Running head: OTITIS MEDIA CAT
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Otitis Media in Children: should we use antibiotics?
Andrew Yantes
University of Mary
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Otitis Media in Children: should we use antibiotics?
Acute Otitis Media (AOM) is the most common childhood infection for which antibiotics
are prescribed and it demonstrates an average expenditure of 350 dollars per child and 2.8 billion
dollars a year in the United States alone (Coker, et al, 2010). Clinic healthcare providers play an
important role in cutting cost as timely and accurate diagnosis play an important role in patient
outcome. Once AOM is diagnosed, however, there is some debate as to how it should be treated.
Multiple systematic reviews have been conducted about the benefit of antibiotic therapy vs.
watchful waiting when treating AOM. Antibiotic therapy is often not necessary in these cases
and can cause negative side effects for the child and increase the incidence of antibiotic
resistance, making treatment of future infectious processes more complicated.
CASE STUDY
J.W. is a 6 year old male brought to your clinic by his mother complaining of left ear pain
and a fever of 100.4 for the last 24 hours. He has no significant medical history, allergies, or
prior surgical history. Neither parent in J.W.’s household smokes and J.W. was breast fed as an
infant. J.W. is not on any special diet and it consists of mostly home cooked meals. Physical
exam reveals thick green mucous in the nares bilaterally, with erythema noted to the left
tympanic membrane. There does not appear to be any bulging or retracting of the tympanic
membrane and the bony landmarks are clearly identified. Cone of light is present at 7 o’clock.
Vital signs are: RR-26, HR 116, BP- 110/52, and T-99.8. You conclude that this patient has
AOM and begin to speculate about treatment options.
PICO
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Among healthy children, ages infant to adolescent (P), does antibiotic therapy (I)
compared with watchful waiting (C) have an impact on the child’s outcome/cost of
therapy/comfort level (O)?
REVIEW OF LITERATURE
Two systematic, evidence based, articles where reviewed in order to determine if, in fact,
watchful waiting was an acceptable and effective means of treating AOM. In an article by Coker,
et al (2010), effectiveness of amoxicillin or ampicillin vs. a placebo in the treatment of AOM
were examined. The success rates of treatment for antibiotic therapy in the articles reviewed
ranged from 70-76%, while the success rate for the placebo (watchful waiting) ranged from 5467% (Coker, et al, 2010). This means that on average antibiotic therapy was about 12.5% more
effective than watchful waiting. Another study by Tahtinen, et al, (2011) stated that randomized
controlled trials demonstrated that treatment of AOM failed in 18.6% of children who received
augmentin, vs failure of 44.9% in children who received a placebo. Clearly, in this trial,
antibiotic treatment was much more effective as watchful waiting failed more than twice as much
as antibiotic therapy.
It is important to consider that the benefit of antibiotic therapy’s effectiveness may be
negligible in light of the adverse side effects children tend to experience when taking
antimicrobial medication. Adverse events were significantly more common in the augmentin
group than in the watchful waiting group. A total of 47.8% of the children in the augmentin
group had diarrhea, as compared with 26.6% in the placebo group; 8.7% and 3.2% of the
children in the respective groups had eczema (Tahtinen, et al, 2011). Coker, et al, (2010) also
examined the rates of adverse events in immediate antibiotic therapy citing trials that showed
diarrhea and rash happening about twice as much in the antibiotic therapy groups vs. the
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watchful waiting, but the rates of adverse events were less frequent (13-19% for diarrhea and 38% for rash). Azithromycin and Ceftriaxone produced the least amount of adverse effects (about
9% experienced adverse effects), with amoxicillin/ampicillin in the middle (about 14%) and
augmentin and cefixime being the highest (20 and 21%) (Coker, et al, 2010).
CLINICAL BOTTOM LINE
Research indicates that in the treatment of AOM, immediate antibiotic therapy is more
effective than no therapy at all, but the benefit may be outweighed by the adverse effects
children experience when receiving antimicrobial therapy. In healthy children who have mild to
moderate uncomplicated cases of AOM, a prescription-on-hold, or watchful waiting may be the
better option as rescue therapy can always be implemented if this strategy fails. It is also
important to consider that some antibiotics cause more adverse effects than others so using
antibiotics known for their minimal side effects should be used at the minimum effective dose
and duration. Because each patient scenario is much different, clinicians should use their clinical
judgement in deciding whether to wait or prescribe therapy immediately. Future studies should
identify patients who may derive the greatest benefit from watchful waiting vs. antimicrobial
therapy, in order to minimize unnecessary antimicrobial treatment. Unnecessary treatment with
the use of antimicrobial therapy contributes to the development of adverse effects and the
development of bacterial resistance, making it harder to treat future cases of AOM. All
healthcare providers should be stewards of antimicrobial therapy in order to minimize regional
and global incidence of bacterial resistance and cut back on unnecessary adverse effects.
Our case study demonstrates an otherwise healthy child with no history of previous AOM
or failed antimicrobial therapy. I speculate that this child would be a good candidate for utilizing
a watchful waiting strategy. This particular patient is not exhibiting an excessive amount of
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discomfort and what he is experiencing may be treated with antipyretics and OTC analgesics
such as acetaminophen and ibuprofen. Prescribing antibiotics in this case could cause the child
extra discomfort from side effects and possible bacterial resistance in the future. If the patient
continues to exhibit worsening symptoms, his mother should be instructed to call the provider
and an antimicrobial treatment option could be implemented as a rescue therapy.
LIMITATIONS TO RESEARCH
Our PICO question sought to examine three outcomes: 1) Patient outcome (resolution of
infection), 2) Patient Comfort (adverse effects experienced), and 3) Cost of therapy. This
question was extremely multifaceted so narrowing the outcome to just one, measurable outcome
would have served the CAT best. However, with adverse medication effects, rising bacterial
resistance and annual cost of antibiotic therapy, as well as the diversity of patient situations, I felt
it necessary to include all three outcome areas to exhaustively answer the PICO question. This
ended up leading to a conclusion that was indecisive and limited to a case by case basis.
There is opportunity for future literature reviews to examine each of these categories
more extensively, independent of each other, and then synergize the information into a more
complete and all-encompassing conclusion. Including topics such as prescription to go or rescue
therapy and their outcomes may also be an effective means of evaluating treatment options for
AOM.
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References
Coker, T., Chan, L., Newberry, S., Limbos, M., Suttorp, M., Shekelle, P., & Takata, G. (2010).
Diagnosis, Microbial Epidemiology, and Antibiotic Treatment of Acute Otitis Media in
Children. The Journal of American Medical Association, 304(19), 2161-2169.
doi:10.1001/jama.2010.1651.
Tähtinen, P., Laine, M., Huovinen, P., Jalava, J., Ruuskanen, O., & Ruohola, A. (2011). A
Placebo-Controlled Trial of Antimicrobial Treatment for Acute Otitis Media. New
England Journal of Medicine, 364(2), 116-26. doi: 10.1056/NEJMoa1007174.