Pragmatic randomised controlled trial of two prescribing strategies for childhood acute otitis media
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Published on: May 6, 2014
P Little1, C Gould, I Williamson
1Community Clinical Sciences (Primary Medical Care Group), University of Southampton, Aldermoor Health Centre, Southampton SO15 6ST. psl3@soton.ac.uk
Insights
Immediate antibiotics for acute otitis media offer slight symptom relief after 24 hours. A delayed prescribing strategy is feasible, acceptable to parents, and significantly reduces antibiotic use.
Area of Science:
- Pediatrics
- Infectious Diseases
- Pharmacology
Background:
- Acute otitis media (AOM) is a common childhood illness often treated with antibiotics.
- There is ongoing debate regarding the optimal prescribing strategy for AOM to balance efficacy and antibiotic stewardship.
Purpose of the Study:
- To compare the effectiveness and parental acceptance of immediate versus delayed antibiotic prescribing for children with AOM.
Main Methods:
- An open randomized controlled trial was conducted in general practices in south west England.
- 315 children (6 months to 10 years) with AOM were randomized to receive either immediate antibiotics or delayed antibiotics (prescription available after 72 hours if symptoms persisted).
- Outcomes included symptom resolution, school absence, and paracetamol consumption.
Main Results:
- Symptom resolution occurred around day 3 on average.
- Immediate antibiotics led to a modest reduction in illness duration (-1.1 days) and disturbed nights, with benefits primarily after the first 24 hours.
- The delayed antibiotic group showed significantly less diarrhea (9% vs 19%) and comparable satisfaction, with only 77% of parents utilizing the delayed prescription.
Conclusions:
- Immediate antibiotic prescription for AOM offers limited additional benefit after the initial 24 hours, as symptoms naturally improve.
- A 'wait and see' approach for prescribing antibiotics in children with AOM who are not severely ill is a feasible and acceptable strategy.
- Delayed antibiotic prescribing can substantially reduce overall antibiotic consumption for acute otitis media.
Objective:
To compare immediate with delayed prescribing of antibiotics for acute otitis media.
Design:
Open randomised controlled trial.
Setting:
General practices in south west England.
Participants:
315 children aged between 6 months and 10 years presenting with acute otitis media.
Interventions:
Two treatment strategies, supported by standardised advice sheets-immediate antibiotics or delayed antibiotics (antibiotic prescription to be collected at parents' discretion after 72 hours if child still not improving).
Main Outcome Measures:
Symptom resolution, absence from school or nursery, paracetamol consumption.
Results:
On average, symptoms resolved after 3 days. Children prescribed antibiotics immediately had shorter illness (-1.1 days (95% confidence interval -0.54 to -1.48)), fewer nights disturbed (-0.72 (-0.30 to -1.13)), and slightly less paracetamol consumption (-0.52 spoons/day (-0.26 to -0.79)). There was no difference in school absence or pain or distress scores since benefits of antibiotics occurred mainly after the first 24 hours-when distress was less severe. Parents of 36/150 of the children given delayed prescriptions used antibiotics, and 77% were very satisfied. Fewer children in the delayed group had diarrhoea (14/150 (9%) v 25/135 (19%), chi(2)=5.2, P=0.02). Fewer parents in the delayed group believed in the effectiveness of antibiotics and in the need to see the doctor with future episodes.
Conclusion:
Immediate antibiotic prescription provided symptomatic benefit mainly after first 24 hours, when symptoms were already resolving. For children who are not very unwell systemically, a wait and see approach seems feasible and acceptable to parents and should substantially reduce the use of antibiotics for acute otitis media.
