Release: May 12, 2000
Contact: Kenneth Satterfield, 407-238-4161 (as of 5/12/2000)
Pediatric Otolaryngologists Assess New Government Report on Acute Otitis Media
Use of antibiotics in treating ear infections in children is a focus of this new critique
Orlando, FL -- In 1997, the Agency for Health Care Policy and Research (AHCPR), now known as the Agency for Healthcare Research and Quality (AHRQ), set out to promote evidence-based practice in everyday care by establishing 12 Evidence-based Practice Centers (EPCs). The EPCs develop evidence reports and technology assessments based on rigorous syntheses of relevant scientific literature, permitting the AHRQ to serve as a "science partner" with public and private organizations.
Acute otitis media (AOM) was nominated as a topic for evidence analysis by the American Academy of Otolaryngology--Head and Neck Surgery, the American Academy of Pediatrics, and the American Academy of Family Physicians in response to a solicitation issued by the AHCPR. These associations were invited to nominate members for the technical expert panel, and others to peer review the draft report. Additional members of the panel represented family medicine, speech/language pathology, nursing, audiology, public health, and the lay community.
Three broad areas were identified as key issues: 1) incidence and prevalence of AOM, treatment and management alternatives, characteristics and size of the affected populations, and the most affected practice settings and providers, 2) burden of illness associated with AOM, including morbidity, mortality, impact on developmental milestones, quality of life, loss of productivity, medical costs to treat the condition, and other economic burdens associated with the disease, and 3) variations in practice associated with the prevention, diagnosis, treatment, or management of AOM.
The Evidence Report on Acute Otitis Media has been completed. A team of researchers set out to familiarize otolaryngologists (ear, nose, and throat specialists) with its findings. The research team made no attempt to provide an exhaustive listing of results; instead, the three-person team emphasized key findings relevant to otolaryngologists, their patients, and referring physicians.
The authors of the study, "Implications of the AHCPR Evidence Report on Acute Otitis Media," are Richard M. Rosenfeld MD, MPH, Department of Otolaryngology, SUNY Health Science Center at Brooklyn, Brooklyn, NY; Margaretha L. Casselbrant, MD, PhD, Department of Pediatric Otolaryngology, Children's Hospital of Pittsburgh, Pittsburgh, PA, and Maureen Hannley, PhD, American Academy of Otolaryngology--Head and Neck Surgery Foundation, Alexandria, VA Their findings were presented at the American Society of Pediatric Otolaryngology (ASPO), meeting May 17-18, in Orlando, FL.
Methodology: An evidence report is accomplished through a series of steps, designed to provide a diverse perspective of the clinical issues, and address the most pressing questions by a comprehensive review and analysis of the existing literature.
The medical societies that recommended AOM as a topic for evidence analysis were invited to nominate members for the technical expert panel, and others to peer review the draft report. Additional members of the panel represented family medicine, speech/language pathology, nursing, audiology, public health, and the lay evidence reports that provide valid and succinct summaries of relevant medical literature. Such reports are not a substitute for clinical judgment, but simply provide additional raw material for the clinician. Essentially, they are professional literature reviews, in which methodologists are guided by clinician-experts nominated by relevant organizations. The reports are similar to meta-analyses in that they emphasize quantitative measures of effect size with a priori protocols to minimize bias and enhance validity.
Results: Findings relevant to those who treat ear, nose, and throat disorders are:
ï AOM is an ever-present condition of early childhood, with over 5 million annual episodes in United States children at a national cost of $3-6 billion.
ï The natural history of AOM is favorable; children not initially treated with antibiotics have clinical success rates of 81 percent at one to seven days (95 percent CI, 72-90 percent) and 78 percent at four-seven days (95 percent CI, 66-90 percent).
ï In studies with close follow-up, few episodes of mastoiditis or other suppurative complications are reported in children not initially treated with antibiotics.
ï The incidence of mastoiditis or other suppurative complications is similar whether or not antibiotics are initially prescribed, but study samples are small and not population-based.
ï Antibiotics have a modest benefit on AOM symptom resolution and failure rates; about eight children would need to be treated with amoxicillin to avoid a single clinical failure.
ï No differences were found in the comparative clinical efficacy of various antibiotics as initial empiric therapy of uncomplicated AOM.
ï No differences were found in the comparative clinical efficacy of short-duration vs. long-duration antibiotic therapy of uncomplicated AOM.
ï Randomized, controlled studies of high internal validity and wide acceptance are still needed to adequately assess the key questions raised in the evidence report.
ï Future studies should employ uniform definitions and diagnostic criteria, use double-blind outcome assessment, and address influencing factors such as age and otitis-prone status.
Conclusions: An understanding of the AOM evidence report will help promote judicious antibiotic therapy because the physician may (1) realize the importance of being a skilled diagnostician, (2) feel less compelled to prescribe an antibiotic when there is questionable or non-severe AOM, especially in children aged 2 years or older, (3) use amoxicillin rather than broad-spectrum alternatives as the first-line drug, and (4) prescribe treatment for less than 7-10 days in children aged two years or older. When initial observation without antibiotics is elected, there should be (1) close follow-up with easy access to care and no extra cost for the family, and (2) reliably and well-informed parents with a knowledge of "treatment" failure signs and symptoms of complications.
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