Management Of Acute Otitis Media Research Articles

Verification of Clinical Practice Guideline for Diagnosis and Management of Acute Otitis Media in Children in Japan

Verification of Clinical Practice Guideline for Diagnosis and Management of Acute Otitis Media in Children in Japan

A proposal to limit otoscopy to reduce unnecessary use of antibiotics: a call for research

Acute otitis media (AOM) is the most common bacterial infection in childhood, accounting for more than 10 million prescriptions written in the USA alone. Otoscopy is the only method to diagnose AOM, is difficult to perform in young children and has been found to be inaccurate. Otoscopy has certain risks, the most common of which are child discomfort, trauma to the external ear canal and parental anxiety. Current guidelines emphasize the importance of making an accurate diagnosis of AOM, which includes the presence of fever, otalgia or both. We propose a new strategy to limit the use of otoscopy to circumstances in which the pretest probability of AOM is high. We suggest indications for mandatory otoscopy and a flow chart outlining a proposal for limiting otoscopy in the management of AOM. Clinical research evaluating the rational use of otoscopy is encouraged to evaluate outcomes and acceptance of this proposal. Limiting otoscopy to clinical conditions in which the likelihood of AOM is high may reduce unnecessary pain and anxiety associated with the procedure, reduce rates of misdiagnosis and support the more judicious use of antibiotics.

Management of Acute Otitis Media After Publication of the 2004 AAP and AAFP Clinical Practice Guideline

Management of Acute Otitis Media After Publication of the 2004 AAP and AAFP Clinical Practice Guideline

Poor adherence to antibiotic prescribing guidelines in acute otitis media--obstacles, implications, and possible solutions.

Many countries now have guidelines on the clinical management of acute otitis media. In almost all, the public health goal of containing acquired resistance in bacteria through reduced antibiotic prescribing is the main aim and basis for recommendations. Despite some partial short-term successes, clinical activity databases and opinion surveys suggest that such restrictive guidelines are not followed closely, so this aim is not achieved. Radical new solutions are needed to tackle irrationalities in healthcare systems which set the short-term physician–patient relationship against long-term public health. Resolving this opposition will require comprehensive policy appraisal and co-ordinated actions at many levels, not just dissemination of evidence and promotion of guidelines. The inappropriate clinical rationales that underpin non-compliance with guidelines can be questioned by evidence, but also need specific developments promoting alternative solutions, within a framework of whole-system thinking. Promising developments would be (a) physician training modules on age-appropriate analgesia and on detection plus referral of rare complications like mastoiditis, and (b) vaccination against the most common and serious bacterial pathogens.

Treatment Failure, Recurrence, and Antibiotic Prescription Rates for Different Acute Otitis Media Treatment Methods

In an era of increasing antibiotic resistance, reliance on empirical antibiotic therapy for management of acute otitis media (AOM) will eventually become an untenable strategy. New research efforts are needed to identify effective treatment alternatives. In this retrospective analysis, we assessed AOM treatment failure (AOMTF), recurrent AOM (RAOM), and antibiotic prescription rates for groups of AOM episodes managed with either immediate antibiotics (ABX), tympanocentesis + observation (Tap + OBS), or tympanocentesis + immediate antibiotics (Tap + ABX). No significant differences in rates of AOMTF or RAOM were observed between any of the treatment groups. The 30-day rate of antibiotic prescriptions written for AOM was significantly lower in the TAP + OBS group (1 prescription per 3.8 episodes) than in the immediate antibiotic therapy groups (1.2 prescriptions per episode), P < .001. The comparative risk of AOMTF was slightly higher among AOM episodes caused by Streptococcus pneumoniae (OR 2.523; CI 1.070-5.944; P = 0.056). Neither the presence of other particular otopathogens, nor the presence of drug-resistant otopathogens, nor the choice of any particular AOM antibiotic therapy correlated with increased risk of either AOMTF or RAOM. The observed absence of significant differences in clinical outcomes between the various treatment groups in this study is consistent with findings published by other authors: alternative AOM therapies can help reduce reliance on antibiotics without inviting significant increases in rates of clinical failure.

National Survey of Pediatricians' Opinions about and Practices for Acute Otitis Media and Xylitol Use

Acute otitis media (AOM) is the main reason for physician visits and antibiotic prescriptions in children. Pediatricians (Peds) are gatekeepers for services and sources of information for families. The 2004 American Academy of Pediatrics/American Academy of Family Physicians (AAP/AAFP) Clinical Practice Guideline: Diagnosis and Management of Acute Otitis Media recommended preventative and management measures for Peds' practice. Treatments for AOM (antimicrobial therapy and surgery) sometimes have questionable effectiveness, risks, and high costs. Thus, Peds should consider using prophylactics for AOM that are easy to administer, cost-effective, and have minimal side effects. Xylitol, a naturally occurring sugar alcohol, is widely used to prevent AOM and for other health conditions in Europe, and as a dental caries prophylaxis in the United States. It would be helpful to know Peds' attitudes and practices to identify barriers to xylitol's use as a prophylaxis for AOM in the United States. To conduct a national survey of Peds in the United States to evaluate how closely they adhered to the AAP/AAFP guideline, and their knowledge and opinions about xylitol use. A randomized, national postal survey. A 48-item questionnaire developed for this study was mailed to a random sample of 506 Peds within the United States during spring 2009. It assessed Peds' demographics, adherence to the guideline, and knowledge and opinions about and use of xylitol as a prophylaxis for AOM in children. The questionnaire response rate was 22% (98 useable/506 mailed - 63 returned undeliverable). Participants were about equal for gender, and almost all were in private practice for over 10 yr. Most had pediatric patients with at least one bout of AOM annually. The majority adhered to the guideline (e.g., almost all routinely assessed and managed patients' pain for AOM and encouraged prevention by recommending that families reduce risk factors). Most used and were comfortable with otoscopy for diagnosing AOM, but not tympanometry. Almost all believed that conductive hearing loss could hinder speech-language and academic development, and AOM could reduce quality of life of children. They also believed that those under 6 mo of age with AOM should receive antibacterial therapy beginning with amoxicillin but did not use complementary and alternative medicine (CAM). Only about half knew about medical uses for xylitol, but of those, most were aware of its use in chewing gum to prevent AOM but had not used it with patients. They were not sure of xylitol's effectiveness or appropriate dosages but cited stomach cramping and diarrhea as possible side effects. Most would use xylitol if evidence supported it and wanted information about it via reprints or electronically. Few agreed that audiologists are important in diagnosing/managing AOM. Most of these Peds adhered to the AAP/AAFP guideline. They were not using CAMs like xylitol for preventing AOM in children. Future research should focus on prevention and the use of xylitol as a possible prophylaxis regimen for AOM in patients.

Otitis media and its consequences: beyond the earache

An international group of multidisciplinary experts on middle-ear and paediatric infections met to explore where consensus exists on the management of acute otitis media. After informal discussions among several specialists of paediatric infectious disease, the group was expanded to include a larger spectrum of professionals with complementary expertise in middle-ear disease. Acute otitis media is a very common bacterial infection in children worldwide, leading to excessive antibiotic consumption in children in most countries and to a substantial burden of deafness and suppurative complications in developing countries. The group attempted to move beyond the existing controversies surrounding guidelines on acute otitis media, and to propose to clinicians and public health officials their views on the actions needed to be taken to reduce the disease burden caused by acute otitis media and the microbial antibiotic resistance from the resulting use of antibiotics. Definition of acute otitis media and diagnostic accuracy are crucial steps to identify children who will potentially benefit from treatment with antibiotics and to eliminate unnecessary prescribing. Although the group agreed that antibiotics are distributed indiscriminately, even to children who do not seem to have the disease, no consensus could be reached on whether antibiotics should be given to all appropriately diagnosed children, reflecting the wide range of practices and lack of convincing evidence from observational studies. The major unanimous concern was an urgent need to reduce unnecessary prescribing of antibiotics to prevent further increases in antibiotic resistance. Prevention of acute otitis media with existing and future viral and bacterial vaccines seems the most promising approach to affect disease burden and consequences, both in developed and developing countries.

Management of Acute Otitis Media After Publication of the 2004 AAP and AAFP Clinical Practice Guideline

Observation without initial antibiotic therapy was accepted as an option for acute otitis media (AOM) management in the 2004 American Academy of Pediatrics and American Academy of Family Physicians clinical practice guideline. The guideline also recommended amoxicillin as the first-line treatment for most children, and analgesic treatment to reduce pain if it was present. Our objective was to compare the management of AOM after publication of the 2004 guideline. We analyzed the National Ambulatory Medical Care Survey, 2002-2006 (N = 1114), which occurred in US physicians' offices. The patients were children aged 6 months to 12 years who were diagnosed with AOM. The time comparisons were the 30-month periods before and after the guideline. The main outcome was the encounter rate at which no antibiotic-prescribing was reported. Secondary outcomes were the identification of factors associated with encounters at which no antibiotic-prescribing was reported and antibiotic- and analgesic-prescribing rates. The rate of AOM encounters at which no antibiotic-prescribing was reported did not change after guideline publication (11%-16%; P = .103). Independent predictors of an encounter at which no antibiotic-prescribing was reported were the absence of ear pain, absence of reported fever, and receipt of an analgesic prescription. After guideline publication, the rate of amoxicillin-prescribing increased (40%-49%; P = .039), the rate of amoxicillin/clavulanate-prescribing decreased (23%-16%; P = .043), the rate of cefdinir-prescribing increased (7%-14%; P = .004), and the rate of analgesic-prescribing increased (14%-24%; P = .038). Although management of AOM without antibiotics has not increased after the publication of the 2004 American Academy of Pediatrics and American Academy of Family Physicians clinical practice guideline, children who did not receive antibiotics were more likely to have mild infections. In accordance with the guideline, the prescribing of amoxicillin and analgesics has increased. Contrary to the guideline, the prescribing of amoxicillin/clavulanate has decreased, whereas the prescribing of cefdinir has increased.

Antimicrobial Therapy of Otitis Media Reduces the Incidence of Mastoiditis

Otitis media is one of the most common infections of children and can rarely lead to bacteremia, meningitis, and mastoiditis [1]. Most episodes of acute otitis media in children are self-limiting and do not require antibiotic treatment. Although antibiotic use in the management of otitis media is routine in the United States, it is common practice in some countries in Europe to initially treat otitis media symptomatically and institute antimicrobial therapy only if clinical improvement does not occur. The implementation of the “watchful waiting” approach recommended by the American Academy of Pediatrics and American Academy of Family Physicians clinical practice guideline for the diagnosis and management of acute otitis media in 2004 [2] contributed to the reduction of antimicrobial use in the treatment of this infection. This option’s premise is that antibiotic treatment of some uncomplicated acute otitis media cases can be deferred if certain criteria are met, including diagnostic certainty and disease severity. The observation option was limited to children 6 months to 2 years of age who are otherwise healthy, with nonsevere illness at presentation, and an uncertain diagnosis, and to children 2 years of age and older with nonsevere symptoms at presentation and an uncertain diagnosis. One of the concerns that was voiced after the introduction of the “watchful waiting” approach was that it would cause an increase the rate of complications following otitis media.

Antibiotic Dosing for Acute Otitis Media in Children

The American Academy of Pediatrics 2004 guidelines on diagnosis and management of acute otitis media (OM) recommends use of high-dose amoxicillin for the treatment of acute uncomplicated OM. With rising childhood obesity, recommended amoxicillin dose of 80 to 90 mg/kg per day often exceed standard adult dose of 1500 mg/d. To study prescribing patterns of primary care physicians for amoxicillin in the treatment of OM. To assess opinions of American Academy of Pediatrics subcommittee members who participated in guideline formulation. This study had 2 parts. Part 1: Retrospective review of medical records of children visiting the hospital between April and June 2008 and with a diagnosis of OM and were prescribed amoxicillin. Part 2: Web-based survey of 14 members of the OM guidelines subcommittee. Part 1: Three hundred fifty-nine children were eligible, with a mean (SD) age of 3.2 (4.0) years and 185 (51.5%) of whom were males. Children weighing 20 kg or less received higher mean daily dose of amoxicillin (74.2 vs 40.4 mg/kg per day, P < 0.00). Part 2: Nine (64.3%) subcommittee members responded to the survey. Most (77.8%) affirmed that the impact of obesity on high-dose amoxicillin recommendation was not discussed during guideline formulation. If a patient's estimated amoxicillin dose exceeded the standard adult dose (1500 mg/d), 66.7% members would prescribe the standard adult dose whereas 33.3% would prescribe the recommended dose of 80 to 90 mg/kg per day. Primary care physicians prescribe a significantly lower-than-recommended amoxicillin dose in older children and those in the higher weight category. The opinion among subcommittee members regarding maximum dose specification of amoxicillin is varied.

診療ガイドラインに基づいた急性中耳炎診療

診療ガイドラインに基づいた急性中耳炎診療

Management of acute otitis media in Pediatrics using The Clinical Practice Guidelines for Acute Otitis Media in Children and relation with otolaryngology

Management of acute otitis media in Pediatrics using <i>The Clinical Practice Guidelines for Acute Otitis Media in Children</i> and relation with otolaryngology

Update: Acute Otitis Media

CME EDUCATIONAL OBJECTIVES 1. Review the recent changes in the microbiology of acute otitis media. 2. Differentiate the physical exam findings characteristic of acute otitis media (AOM) from those of otitis media with effusion (OME). 3. Discuss the evidence to support antimicrobial management of AOM in children.

Évaluation de la prise en charge de l’otite moyenne aiguë du nourrisson et de l’enfant en médecine de ville dans le Nord de la France

To assess the management of acute otitis media in children by paediatricians and general practitioners in the North of France compared with the AFSSAPS (Agence Française de Sécurité Sanitaire des Produits de Santé) guideline's recommendations of 2005.All eligible family paediatricians (n=68) and a group of general practitioners (n=200) first received a phone call invitation to participate to the study. The volunteers responded to a questionnaire by phone call.The response rates were 67, 6 % for the group of paediatricians and 64, 5 % for the group of general practitioners. The guideline's recommendations were followed by respectively 28, 3 % and 9, 3 % of primary care physicians. The observation option, recommended in children aged more than 2 years, was followed by 46, 5 % of general practitioners and 54, 3 % of paediatricians. The durations of antibiotics were poorly respected by the 2 groups of physicians. In case of allergy to penicillin, the paediatricians followed more the recommendations than the general practitioners.Educational interventions are needed in order to improve the adherence to guidelines of paediatricians and general practitioners for the management of acute otitis media in children.

Parental experiences and attitudes regarding the management of acute otitis media--a comparative questionnaire between Finland and The Netherlands

Both treatment guidelines and the amount of antibiotics used for acute otitis media (AOM) vary across western countries. Parental expectations and their awareness of antimicrobial use and resistance, which may also be influenced by the guidelines, are not yet completely known. To compare parental experiences and opinions regarding the management of AOM in children with AOM in Finland and The Netherlands. We sent the questionnaires via public day care in Turku, Finland, and Utrecht, The Netherlands. We asked about family background, child's history of AOM and parental experiences and attitudes about AOM treatment and antimicrobial resistance. Of 1151 participants, 83% in Finland and 49% in The Netherlands had had at least one episode of AOM. Antibiotics were used more frequently in Finland than in The Netherlands, 99% versus 78%, respectively. More Finnish parents reported to believe that antibiotics are necessary in the treatment of AOM as compared to Dutch parents. Use of analgesics for AOM was similar (80% in Finland and 86% in The Netherlands). One-third of the parents had discussed resistance with their doctor. According to parental experiences, antimicrobial resistance had caused more problems in Finland than in The Netherlands (20% versus 2%). Finally, 88% of parents in Finland and 65% in The Netherlands were worried that bacteria could become resistant to antibiotics. Treatment practices and parental expectations seem to interact with each other. Therefore, if we aim to change AOM treatment practices, we have to modify both guidelines and parental expectations.

Acute otitis media: Antimicrobial treatment or the observation option?

The "observation option" was a recommendation cited in the American Academy of Pediatrics/American Academy of Family Physicians clinical practice guideline for the diagnosis and management of acute otitis media (AOM) in 2004. This option's premise is that antibiotic treatment of some uncomplicated AOM cases can be deferred if certain criteria are met, including diagnostic certainty and disease severity. Although this recommendation was controversial, physicians expressed relief at its publication because they felt that not all cases of AOM needed treatment with antibiotics. Studies of the guideline's acceptability, practicality, applicability, and effectiveness have been positive. The Centers for Disease Control and Prevention support it wholeheartedly. Nevertheless, reluctance persists, and the medical community has voiced some objections. During this current crisis of antibiotic resistance, the observation option has become a point of contention.

Management of Acute Otitis Media by Primary Care Physicians: Trends Since the Release of the 2004 American Academy of Pediatrics/American Academy of Family Physicians Clinical Practice Guideline

Management of Acute Otitis Media by Primary Care Physicians: Trends Since the Release of the 2004 American Academy of Pediatrics/American Academy of Family Physicians Clinical Practice Guideline

The rocky road to rational prescribing

Primary care physicians frequently see simple cases of acute otitis media (AOM), whilst specialists are generally presented with more complicated cases. Despite the high disease burden and high rates of consultation, diagnosis and management of AOM is currently suboptimal. Furthermore, problems with diagnosis and management have a direct impact upon worsening antibiotic resistance. This article discusses the unmet needs in AOM that need to be addressed in order to improve patient assessment and management. There is a need to further educate the public in order to ‘demedicalize’ this common disease. Effective vaccination is also an important component of optimal management.

The concept and practice of a wait-and-see approach to acute otitis media

We review the contemporary management of acute otitis media, including symptomatic care, the rationale and literature for utilizing the wait-and-see approach, and the indications for immediate therapy with antibiotics. Current guidelines recommend selective use of observation in children diagnosed with acute otitis media. Recent evidence suggests that a wait-and-see approach will reduce the use of antibiotics and decrease adverse events associated with their use. Earlier studies found that antimicrobials reduce pain and discomfort in the acute phase of illness compared with placebo. A recently published trial, however, suggests that when analgesics are utilized there may be minimal or no difference in otalgia whether antibiotics are prescribed or withheld. Treatment of acute otitis media is the most frequent indication for prescribing antibiotics in the pediatric population. Evidence suggests there is marginal benefit from antibiotics for most children diagnosed with AOM. Based on current data, we propose an algorithm for the management of children with AOM that includes a wait-and-see approach with specific indications for immediate treatment with antibiotics. A wait-and-see approach to acute otitis media that empowers families by using a shared decision-making model will reduce the use of antibiotics and will decrease resistance to antimicrobials.

Usefulness of &ldquo;The Guideline of Diagnosis and Management of Acute Otitis Media&rdquo;

Usefulness of &ldquo;The Guideline of Diagnosis and Management of Acute Otitis Media&rdquo;