AOM Guideline Failed to Rein In Prescribing

Family education about antibiotic use might make physician compliance with the guideline more likely.

Source DR. SIEGEL

My Take

No Surprises in This Study

The finding that the 2004 AAP/AAFP guideline for AOM treatment has not substantially increased the proportion of the pediatric AOM cases being managed without antibiotics is not especially surprising.

Many physicians are uncomfortable with the watchful waiting recommendation because there is reasonable evidence that certain children benefit significantly from antibiotics. For example, the findings of a recent meta-analysis suggest that antibiotics are effective for the treatment of AOM in children younger than 2 years old who have bilateral disease and in children with both otorrhea and AOM (Lancet 2006;368:1429-35).

Additionally, the guideline calls for the use of antibiotics for the treatment of severe disease, which is a subjective characterization.

The gap between the guideline recommendations and clinical practice will likely widen further in the near future, with the upcoming publication of new studies linking watchful waiting with a greater proportion of children in whom the signs and symptoms of AOM last beyond 3 or 4 days.

Despite the guideline controversy, the reduction of antibiotic prescribing continues to be an important goal. To achieve it, we should focus on developing a vaccine that prevents viral and bacterial respiratory tract infections, practicing restraint in treating nonfocal upper respiratory tract infections with antibiotics, and establishing more accurate diagnostic criteria for AOM and sinusitis.

Another important goal should be the selection of appropriate antibiotics for the likely pathogens. Currently, the spectrum of antibiotics that are prescribed portray a lack of understanding of the effectiveness of various antibiotics against various pathogens.

For example, data on the increase in the use of azithromycin are problematic as it is a drug with a long half-life and is believed to promote the emergence of resistance to a greater extent than some other antibiotics.

Even so, studies have shown that pediatricians choose azithromycin twice as often in children with recurrent AOM, which is backward, as it would be less likely to be effective in a recurrent episode than in a first.

I think this confirms that selection of antibiotics is based more on convenience, taste, and possibly marketing than on an understanding of the activity and limitations of the antibiotic.