By Philip R. Fischer, MD, DTM&H
Professor of Pediatrics, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN; Department of Pediatrics, Sheikh Shakhbout Medical City, Abu Dhabi, United Arab Emirates
SYNOPSIS: Otitis media usually resolves spontaneously. Antibiotics should not routinely be administered to children with acute uncomplicated otitis media.
SOURCE: Frost HM, Hersh AL. Rethinking our approach to management of acute otitis media. JAMA Pediatr 2022; Feb 21. doi: 10.1001/jamapediatrics.2021.6575. [Online ahead of print].
Acute otitis media is common. Current evidence-based expert guidelines suggest that initial treatment of most children with non-severe acute otitis media should center on observation, without antibiotic therapy. For the few children who need antimicrobial treatment, amoxicillin is suggested, and the recommended duration of treatment is five to seven days.
What happens in actual practice is far different from what is recommended. More than 10 million antibiotic courses are prescribed in the United States each year for acute otitis media, representing 95% of all children seen for otitis media. Amoxicillin is used just 60% of the time, and 94% of children are treated for a full 10 days.
Acute otitis media can be caused by viruses or bacteria. The most common bacterial causes are pneumococcus, Haemophilus influenzae (often non-typable strains), and Moraxella catarrhalis. Viral otitis media neither requires nor responds to antibiotic treatment. Pneumococcal otitis media resolves spontaneously in just 19% of cases, while spontaneous resolution is more common with H. influenzae (48%) and M. catarrhalis (75%). With widespread use of effective pneumococcal vaccines in children during the past two decades, pneumococcal otitis media is seen much less frequently. Current data suggest that 78% to 85% of bouts of acute otitis media resolve spontaneously without antibiotics.
In 2017, it was estimated that each year 2.5 million children in the United States had parent-reported adverse reactions to antibiotics prescribed for acute otitis media. In addition, antibiotic use in children can be associated with later-life health problems and community development of antibiotic resistance.
Combining the data sources reviewed in the paper by Frost and Hersh, of every 20 children treated for acute otitis media, one will benefit and five will have immediate adverse effects.
H. influenzae and M. catarrhalis often produce beta-lactamase. Thus, if an antibiotic were needed, amoxicillin-clavulanate theoretically could be preferable to amoxicillin. Nonetheless, 97% of children with acute otitis media recover, whether treated with amoxicillin or amoxicillin-clavulanate. And adverse effects (mild gastrointestinal symptoms) are more common with broad-spectrum rather than narrow-spectrum antibiotics (36% vs. 25%), as are Closdridioides difficile infections and the development of antimicrobial resistance.
Thus, routine use of antimicrobial treatment for acute otitis media in children causes more harm than good. Practical, widespread implementation of antimicrobial stewardship measures is necessary. Paradigms should shift from “what is the best antibiotic for the likely causative germs” to “most children do better without antimicrobial treatment for otitis media.” A widely proposed strategy of proven effectiveness is, on diagnosis of otitis media, to explain the real risks and limited benefits of antibiotic treatment and then to provide an antibiotic prescription to be filled in two days if symptoms then are not resolving. The old, now-disproven notions that “bacterial infections require antibiotic treatment” and that “untreated otitis media leads to dangerous complications” need to be relegated to history.
COMMENTARY
In 2004, the American Academy of Pediatrics and the American Academy of Family Medicine jointly released guidelines for the management of uncomplicated acute otitis media in children ages 2 months to 12 years.1,2 Of note, the guidelines were meant to be applied to previously healthy children, not to those with chronic or recurrent ear infections, those with Down syndrome, or to those with cochlear implants.1 It was recommended that pain should be managed in children experiencing pain and that observation for 48-72 hours without antibiotic treatment be considered, with follow-up for those not improving.1 For those receiving an antibiotic, amoxicillin was recommended.1
The American Academy of Pediatrics offered updated guidelines in 2013, focusing this time on children ages 6 months to 12 years, still with uncomplicated acute otitis media.3 Antibiotics were suggested if the child had severe pain, a temperature greater than 39°C, or more than 48 hours of symptoms.3 For children without evidence of these more severe presentations but with bilateral otitis media, antibiotic treatment was suggested up to age 23 months; observation with analgesia and follow-up was to be considered for those younger than 2 years of age with unilateral otitis media and patients more than 2 years of age.3 When antibiotics were to be used, amoxicillin was recommended unless the patient had received amoxicillin during the preceding month, had purulent conjunctivitis, or was penicillin-allergic.3
By 2018, 17 European countries had national guidelines for the management of acute otitis media.4 A “watchful waiting” approach without antibiotic treatment was recommended by 15 of the 17 national guidelines, and amoxicillin was the antibiotic of choice in 14 of the 17 guidelines when an antibiotic was needed.4
In 2012, Korean guidelines were published, suggesting an “observation policy” without antibiotics for children older than 2 years of age with acute otitis media, and amoxicillin treatment for some younger children.5 In Japan, a series of guidelines was updated through 2018 (published in 2020), recommending a “wait and see” approach without antibiotics for children with mild illness and amoxicillin for children with more severe illness.6
Thus, there is widespread agreement around the world that uncomplicated acute otitis media in otherwise healthy children does not necessarily require antibiotic treatment, especially for mild cases. Guidelines vary slightly in terms of the ages of children, the grading systems of evidence, and the definitions of severe symptoms that might prompt a clinician to choose antimicrobial treatment, but there is consistency in the recommendation for analgesia without antibiotic treatment for many children with acute otitis media. The guidelines are not disputed or debated; rather, they are largely ignored by practitioners.7
Why are evidence, common sense, and guidelines disregarded? Why do physicians still prescribe antibiotics for most children with acute uncomplicated otitis media? Perhaps some clinicians still cling to the notion that incompletely treated otitis media leads to meningitis in children, even though there is scant to no evidence of that being the case, especially in the post-pneumococcal vaccine era. Perhaps doctors sense a need to “do something,” not realizing that accurate scientific information, reassurance, and pain management (topical and/or oral) are perfectly effective for the vast majority of children with acute otitis media. Or, perhaps, old habits and old teachings simply persist, without logical reason or thought — resulting in excessive medical costs, medication side effects, and antimicrobial resistance.
The data are clear. Modern science suggests that previously healthy children with uncomplicated acute otitis media usually can be treated effectively with observation and analgesia, without an antibiotic.
REFERENCES
- American Academy of Pediatrics Subcommittee on Management of Acute Otitis Media. Diagnosis and management of acute otitis media. Pediatrics 2004;113:1451-1465.
- American Academy of Family Physicians; American Academy of Otolaryngology-Head and Neck Surgery; American Academy of Pediatrics Subcommittee on Otitis Media with Effusion. Otitis media with effusion. Pediatrics 2004;113:1412-1429.
- Lieberthal AS, Carroll AE, Chonmaitree T, et al. The diagnosis and management of acute otitis media. Pediatrics 2013;131:e964–e999.
- Suzuki HG, Dewez JE, Nijman RG, Yeung S. Clinical practice guidelines for acute otitis media in children: A systematic review and appraisal of European national guidelines. BMJ Open 2020;10:e035343.
- Lee HJ, Park SK, Choi KY, et al. Korean clinical practice guidelines: Otitis media in children. J Korean Med Sci 2012;27:835-848.
- Hayashi T, Kitamura K, Hashimoto S, et al. Clinical practice guidelines for the diagnosis and management of otitis media in children – 2018 update. Auris Nasus Larynx 2020;47:493-526.
- Deniz Y, van Uum RT, de Hoog MLA, et al. Impact of acute otitis media clinical practice guidelines on antibiotic and analgesic prescriptions: A systematic review. Arch Dis Child 2018;103:597-602.
Otitis media usually resolves spontaneously. Antibiotics should not routinely be administered to children with acute uncomplicated otitis media.
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