AOM Guideline Failed to Rein In Prescribing

The percentage of pediatric acute otitis media visits during which an antibiotic was not prescribed did not increase significantly in the 30 months after the dissemination in 2004 of the well-publicized clinical practice guideline that allowed for patient observation without initial antibiotic therapy, according to Dr. Andrew Coco of the Lancaster (Pa.) General Research Institute and his colleagues.

They analyzed data on 1,114 acute otitis media (AOM) patients aged 6 months to 12 years that was collected between 2002 and 2006 as part of the National Ambulatory Medical Care Survey, comparing the clinical management strategies during the 30-month periods before and after the publication of the 2004 American Academy of Pediatrics and American Academy of Family Physicians clinical practice guideline.

The primary study end point was the rate of AOM encounters with no reported antibiotic prescribing. Secondary end points were predictors of AOM encounters at which no antibiotic prescribing was reported and the rates of antibiotic prescribing and analgesic prescribing. Eighty-two percent of visits were with pediatricians, 14% were with family physicians, and 4% were with other physicians (Pediatrics 2010;125:214-20).

During the study overall, antibiotics were not prescribed in 13% of the visits, according to the analysis. In the 30 months prior to the publication of the clinical guideline, 11% of the AOM diagnoses were managed without an antibiotic, compared with 16% after the guideline publication, which does not represent a significant difference, they reported.

“It seems that, despite the guideline's endorsement, physicians have been reluctant to frequently use the observation option, perhaps because of perceptions of parental reluctance to accept this approach and barriers to follow-up,” they wrote

“It is encouraging that children who did not receive antibiotics were also less likely to present with symptoms of severe infection, such as fever or ear pain,” the authors wrote.

An unexpected finding, was the fact that amoxicillin/clavulanate prescribing, which the guideline recommends for the treatment of children with severe infection and those with treatment failure, decreased from 23% to 16%. This is, however, consistent with physicians' historical lack of enthusiasm for prescribing the combination treatment for severe infections, they wrote.

Physicians in the study “were choosing cefdinir as a second-line agent instead, perhaps because of a more convenient dosing schedule, a lower incidence of diarrhea, or more aggressive marketing,” the investigators wrote. Its use doubled from 7% to 14% of all antibiotics prescribed after publication of the guideline.

The proportion of visits at which amoxicillin was prescribed increased from 40% to 49%, which is consistent with the guideline.

The rate of analgesic prescribing also increased from 14% to 24%—an indication that pediatric providers “have accepted this strong recommendation to treat the pain that is often associated with AOM, which is a reversal of previous findings showing that treating otalgia is not prioritized by clinicians,” Dr. Coco and his associates wrote. “It would seem that physicians were more willing to adopt a recommendation from the guideline to add a treatment [analgesic agents] rather than to withhold one [antibiotics].”

The study authors reported having no conflicts of interest.

My Take

Watchful Waiting Is Uncomfortable

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 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.

STEPHEN I. PELTON, M.D,. is director of pediatric infectious diseases at Boston Medical Center. He is a consultant for GlaxoSmithKline, Novartis, and Wyeth and is on the speakers bureau for MedImmune Inc. and Sanofi Pasteur Inc.

VITALS

The percentage of pediatric acute otitis media visits during which an antibiotic was not prescribed did not increase significantly in the 30 months after the dissemination in 2004 of the well-publicized clinical practice guideline that allowed for patient observation without initial antibiotic therapy, according to Dr. Andrew Coco of the Lancaster (Pa.) General Research Institute and his colleagues.

They analyzed data on 1,114 acute otitis media (AOM) patients aged 6 months to 12 years that was collected between 2002 and 2006 as part of the National Ambulatory Medical Care Survey, comparing the clinical management strategies during the 30-month periods before and after the publication of the 2004 American Academy of Pediatrics and American Academy of Family Physicians clinical practice guideline.

The primary study end point was the rate of AOM encounters with no reported antibiotic prescribing. Secondary end points were predictors of AOM encounters at which no antibiotic prescribing was reported and the rates of antibiotic prescribing and analgesic prescribing. Eighty-two percent of visits were with pediatricians, 14% were with family physicians, and 4% were with other physicians (Pediatrics 2010;125:214-20).

During the study overall, antibiotics were not prescribed in 13% of the visits, according to the analysis. In the 30 months prior to the publication of the clinical guideline, 11% of the AOM diagnoses were managed without an antibiotic, compared with 16% after the guideline publication, which does not represent a significant difference, they reported.

“It seems that, despite the guideline's endorsement, physicians have been reluctant to frequently use the observation option, perhaps because of perceptions of parental reluctance to accept this approach and barriers to follow-up,” they wrote

“It is encouraging that children who did not receive antibiotics were also less likely to present with symptoms of severe infection, such as fever or ear pain,” the authors wrote.

An unexpected finding, was the fact that amoxicillin/clavulanate prescribing, which the guideline recommends for the treatment of children with severe infection and those with treatment failure, decreased from 23% to 16%. This is, however, consistent with physicians' historical lack of enthusiasm for prescribing the combination treatment for severe infections, they wrote.

Physicians in the study “were choosing cefdinir as a second-line agent instead, perhaps because of a more convenient dosing schedule, a lower incidence of diarrhea, or more aggressive marketing,” the investigators wrote. Its use doubled from 7% to 14% of all antibiotics prescribed after publication of the guideline.

The proportion of visits at which amoxicillin was prescribed increased from 40% to 49%, which is consistent with the guideline.

The rate of analgesic prescribing also increased from 14% to 24%—an indication that pediatric providers “have accepted this strong recommendation to treat the pain that is often associated with AOM, which is a reversal of previous findings showing that treating otalgia is not prioritized by clinicians,” Dr. Coco and his associates wrote. “It would seem that physicians were more willing to adopt a recommendation from the guideline to add a treatment [analgesic agents] rather than to withhold one [antibiotics].”

The study authors reported having no conflicts of interest.

My Take

Watchful Waiting Is Uncomfortable

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 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.

STEPHEN I. PELTON, M.D,. is director of pediatric infectious diseases at Boston Medical Center. He is a consultant for GlaxoSmithKline, Novartis, and Wyeth and is on the speakers bureau for MedImmune Inc. and Sanofi Pasteur Inc.

VITALS

The percentage of pediatric acute otitis media visits during which an antibiotic was not prescribed did not increase significantly in the 30 months after the dissemination in 2004 of the well-publicized clinical practice guideline that allowed for patient observation without initial antibiotic therapy, according to Dr. Andrew Coco of the Lancaster (Pa.) General Research Institute and his colleagues.

They analyzed data on 1,114 acute otitis media (AOM) patients aged 6 months to 12 years that was collected between 2002 and 2006 as part of the National Ambulatory Medical Care Survey, comparing the clinical management strategies during the 30-month periods before and after the publication of the 2004 American Academy of Pediatrics and American Academy of Family Physicians clinical practice guideline.

The primary study end point was the rate of AOM encounters with no reported antibiotic prescribing. Secondary end points were predictors of AOM encounters at which no antibiotic prescribing was reported and the rates of antibiotic prescribing and analgesic prescribing. Eighty-two percent of visits were with pediatricians, 14% were with family physicians, and 4% were with other physicians (Pediatrics 2010;125:214-20).

During the study overall, antibiotics were not prescribed in 13% of the visits, according to the analysis. In the 30 months prior to the publication of the clinical guideline, 11% of the AOM diagnoses were managed without an antibiotic, compared with 16% after the guideline publication, which does not represent a significant difference, they reported.

“It seems that, despite the guideline's endorsement, physicians have been reluctant to frequently use the observation option, perhaps because of perceptions of parental reluctance to accept this approach and barriers to follow-up,” they wrote

“It is encouraging that children who did not receive antibiotics were also less likely to present with symptoms of severe infection, such as fever or ear pain,” the authors wrote.

An unexpected finding, was the fact that amoxicillin/clavulanate prescribing, which the guideline recommends for the treatment of children with severe infection and those with treatment failure, decreased from 23% to 16%. This is, however, consistent with physicians' historical lack of enthusiasm for prescribing the combination treatment for severe infections, they wrote.

Physicians in the study “were choosing cefdinir as a second-line agent instead, perhaps because of a more convenient dosing schedule, a lower incidence of diarrhea, or more aggressive marketing,” the investigators wrote. Its use doubled from 7% to 14% of all antibiotics prescribed after publication of the guideline.

The proportion of visits at which amoxicillin was prescribed increased from 40% to 49%, which is consistent with the guideline.

The rate of analgesic prescribing also increased from 14% to 24%—an indication that pediatric providers “have accepted this strong recommendation to treat the pain that is often associated with AOM, which is a reversal of previous findings showing that treating otalgia is not prioritized by clinicians,” Dr. Coco and his associates wrote. “It would seem that physicians were more willing to adopt a recommendation from the guideline to add a treatment [analgesic agents] rather than to withhold one [antibiotics].”

The study authors reported having no conflicts of interest.

My Take

Watchful Waiting Is Uncomfortable

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 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.

STEPHEN I. PELTON, M.D,. is director of pediatric infectious diseases at Boston Medical Center. He is a consultant for GlaxoSmithKline, Novartis, and Wyeth and is on the speakers bureau for MedImmune Inc. and Sanofi Pasteur Inc.

VITALS