Delayed Therapy for Otitis Media

Abstract

To the Editors: Grossman et al1 described the effects of implementing the delayed antibiotic therapy approach on antibiotics consumption in Israeli children with first documented acute otitis media (AOM). Indeed, it is important to evaluate the impact of newly implemented guidelines on patient care. However, we have reasons to believe that the study design prohibits drawing the conclusion stated in the article. First of all, the authors report the effect of implementation of the delayed antibiotic therapy approach for the treatment of AOM in children on antibiotic consumption. However, the primary aim of new guidelines is to affect physicians' behavior. Because the authors have not identified the actual prescriptions of antibiotics, antibiotic consumption appears to be a poor surrogate marker for physicians' prescribing behavior. If the latter had been measured, more appropriate findings could have been presented. Second, also stated by the authors to have been reported in other studies,2,3 the decrease in antibiotic use for AOM could be the result of diagnostic transfers (ie, the shift by physicians to diagnoses other than AOM that justify antibiotic treatment). Nevertheless, the authors do not address how this may have influenced their results. Their study shows a trend of decreasing incidence of AOM in children aged 0.5 to 2 years, which is not explained further. However, especially in this age group alternative diagnoses may have led to the decreased antibiotic use found. The impact of this plausible explanation on the authors' findings should be addressed. Finally, the authors report that implementation of the new guideline is associated with a significant reduction in use of antibiotics, reversing an upward trend. However, undefined factors other than the new guideline may have caused these alterations. The design of this study, an uncontrolled time series, does not allow ruling out that the results are caused by other factors. Gijs Elshout, MD, MSc Marlies Hordijk Johannes C. van der Wouden, PhD Department of General Practice Erasmus Medical Center University Medical Center Rotterdam, The Netherlands