Otitis, Antibiotics, and the Greater Good

Abstract

A major paradigm shift lies at the core of the new clinical practice guideline for acute otitis media (AOM),1 ie, the option of allowing selected children to fight an ear infection on their own before the initiation of antibiotic treatment. These children initially receive analgesics, with antibiotics being reserved for those whose conditions worsen or fail to improve within 48 to 72 hours. Although new to many US physicians, the observation option for AOM is an official policy in the Netherlands, Sweden, and now New York State.2 By offering the observation option, the new guideline changes the central AOM management decision from which antibiotic should be given3 to whether an antibiotic should be given at all.4 The paradigm shift is needed because 5.2 million AOM episodes each year5 are treated with antibiotics in the United States, although most would resolve spontaneously. Stated simply, this volume of antibiotic use for largely self-limiting infections does not serve the greater good. Antibiotics are therapeutic agents that affect society, not just individuals.6 Each course of therapy creates selective pressure for resistant bacteria in the child's nasopharynx, which spread readily among families, schools, and child care centers. These organisms, and those they create with resistance genes in transferrable plasmids, may cause fatal infections among healthy or immunocompromised individuals.7 The number of resistant bacterial pathogens throughout the world continues to increase each year.8,9 More …