An American addiction?

May 2001

---Philip A. Brunell, MD

I recently attended a meeting at which an abstract appeared that compared the recommendations for treating acute otitis media (AOM) in different countries (19th Annual Meeting of the European Society of Paediatric Infectious Diseases, Istanbul, Turkey, March 26-28, 2001, p42). The table is produced for your examination.

On examination of this table, it appears that all the countries surveyed either decreased their recommendations for antibiotic use or continued their policy of restricted use, except the United States, which increased the recommended dosage. One must ask if this disparity is indicative of a difference in otitis media or a difference in prescribing physicians. In the United States, AOM caused by resistant pneumococci has been increasing. This has been associated with the increased use of antimicrobials most commonly to treat “acute otitis media.”

Perhaps the abstract is a bit harsh as there have been recommendations for more restrained use of antimicrobials. A 5-7 day course has been suggested for “certain patients” (Pediatrics. 1998;101suppl:165). This shortened course appears to be supported by a recent large prospective study (Oto Head Neck Surg, 2001;124:381) and by meta-analysis published in the Journal of the American Medical Association (JAMA. 1998;279:1736).

Everyone seems to agree both that we use too many antimicrobials and that there is no ready solution to this problem. Part of the problem is simply that we over diagnose AOM. Mike Pichichero, MD, in his excellent commentary on the JAMA article points out that the authors of the article failed to take into account the accuracy of diagnosis in the various studies which they included in the meta-analysis (JAMA. 1998;279:1748). It is well recognized that physicians have different criteria for the diagnosis of AOM and that a diagnosis based on physical examination may not be confirmed by tympanocentesis. Bacteria, the only organisms that might benefit from treatment, are isolated from about half of the ears considered to represent AOM.

It is difficult to compare studies of antimicrobial effectiveness when different criteria may be used for the diagnosis of AOM and also for outcome. The “Pollyanna phenomenon” (J Pediatr. 1992;120:72) expresses the frustration of evaluating the effectiveness of treating of AOM. Children who actually have AOM and may benefit from therapy as they are included in the same treatment group as those who are diagnosed as AOM and do not have bacterial infections. Thus, the effect of treatment will be diluted. Almost all children who have AOM caused by bacteria recover in the absence of therapy without significant complications. In the past few issues of Infectious Diseases in Children, Richard Schwartz, MD, has attempted to present some basics, which should help with the diagnosis of otitis media. These include using the appropriate speculum, cleaning ears so that the tympanic membrane can be visualized, maintenance of equipment, and suggesting some criteria for diagnosis.

Cleaning ears is a pain! Evaluating a child with unexplained fever or with otalgia without visualizing the eardrum is unacceptable. One of my pet peeves is the listing of otitis media as a physical finding rather than describing the “position, color, translucency and mobility” of the drum or the presence of pus in the canal. I believe this should be encouraged in chart audits. It may make us think more carefully about the criteria we use for diagnosis (Pediatrics. 1998;101 suppl:165).

There has been some reticence in establishing more definitive criteria for the diagnosis of AOM probably in recognition of the fact that a certain amount of gestalt goes into any diagnostic process. However, criteria are intended as guidelines and not commandments handed down on Sinai. It would be useful to go back to study charts and compare the description of the ear examination (if recorded) of children who have bacteria isolated at paracentesis and those who do not. This might provide better information on which to define criteria. It is of interest that investigators who study AOM tend to have much higher isolation rates of bacteria at paracentesis suggesting that they have a good idea of which ears are likely to yield bacteria.

It also is recognized that we may disagree on what we see. I always used to take a two-headed otoscope on teaching rounds. It might not be a bad idea to have one in the office if there are colleagues (and time) with whom to consult.

I do not mean to simplify a complex problem. The acceptance of parents certainly is important. Many come into the office because “they want an antibiotic.” Education of parents is expensive; it requires time. Some will be resistant to any explanations. In my own practice, I did not encourage those patients to remain with me. However, practitioners will have their own threshold.

Can we safely withhold therapy? In the Netherlands where antimicrobials are prescribed parsimoniously, there may be slightly more mastoiditis than in other countries with more liberal use (Pediatr Infect Dis J. 2001;20:140). In the US, however, increasing pneumococcal resistance does not seem to be associated with significantly increased number of cases of pneumococcal mastoiditis (Pediatrics. 2000;106:595).

The availability of vaccines against Haemophilus and pneumococcus may have only a modest effect on decreasing AOM but they should give us confidence in withholding therapy from children with fever without an obvious source. I think we have all seen febrile kids with a red drum and no other abnormalities on examination of the ear and given antibiotics for “otitis media.” The widespread use of vaccines should enable us to tilt in the direction less permissive in use of antimicrobials in this situation.

Most of my generation survived childhood and AOM before antibiotics were available. Perhaps that is why we are willing to just stand there and do nothing.