COMMENTARY

Antibiotics for Acute Otitis Media in Children

Principles for Judicious Antibiotic Prescribing

Lauri Hicks, DO

Disclosures

November 19, 2013

Editorial Collaboration

Medscape &

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Hello. I'm Lauri Hicks, medical director of CDC's Get Smart: Know When Antibiotics Work program. Did you know that ear infection, specifically acute otitis media (AOM), leads to more antibiotic prescriptions than any other syndrome? Just this year, the American Academy of Pediatrics (AAP) released updated clinical practice guidelines for the diagnosis and management of AOM. Although many episodes are self-limited, more than 3 out of 4 visits for AOM result in an antibiotic prescription. I urge you to apply 3 principles of judicious antibiotic use in your practice to improve the quality of care for your patients with AOM and reduce unnecessary antibiotic use.

Principle 1. Determine the likelihood of a bacterial infection. The AAP guideline states that an AOM diagnosis requires either of the following 2 conditions: evidence of middle-ear effusion, as demonstrated by moderate to severe bulging of the tympanic membrane (TM), or new onset of otorrhea that is not caused by otitis externa. AOM may also be diagnosed when a child presents with only mild bulging of the TM but with additional symptoms of recent onset of ear pain or intense erythema of the TM. If your patient does not have these findings, antibiotics are not indicated.

Principle 2. For patients who meet diagnostic criteria for AOM but may not need antibiotic treatment, apply principle 2: Weigh the benefits vs the harms of antibiotics. It's important to consider the potential harms of antibiotics every time you prescribe them. Antibiotic-related adverse drug events are among the most frequent causes of drug-related emergency room visits among children in the United States. Although symptoms may improve more rapidly with antibiotic therapy, each time a patient receives an antibiotic, there is a risk for adverse events, including diarrhea, dermatitis, C difficile colitis, and subsequent development of antibiotic resistance.

At least half of patients with AOM will recover without antibiotic therapy. If your patient has findings consistent with AOM, always consider disease severity, laterality, and patient age when determining whether to prescribe an antibiotic. Children who benefit the most from antibiotics are less than 24 months of age, have severe disease, or have bilateral infection. Consider observation, also termed "wait and see," or "delayed prescribing" instead of immediate antibiotic therapy. Observation may be considered an alternative strategy for AOM management for children at least 6 months of age without severe symptoms. Studies among patients with AOM have shown that this approach reduces antibiotic use, is well accepted by families, and when supported by close follow-up and patient education, does not result in worse clinical outcomes. The use of this approach is an opportunity to engage in a discussion about the potential benefits and risks associated with antibiotic therapy.

Principle 3. If your patient has a diagnosis of AOM and the benefits of prescribing outweigh the harms, apply principle 3: Implement judicious prescribing strategies. Select the recommended antibiotic agent that treats the most likely pathogens: amoxicillin or amoxicillin-clavulanate. Prescribe the appropriate dose for the shortest duration required, commensurate with patient age and disease severity. For children 2 years or younger with severe symptoms, a 10-day course is recommended. For children 2-5 years old with mild or moderate disease, a 7-day course is recommended. For children 6 years or older with mild to moderate disease, the recommended treatment course is 5-7 days.

Remember that the principles of judicious antibiotic use include establishing the likelihood of a bacterial infection, weighing the benefits vs the harms of antibiotics, and employing judicious prescribing practices. If parents demand antibiotics when they are not indicated, we recommend sharing your treatment rules, highlighting the potential adverse effects of antibiotics, and creating a treatment plan directed at symptomatic relief.

When it comes to managing AOM, we recognize the challenges that you face with making an accurate diagnosis and communicating your findings and treatment plans to parents. To encourage appropriate antibiotic use, CDC has created resources for both patients and providers, such as symptomatic prescription pads. For more information about guidelines and other tools related to antibiotic use, refer to the links below and visit our Get Smart site. Thanks for tuning in to this CDC Expert Video Commentary on Medscape.

Web Resources

AAP Clinical Practice Guideline: The diagnosis and management of acute otitis media

CDC Commentary on Medscape: Don't give in and give those antibiotics!

CDC's Get Smart: Know When Antibiotics Work Program (Get Smart)

Get Smart About Antibiotics Week

Appropriate antibiotic-use materials to use with patients

Continuing medical education opportunities related to appropriate antibiotic use

Treatment guidelines for upper respiratory tract infections

CDC Report: Antibiotic resistance threats in the United States, 2013

Lauri Hicks, DO, is a medical epidemiologist in the Respiratory Diseases Branch (RDB), National Center for Immunization and Respiratory Diseases (NCIRD), Centers for Disease Control and Prevention (CDC). Dr. Hicks attended medical school at the Philadelphia College of Osteopathic Medicine and completed her internal medicine residency and chief medicine residency at the University of Connecticut. This was followed by a 2-year position as an Epidemic Intelligence Service Officer at CDC. After completing a postdoctoral fellowship in infectious diseases at Brown University, Dr. Hicks returned to CDC to lead respiratory outbreak response and the Legionnaires' disease program.

In 2008, she became the medical director for the "Get Smart: Know When Antibiotics Work" program, which aims to educate healthcare providers and the public about appropriate antibiotic use. She leads research on antibiotic use and resistance trends and serves as the campaign spokesperson. Globally she has fostered CDC-European Union (EU) collaboration leading to joint antibiotic awareness observances in many countries in the EU, but also in Canada and Australia.

She is an Adjunct Assistant Professor of Medicine at the Warren Alpert Medical School of Brown University.

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