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BMJ No 7104 Volume 315 Editorial Saturday 9 August 1997
Acute otitis media in childrenFewer children should be treated with antibioticsSee Paper p 350Most general practitioners in Britain would treat a child with acute otitis media with antibiotics.(1) However, papers published recently in the BMJ cast doubt on the effectiveness of this policy.(2,3) The authors concluded that antibiotics offer only limited benefits and that most children with acute otitis media can be managed without them. If justified, the authors' conclusions would have important implications for British general practice. Acute otitis media is one of the commonest childhood problems seen by general practitioners. Every year, about 10% of under 5 year olds and 3.5% of 5-15 year olds are seen by their general practitioner at least once with the condition. Hence, a typical general practitioner will see about 20 children with acute otitis media every year.(4) As there are more than 30,000 general practitioners in Britain, a more restricted role for antibiotics in the management of acute otitis media would lead to a substantial reduction in the prescribing of antibiotics. This in turn would result in fewer children experiencing the side effects of antibiotics and less likelihood of antibiotic resistance developing. The potential benefits of reduced antibiotic prescribing are clear, but are the authors of the two papers right to call for a more restricted role for antibiotics in the management of acute otitis media? Del Mar and colleagues carried out a meta-analysis of six randomised controlled trials.(2) They found no difference in the percentage of children who still had pain 24 hours after starting treatment (39% in the treatment group v 40% in the control group). However, after two to seven days, fewer children in the antibiotic group had pain than children in the placebo group (9.7% v 14.3%). Moreover, the risk of contralateral otitis media was also reduced by 43%. There was no significant difference in the prevalence of deafness at one month or in the percentage of children with recurrent acute otitis media. Del Mar et al concluded that the early use of antibiotics provides only modest benefits, with 17 children requiring treatment at first presentation to prevent one child experiencing pain at two to seven days. However, their meta-analysis had only limited power to show whether antibiotics had an effect on some important outcomes. Thus, some differences which may be clinically significant did not achieve statistical significance - for example, a 50% reduction in the risk of perforation of the ear drum and a 20% reduction in deafness at three months in those treated with antibiotics. Furthermore, all of the trials in the meta-analysis were too small to look at rare complications like mastoiditis and meningitis. In their review, Froom and colleagues found that there are still many unanswered questions about the role of antibiotics in the management of acute otitis media.(3) The benefits of antibiotic treatment on short term and long term outcomes remain unproved; uncertainty exists over whether antibiotics prevent rare complications; and it is not known whether treatment of high risk groups with antibiotics prevents poor outcomes. Furthermore, the treatment of acute otitis media varies worldwide, with a much higher use of antibiotics in the United States and in Britain than in the Netherlands.(5) Despite the lower rate of use of antibiotics by Dutch general practitioners, the incidence of complications from acute otitis media is no higher in the Netherlands than in countries where antibiotics are used more frequently.(1)(5) Further support for a restricted role for antibiotics in upper respiratory tract infections is provided by a recent randomised trial of prescribing strategies carried out by Little and colleagues. This showed that antibiotics had little effect on the duration of symptoms in patients with sore throats.(6) The authors also found, as reported in this week's BMJ (p 350), that prescribing antibiotics for patients with sore throats had no effect on the rate of early return for medical advice or on relapse and complication rates.(7) Furthermore, patients who were prescribed antibiotics were nearly 40% more likely to attend the surgery when they had another episode of sore throat. Hence, by prescribing antibiotics for mild and moderate upper respiratory tract infections, general practitioners run the risk of medicalising minor self limiting illnesses and increasing their future workload. General practitioners will need to consider all these points when determining their policy on the use of antibiotics in children with acute otitis media. They will also need to consider the opinions of clinicians who support the use of antibiotics such as Klein(8) and Berman.(9) Although Klein and Berman accept that only around one third of children with acute otitis media require antibiotics to help cure the condition, they advocate using antibiotics for all episodes of acute otitis media as there are currently no clinical criteria for identifying which children will need antibiotics. Further research on the management of acute otitis media is clearly needed to resolve some of the unanswered questions and to allow general practitioners to base their treatment decisions on sound evidence.(2,3)(10) Randomised trials should include patient and carer centred outcomes such as the absence of children from school or nursery and the time parents have to take off work to look after a sick child. Any future trials should also be large enough to show how effective antibiotics are in reducing important complications of acute otitis media such as persistent deafness. Trials are also needed of the effectiveness of antibiotics in subgroups of children at high risk of poor outcomes. Until better evidence is available, most general practitioners are likely to continue to treat children with acute otitis media with antibiotics. However, where the diagnosis is in doubt or where the child is not unduly ill, a restricted use of antibiotics and a more open discussion with parents about the options for treatment would be appropriate. Azeem Majeed
Senior lecturer in general
practice
Division of General Practice and Primary Care, References 1 Froom J, Culpepper L, Grob P, Bartelds A, Bowers P, Bridge-Webb C, et al. Diagnosis and antibiotic treatment of acute otitis media: report from International Primary Care Network. BMJ 1990;300:582-6. 2 Del Mar C B, Glasziou P P, Hayem M. Are antibiotics indicated as initial treatment for acute otitis media? BMJ 1997;314:1526-9. 3 Froom J, Culpepper L, de Melker R A, Jacobs M, van Buchem L, Green L A, et al. Antimicrobials for acute otitis media? A review from the International Primary Care Network. BMJ 1997;315:98-102. 4 McCormick A, Fleming D, Charlton J, Royal College of General Practitioners, Office of Population Censuses and Surveys, Department of Health. Morbidity statistics from general practice. Fourth national study, 1991-1992. London: HMSO, 1995. 5 Van Buchem F L, Peeters M F, van't Hof M A. Acute otitis media: a new treatment strategy. BMJ 1985; 290: 1033-7. 6 Little P, Williamson I, Warner G, Gould C, Gantley M, Kinmouth A L. Open randomised trial of prescribing strategies in managing sore throat. BMJ 1997;314:722-7. 7 Little P, Williamson I, Warner G, Gould C, Gantley M, Kinmouth A L. Reattendance and complications in a randomised trial of prescribing for sore throat: the medicalising effect of prescribing antibiotics. BMJ 1997;315:350-2. 8 Klein J O. Otitis media. Clin Infect Dis 1994;19:823-33. 9 Berman S. Otitis media in children. N Engl J Med 1995;332:1560-5. 10 Claessen J Q P J, Appelman C L M, Touw-Otten F W M M, de Melker R A, Hordijk G J. A review of clinical trials regarding treatment of acute otitis media. Clin Otolaryngol 1992;17:251-7.
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