Pediatric Press Newsletter

Publication date: 2003-07-11

Acute Otitis Media: Appropriate Antibiotic Utilization

This report was reviewed for medical and scientific accuracy by Amisha Malhotra, MD, Assistant Professor of Pediatrics, University of Medicine & Dentistry of New Jersey-Robert Wood Johnson Medical School, New Brunswick, New Jersey

Expert Commentary

George H. McCracken Jr., MD, Professor of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas

Appropriate antibiotic treatment of acute otitis media is essential for successful patient outcomes and the prevention of antibiotic resistance. Concern over the latter is evidenced by prescribing trends—decreased use of standard antibiotic therapies (amoxicillin) and increased use of expensive, broader-spectrum antibiotic agents for initial therapy. Evidence from poorly designed clinical trials and meta-analyses have likely contributed to the misconception that standard antibiotic therapies are only modestly effective in treating acute otitis media and the greater acceptance of "watchful waiting" or delayed treatment in patients with acute otitis media, especially those younger than 2 years of age.

Current treatment guidelines suggest that standard therapies remain effective in patients who truly have acute otitis media. They emphasize the importance of accurate diagnosis, including the differentiation of acute otitis media, a condition that is likely to respond to antibiotic therapy, and otitis media with effusion, a condition that is not. Unlike "watchful waiting", this approach prevents unnecessary antibiotic prescribing while allowing timely treatment of patients who have underlying bacterial infections. Furthermore, these guidelines recommend reservation of broader-spectrum antibiotic agents for patients who cannot tolerate or who do not respond to first-line therapy, thus minimizing the risk for the development of resistance to these agents while assuring success to treatment with broader-spectrum antibiotics (eg, amoxicillin-clavulanate).

The introduction of pneumococcal conjugate vaccine may further help preserve the efficacy of standard antibiotic therapies for acute otitis media. While the overall effect on pneumococcal conjugate vaccine on the incidence of acute otitis media is modest at best, its use may result in a shift in bacterial etiology; possibly from high-level resistant strains of Streptococcus pneumoniae (S. pneumoniae) to the more antibiotic-susceptible pneumococci and to Haemophilus influenzae (H. influenzae). Additional data are required to validate this notion.

Standard antibiotic therapies maintain an important role in the management of acute otitis media. Judicious use of these antibiotic therapies in patients with acute otitis media, as well as in patients with other bacterial infections, should help preserve their effectiveness and clinical utility.

Perspective

Acute otitis media is a common pediatric diagnosis—approximately three-fourths of all children in the United States will have experienced at least one episode of acute otitis media by the time they reach 3 years of age.¹ For years, amoxicillin was generally accepted by physicians as the standard therapy for acute otitis media. However, concerns over antibiotic overuse and the development of antibiotic resistance have resulted in changes in the way physicians diagnose and treat acute otitis media. Several recent studies have analyzed these changing prescribing patterns and raised important concerns regarding the impact of these changes on clinical outcomes.

Changing Patterns of Antibiotic Use in Clinical Practice

Appropriate antibiotic use is essential to slow the development of antibiotic resistance. Evidence-based guidelines from the Centers for Disease Control and Prevention (CDC)^2,3 and Institute for Clinical Systems Improvement (ICSI)⁴ recommend amoxicillin as first-line therapy for acute otitis media (Table 1). According to the Drug-resistant Streptococcus pneumoniae Therapeutic Working