Antibiotic prescription rates, mastoiditis incidence examined

Incidence of mastoiditis among children in the United Kingdom remained stable despite decreased antibiotic prescribing for otitis media.

Trends in the incidence of mastoiditis in the three months following an episode of otitis media in 2,622,345 children aged 3 months through 15 years between 1990 and 2006 were retrospectively examined.

The data from the United Kingdom’s General Practice Research Database indicated that despite a 50% decline in antibiotic prescriptions for otitis media during the study period, rates of mastoiditis remained consistent at approximately 1.2 cases per 10,000 child years.

When general practitioners prescribed antibiotics to treat otitis media, cases of mastoiditis decreased by half (OR=0.56, 95% CI, 0.44 to 0.71), but an estimated 4,831 episodes of otitis media would need to be treated to prevent just one case.

The researchers projected that completely stopping prescribing antibiotics for otitis media might lead to an additional two cases of mastoiditis per 10,000 otitis media episodes. In the United Kingdom in 2006, approximately 1,273,750 cases of otitis media occurred, of which 58% were treated using antibiotics. Based upon these figures, an additional 255 cases of childhood mastoiditis may occur annually in the United Kingdom if primary caregivers ceased prescribing antibiotics for otitis media altogether, while the total number of antibiotic prescriptions per year would be reduced by 738,775.

“GPs should not base their decision to prescribe antibiotics for the treatment of otitis media on the fear of the development of mastoiditis, as this risk is extremely low and the NNT is very high. Although mastoiditis is a serious disease, most children make an uncomplicated recovery following mastoidectomy or IV antibiotics,” the researchers wrote. “Treating these additional otitis media episodes could pose a larger public health problem in terms of antibiotic resistance.”

In July 2008, the National Institute for Health and Clinical Excellence (NICE) published a new set of clinical guidance recommending either a delayed or no antibiotic prescribing policy for the treatment of self-limiting respiratory tract infections, including acute otitis media. – by Nicole Blazek

Pediatrics. 2009;123:424-430.

Of course extensive and inappropriate use of antibiotics for respiratory infections that are likely to be viral poses concerns regarding drug resistance. The key is to improve skills in diagnosing acute otitis media and using drugs for the children who are likely to benefit. The expanding middle ear abscess is painful, children are distressed and parents spend sleepless nights.

We don’t use antimicrobial agents in children with acute otitis media solely for prevention of mastoiditis and other suppurative complications. We use antibiotics because the drugs kill bugs and make the child more comfortable more quickly. I am sure the U.K. investigators would agree with the eminent sage of Bardstown, Ky., Dr. Stan Block, “We should be kind to little children.”

– Jerome O. Klein, MD

Infectious Diseases in Children Editorial Board member