Delayed Prescribing—A Sensible Approach to the Management of Acute Otitis Media

Abstract

BASED ON EXPERIENCE IN HOLLAND, 1 EVIDENCE FROM systematic reviews, and recent evidence in the United Kingdom, many northern European countries, including the United Kingdom, have developed guidelines to advise physicians to delay for a short time before prescribing antibiotics for children with acute otitis media (AOM). The Dutch developed a policy of no prescription for AOM unless the patient has significant otalgia, fever, or both 72 hours after seeing the physician, or if a prolonged otic discharge develops. One study showed that if this watchful-waiting approach is used, there are likely to be few cases of complications (only 1 case of mastoiditis occurred in a 5000-patient cohort, and this patient had waited nearly a week). Patients and their families should be given clear advice about returning to see their physician if signs of complications occur, ie, worsening systemic features such as fever or vomiting. The study by Spiro and colleagues in this issue of JAMA is a welcome addition to the literature, suggesting that a “waitand-see” approach in the management of AOM is effective in the emergency department setting. Children randomized to the wait-and-see approach used fewer antibiotics (38% compared with 87%), and there was no difference in subsequent fever, otalgia, or unscheduled visits for medical care. The study provides evidence that there is probably little to be gained in terms of symptom resolution by immediate prescription of antibiotics for most children. Compared with previous trials of delayed antibiotic prescribing, the effect sizes are smaller than a Canadian study and similar to a United Kingdom study that used similar exclusion criteria. Further evidence of the limited utility of providing immediate antibiotics comes from a Cochrane review that suggests more than 15 children have to be treated for 1 child to benefit. The study by Spiro at al demonstrates that the wait-andsee approach is acceptable to parents in the United States, a finding that could have a substantial influence on the traditionally high rate of prescribing antibiotics for AOM in the United States. It also demonstrates that a wait-and-see approach works in the emergency department setting, where patients have no ongoing relationship with a physician. That children in such a setting might have worse outcomes had been a concern. However, several notes of caution are required. Both this study and previous studies excluded children whom clinicians considered to be toxic, and thus it would be unwise to extrapolate these results to very sick children. Furthermore, most children with AOM present within 24 hours after symptom onset. It would be unwise to suggest a further delay of 72 hours if the child already has a high fever and severe otalgia for 72 hours or longer, so the delaying times should be adjusted for the length of prior severe otalgia and fever. Especially in an emergency department setting, it would be advisable for physicians to emphasize the importance of repeat assessment if symptoms do not improve following the delayed prescription. There are several potential advantages of delayed prescribing. First, delayed prescribing rationalizes antibiotic use. Evidence from a systematic review of delayed prescribing trials for a variety of respiratory infections supports findings from the current study that delayed prescribing is likely to reduce antibiotic use. The study by Spiro et al suggests that a waiting period of 48 hours is likely to result in 62% of patients not using antibiotics; advising a wait of 72 hours is likely to result in even fewer antibiotic prescriptions being used. When patients are asked to return to collect their delayed antibiotic prescription from the physician’s office, antibiotic use is likely to be little greater than using a policy of no initial offer of antibiotics. Second, delayed prescribing changes patient and family beliefs about antibiotics. Prescribing antibiotics probably fuels a cycle of belief in antibiotics, subsequent reattendance, and further antibiotic request and use. Delayed prescribing appears to be as effective as not prescribing antibiotics in changing beliefs, and it also changes subsequent consultation behavior. Delayed prescribing has similar or lower rates of reattendance when compared with not prescribing. Third, delayed prescribing achieves acceptable symptom control. Previous systematic reviews of delayed prescribing have called for more evidence on this point. Most trials, including the trial by Spiro