451-1465.
- Arguedas A. Pediatr Infect Dis J. 2006;25:211-18.
- Chan LS. Pediatrics. 2001;108:248-54.
- Coco A. Pediatrics. 2010;125:214-220.
- Glaszious PP. Cochrane database of systematic reviews. Hamilton, Canada: B.C. Decker, 2002-3.
- Halasa NB. J Pediatr. 2004;144:200-205.
- Poole MD. Internatl J Pediatr Otorhinolaryngol. 2002;63:1-13.
- Rosenfeld R. J Pediatr. 1994;124:355-67.
- Siegel RM. Pediatrics. 2003;112:527-531.
- Spiro DM. JAMA. 2006;296:1235-1241.