COMMENTARY

5 Best of 2017: Pediatrics Viewpoints

William T. Basco, Jr., MD

Disclosures

December 28, 2017

In This Article

Most Widely Read Viewpoints of 2017

At the end of each year, I like to revisit some of the most widely read pediatric Viewpoint columns from the previous 12 months. To no surprise, the most read articles of 2017 were about problems most commonly seen by pediatric providers (acute otitis media and obesity), challenging decisions (testing for pharyngitis), and information on treating a vexing condition (migraine). The popularity of these topics-as determined by you, our readers-and the comments they generated underscore how important they are in pediatric practice. Read on!

Treating AOM: 5 Days or 10?

In a clinical trial in children aged 6-23 months, Hoberman and colleagues[1] aimed to determine whether a 5-day course of antibiotic treatment was not inferior to a 10-day treatment course for the treatment of acute otitis media (AOM). All children had AOM with onset ≤ 48 hours before enrollment and had symptoms above an objective threshold determined by the researchers (assessed by looking for effusion, bulging, and scores on pain assessment tools). Parents were asked to report seven different items, including crying, irritability, tugging at the ears, fever, and other measures of how the child was feeling. The children were assigned to receive amoxicillin-clavulanate (90 mg/kg/day of the amoxicillin component) either for a standard duration of 10 days or for a reduced duration of 5 days followed by identical-looking placebo for 5 days.

The investigators followed the families to ensure medication adherence and obtain symptom reports, and the children completed a clinical examination at the end of therapy (day 12-14). Longer-term outcomes were assessed with in-office assessments every 6 weeks until each respective respiratory season ended. The main outcome of each episode of AOM was clinical success or clinical failure. A recurrence of AOM was any episode that occurred after day 16 from the initial diagnosis.

Slightly more than half (51%) of the enrolled children were younger than 1 year of age, and 58% had exposure to three or more other children for at least 10 hours weekly. Approximately 55% of all of the children had what was considered a severe illness, based on fever and pain, and 49% of the children had bilateral otitis at enrollment. The study was discontinued early because an interim analysis showed that the shorter course was not performing in a noninferior manner, with too many failures among the children treated for only 5 days. Clinical failure was 34% in the 5-day treatment group compared with 16% in the 10-day treatment group, correlating to a number-needed-to-treat of 6 to prevent one clinical failure. Even subgroup analysis showed that 10 days of treatment performed consistently better than 5 days. Symptom scores in the second week of enrollment (6-14 days) were consistently higher in the children who received 5 days of therapy compared with those who received 10 days of therapy. Of interest, the differences in frequency of diarrhea, diaper dermatitis, and effusion at the 2-week assessment between the two groups was not statistically significant.

Viewpoint

This was the number-one pediatric Viewpoint of 2017, no doubt because of the prevalence of AOM in pediatric practice. I applaud this effort to determine whether we could reduce antibiotic exposure, but these data suggest that in these young children with AOM, the stewardship should not take the form of a reduced duration of therapy. That said, antimicrobial stewardship is an important need, and a clinician can still contribute to antimicrobial stewardship in the setting of AOM by being more careful in making the diagnosis and not overtreating the persistent effusions that were present in many study participants. Almost two thirds of these children, regardless of treatment group, still had effusions 2 weeks after initiating antimicrobial treatment. For a review of AOM diagnosis and treatment, see the AAP guideline.

Comments

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