BMJ 1999;318:715-716 ( 13 March )

General Practice

An evidence based approach to reducing antibiotic use in children with acute otitis media: controlled before and after study

Christopher Cates, general practitioner. 

Manor View Practice, Bushey Health Centre, Bushey, Hertfordshire WD2 2NN

chriscates{at}email.msn.com

Two recent reviews questioned the routine use of antibiotics in the initial management of acute otitis media. ^{1 2} My practice partners and I responded to the reviews by changing our policy, with the aim of reducing such prescribing in children. We measured the change one year after adopting the new policy.

	Methods and results

Top Methods and results Comment References

From July 1997 my practice partners and I changed our policy on routine prescription of antibiotics in the initial management of acute otitis media in children. In children who were not particularly ill we gave the parents a handout that summarised the limited benefit of antibiotics on the basis of the data presented in the Cochrane review.¹ We advised parents to give regular paracetamol suspension; we also offered an antibiotic prescription but asked the parents to keep it for a day or two. They could redeem it at a pharmacy if the child did not got better over this period.

A local practice acted as a concurrent control. Both practices use amoxicillin suspension as the antibiotic of choice in children with acute otitis media, and, although the doctors in the control practice were aware of the new evidence, they did not use the handout or use deferred prescriptions. Monthly prescribing rates of all amoxicillin suspensions were obtained for each practice from the district health authority. The 12 months before July 1997 were used for baseline comparison, and the following 12 months were used to assess the impact of our change in policy. Both practices had closely similar list sizes (about 11 000 patients) throughout the study. As there was seasonal and annual variation in prescribing levels, monthly odds of prescriptions issued in relation to the national total were calculated for each practice; these were weighted and pooled by using the Mantel-Haenszel method.³

Prescriptions for other antibiotic suspensions were also checked in our practice by comparing figures from the reports on level 3 prescribing analysis and cost data (PACT) with national figures, to check that other antibiotics were not being substituted for amoxicillin.

The table shows the monthly prescriptions for amoxycillin suspension for each practice, along with national totals. The median number of prescriptions per month in our practice fell from 75 to 47 after the change (median difference 30.5 (95% confidence interval 14 to 31, 2P=0.0065, Mann-Whitney U test). Compared with the national levels, the fall in prescribing amoxicillin suspension in our practice was 32% (25% to 39%) and in the control practice was 12% (4% to 20%).

View this table: [in this window] [in a new window]   Monthly totals of prescriptions for all amoxicillin suspensions for 12 months before (1996-7) and after (1997-8) new prescribing policy was introduced

In the six months after the change in policy the number of antibiotic suspensions prescribed in our practice was 19% lower (16% to 21%) than in the same six months of the previous year. Over this period national prescribing of all antibiotic suspensions fell by 3%.⁴

	Comment

Top Methods and results Comment References

Before my partners and I changed our policy, acute otitis media accounted for over half of all antibiotics prescribed for children in our practice. After our change in policy the proportion fell to a third, and as a consequence total antibiotic use for all infections in childhood fell by one fifth. As the evidence is not yet available to identify which children with acute otitis media benefit most from antibiotics we deferred prescriptions in those who were not systemically unwell (as suggested in the editorial comment accompanying one of the reviews in the BMJ ⁵).

We found that most parents welcomed the written handout. The deferred prescription also acted as a safety net while they waited to see if the ear infection would resolve by itself and was often not redeemed. We are continuing with this policy, and in the current battle against antimicrobial resistance we would commend this approach to initial management of acute otitis media as a way of reducing the antibiotic load on children in the community.

	Acknowledgments

A copy of the leaflet given to patients can be supplied by the author.

I thank my partners (Drs T Boyd, B Bintcliffe, J Glover, M Buist, and P Davis) for taking part in the study and the control practice for allowing me the use of their prescribing data; Mrs Frances Wilson (West Hertfordshire Health Authority) for providing prescribing data for both practices; Dr John Ferguson (medical director of the Prescription Pricing Authority, Newcastle upon Tyne) and Mr A M Savva (Statistics Division 1E of the Department of Health) for providing the national figures; Iain Chalmers and Professor C Del Mar for helpful comments; and Dr M Cucherat for use of the software package to perform the Mantel-Haenszel analysis.

Contributors: CC had the original idea for the study, collected and analysed the data, and drafted and revised the paper. His partners helped him to construct the handout. CC is the guarantor for the paper.

Funding: NHS Executive (North Thames) provided funding for protected time for CC.

Competing interests: None declared.

	References

Top Methods and results Comment References

1. Glasziou PP, Hayem M, Del Mar CB. Antibiotic versus placebo for acute otitis media in children. In: Cochrane Collaboration ed. Cochrane Library. Issue 1. Oxford: Update Software , 1997.
2. Froom J, Culpepper L, Jacobs M, DeMelker RA, Green LA, van Buchem L, et al. Antimicrobials for acute otitis media? A review from the International Primary Care Network. BMJ 1997; 315: 98-102[Free Full Text].
3. Cucherat M, Boissel JP, Leizorovicz A. Easy MA. A programme for the meta-analysis of clinical trials. Computer Methods and Programs in Biomedicine 1997; 53: 187-190[Medline].
4. Prescription cost analysis (England). London: Department of Health , 1996, 1997.
5. Majeed A, Harris T. Acute otitis media in children. BMJ 1997; 315: 321-322[Free Full Text].

(Accepted 10 December 1998)

---

© BMJ 1999
CiteULike    Complore    Connotea    Del.icio.us    Digg    Reddit    Technorati    What's this?

Related Articles

Reducing antibiotic use in children with acute otitis media

R W Clarke and Christopher Cates
BMJ 1999 319: 124. [Extract] [Full Text]

Staff: the major asset of a health service
BMJ 1999 318: 0. [Full Text] [PDF]

Avoiding antibiotics for acute otitis media reduces community load
BMJ 1999 318: 0. [Full Text]

This article has been cited by other articles:

• Berman, S. (2008). Otitis Media, Shared Decision Making, and Enhancing Value in Pediatric Practice. Arch Pediatr Adolesc Med 162: 186-188 [Full text]  
• Merenstein, D., Diener-West, M., Krist, A., Pinneger, M., Cooper, L. A. (2005). An Assessment of the Shared-Decision Model in Parents of Children With Acute Otitis Media. Pediatrics 116: 1267-1275 [Abstract] [Full text]  
• Cober, M. P., Johnson, C. E (2005). Otitis Media: Review of the 2004 Treatment Guidelines. The Annals of Pharmacotherapy 39: 1879-1887 [Abstract] [Full text]  
• Marchetti, F., Ronfani, L., Nibali, S. C., Tamburlini, G., for the Italian Study Group on Acute Otitis Media, (2005). Delayed Prescription May Reduce the Use of Antibiotics for Acute Otitis Media: A Prospective Observational Study in Primary Care. Arch Pediatr Adolesc Med 159: 679-684 [Abstract] [Full text]  
• McCormick, D. P., Chonmaitree, T., Pittman, C., Saeed, K., Friedman, N. R., Uchida, T., Baldwin, C. D. (2005). Nonsevere Acute Otitis Media: A Clinical Trial Comparing Outcomes of Watchful Waiting Versus Immediate Antibiotic Treatment. Pediatrics 115: 1455-1465 [Abstract] [Full text]  
• Le Saux, N., Gaboury, I., Baird, M., Klassen, T. P., MacCormick, J., Blanchard, C., Pitters, C., Sampson, M., Moher, D. (2005). A randomized, double-blind, placebo-controlled noninferiority trial of amoxicillin for clinically diagnosed acute otitis media in children 6 months to 5 years of age. CMAJ 172: 335-341 [Abstract] [Full text]  
• Carter, S, Laird, C (2005). 10 Assessment and care of ENT problems. Emerg. Med. J. 22: 128-139 [Full text]  
• Rosenfeld, R. M. (2004). Otitis, Antibiotics, and the Greater Good. Pediatrics 114: 1333-1335 [Full text]  
• Doyne, E. O., Alfaro, M. P., Siegel, R. M., Atherton, H. D., Schoettker, P. J., Bernier, J., Kotagal, U. R. (2004). A Randomized Controlled Trial to Change Antibiotic Prescribing Patterns in a Community. Arch Pediatr Adolesc Med 158: 577-583 [Abstract] [Full text]  
• Siegel, R. M., Bien, J. P. (2004). Acute Otitis Media in Children: A Continuing Story. Pediatr. Rev. 25: 187-193 [Full text]  
• Subcommittee on Management of Acute Otitis Media, (2004). Diagnosis and Management of Acute Otitis Media. Pediatrics 113: 1451-1465 [Abstract] [Full text]  
• Arroll, B., Kenealy, T., Goodyear-Smith, F., Kerse, N. (2003). Delayed prescriptions. BMJ 327: 1361-1362 [Full text]  
• Siegel, R. M., Kiely, M., Bien, J. P., Joseph, E. C., Davis, J. B., Mendel, S. G., Pestian, J. P., DeWitt, T. G. (2003). Treatment of Otitis Media With Observation and a Safety-Net Antibiotic Prescription. Pediatrics 112: 527-531 [Abstract] [Full text]  
• Del Mar, C. B., MD, M. B. (2002). Delayed prescription reduced antibiotic use in the common cold. Evid. Based Med. 7: 191-191 [Full text]  
• Macfarlane, J., Holmes, W., Gard, P., Thornhill, D., Macfarlane, R., Hubbard, R., van Weel, C. (2002). Reducing antibiotic use for acute bronchitis in primary care: blinded, randomised controlled trial of patient information leaflet * Commentary: More self reliance in patients and fewer antibiotics: still room for improvement. BMJ 324: 91-91 [Abstract] [Full text]  
• Mangione-Smith, R., McGlynn, E. A., Elliott, M. N., McDonald, L., Franz, C. E., Kravitz, R. L. (2001). Parent Expectations for Antibiotics, Physician-Parent Communication, and Satisfaction. Arch Pediatr Adolesc Med 155: 800-806 [Abstract] [Full text]  
• Little, P., Gould, C., Williamson, I., Moore, M., Warner, G., Dunleavey, J. (2001). Pragmatic randomised controlled trial of two prescribing strategies for childhood acute otitis media. BMJ 322: 336-342 [Abstract] [Full text]  
• Del Mar, C. (2000). Sore throats and antibiotics. BMJ 320: 130-131 [Full text]  
• Rivara, F. P. (1999). Are Guidelines Following Guidelines?. AAP Grand Rounds 2: 15-15 [Full text]  
• Clarke, R W, Cates, C. (1999). Reducing antibiotic use in children with acute otitis media. BMJ 319: 124-124 [Full text]  

Rapid Responses:

Read all Rapid Responses

Antibiotics and Third World economics

B Chapman Boyd
bmj.com, 15 Mar 1999 [Full text]

Which children are in need of antibiotic treatment for acute otitis media?

Morten Lindbęk
bmj.com, 15 Mar 1999 [Full text]

Citizens' participation, not just reduced costs

Virginio Oddone
bmj.com, 14 Mar 1999 [Full text]

Tackling antibiotic resistance: fewer antibiotics necessitate more precise diagnosis

Ajay Kumar
bmj.com, 7 Apr 1999 [Full text]