It appears that prescribing antibiotics for children’s ear infections is modestly more effective than doing nothing, but the antibiotics cause a significant number of side effects in children. If 100 children of average risk develop middle ear infection (acute otitis media), 80 of them will get better within three days with no antibiotic medications, while 92 would if you gave every single one of them ampicillin/amoxicillin. However, the antibiotics would cause 3 to 10 cases of rash and 5 to 10 cases of diarrhea, researchers from Geffen School of Medicine at UCLA, Los Angeles and RAND at Santa Monica wrote in JAMA (Journal of the American Medical Association).
Middle ear infection, medically known as acute otitis media or AOM, is the childhood infection for which most antibiotics in the USA are prescribed. In 2006, a study revealed that $2.8 billion was spent on AOM antibiotics, an average of $350 per child with the infection.
The authors wrote:
- “Timely and accurate diagnosis and appropriate management of AOM may have significant consequences for ambulatory health care utilization and expenditures… however, wide variation exists in diagnosis and treatment.”
Tumaini R. Coker, M.D., M.B.A. and team set out to assess recent trial results and changes in clinician practice. They carried out an orderly evaluation of relevant studies to support the current American Academy of Pediatrics’ guidelines on AOM practice.
They examined:
- How precise and accurate AOM diagnosis is
- The link between heptavalent pneumococcal conjugate vaccine (PCV7) use and changes in AOM microbial epidemiology
- Doctors’ decisions regarding antibiotic use, the comparative efficacies of various antibiotics, and side effects linked to antibiotics
135 studies were identified and included in their review. The researchers examined those in which at least three articles looked at the same comparisons.
They found that when the ear was examined with an otoscope* and there was bulging of the eardrum membrane as well as redness, the diagnosis of AOM was accurate.
* An otoscope is a device for examining the inside of the ear, particularly the eardrum. It consists mainly of a magnifying lens and a light.
The authors wrote:
- “Perhaps the most important way to improve diagnosis is to increase clinicians’ ability to recognize and rely on key otoscopic findings.”
In some studies the researchers found that Streptococcus pneumoniae prevalence dropped while Haemophilus influenzae rose after PCV7 (heptavalent pneumococcal conjugate vaccine). They also found that clinical success with ampicillin or amoxicillin use was 73%, compared to 60% with a placebo, while rash and/or diarrhea rates rose by 3% to 5%. Out of four studies examined, two showed better clinical success for immediate compared to delayed antibiotics.
The authors wrote:
- “Of 100 average-risk children with AOM, approximately 80 would likely get better within about 3 days without antibiotics. If all were treated with immediate ampicillin/amoxicillin, an additional 12 would likely improve, but 3 to 10 children would develop rash and 5 to 10 would develop diarrhea. Clinicians need to weigh these risks (including possible long-term effects on antibiotic resistance) and benefits before prescribing immediate antibiotics for uncomplicated AOM.”
The authors explained there was no information on the long-term effects of bacterial resistance.
They concluded:
- “We found evidence to guide the diagnosis and management of AOM in children; however, further research is needed that (1) examines clinicians’ diagnostic accuracy and precision using the 3 AOM diagnostic criteria [acute symptoms of infection, evidence of middle ear inflammation, and effusion]; (2) continues surveillance of AOM microbiology, especially in view of the newly approved PCV13; and (3) produces more high-quality studies on AOM management that include clear diagnostic criteria, a better-defined menu of clinical success measures that are universally applied, and more investigation into the comparative antibiotic-related adverse event rates that assesses whether any antibiotic regimen is superior to amoxicillin.”
Tumaini R. Coker, MD, MBA; Linda S. Chan, PhD; Sydne J. Newberry, PhD; Mary Ann Limbos, MD, MPH; Marika J. Suttorp, MS; Paul G. Shekelle, MD, PhD; Glenn S. Takata, MD, MS
JAMA. 2010;304(19):2161-2169. doi:10.1001/jama.2010.1651
Written by Christian Nordqvist