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Would a watchful waiting approach reduce antibiotic use for AOM?
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Antibiotic use is a shared decision.
Antibiotic use in acute otitis media should be a shared decision between doctors and families. The spontaneous resolution rate of acute otitis media is high. So high in fact, it is questionable at best whether antibiotics are of any value in the treatment of this infection other than shortening the course by about one day. Given that antibiotics have potential side effects and may be difficult to administer, the limited benefit of shortened illness, may or may not be of significant value to a family if the child is offered adequate pain control. The only way of knowing, is to involve the family in the discussion.
I think practitioners sometimes make decisions based on presumptions, such as parents come to office wanting antibiotics. Parents bring their child to the office with ear infections because they are concerned about the outcome and because their child is in pain. Parents are more sophisticated and have access to more information than ever before; we need to recognize this and discuss all reasonable treatment plans. With acute otitis media, both treating with antibiotics and watchful waiting are reasonable options and both strategies should be discussed.
The great advantage of using the Safety-Net Antibiotic Prescription is that the family has the security of access to antibiotics if the infection does not improve over the 24 to 48 hours following diagnosis or if the family reconsiders and prefers antibiotics. Perhaps the biggest advantage of the SNAP is that families are involved in the decision and are empowered in caring for their child within the context of their needs and beliefs.
Robert Siegel, MD, Center for Better Health and Nutrition of the Heart Institute at Cincinatti Children’s Hospital.
Use DATA, rather than WASP or SNAP.
Acute otitis media is one of the most common diagnoses made in children in the primary care setting. Because it is so common, the diagnosis of AOM is one of the most frequent indications for the prescription of antibiotics.
The current enthusiasm for watchful waiting as an approach to management of 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-ananlyses that have summarized the randomized controlled clinical trials of antimicrobial drug therapy for AOM in children. Although these meta-analyses are flawed by the inclusion of studies without stringent definitions for the diagnosis of AOM, they support the conclusion that antibiotics exert only a modest benefit 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. Some investigators advocate delaying treatment for 48 to 72 hours to avoid prescribing antibiotics for children in whom the episode of AOM may resolve spontaneously. In addition to concern about the escalation of antibiotic resistance, there are worries about both the costs and the side effects associated with the use of antibiotics that may not be necessary.
The wait and see approach (WASP) or safety net antibiotic prescription (SNAP) are treatment strategies that are trying to compensate for poor diagnostic skills that lead to overdiagnosis of AOM when practitioners mistake otitis media with effusion for AOM. I would rather see us put our energy into teaching students, residents, fellows and practitioners to diagnose AOM accurately. I recommend a DATA strategy rather than WASP or SNAP, or Diagnose Accurately and Treat Appropriately. Please see this website for wonderful instructional modules on diagnosis of AOM: pedsed.pitt.edu - Go to courses and then go to ePROM.
Ellen Wald, MD, Infectious Diseases in Children Editorial Board Member.