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Diagnostic certainty for acute otitis media
1Department of Otolaryngology, Long Island College Hospital and State University of New York (SUNY), Downstate Medical Center, 339 Hicks Street, Brooklyn, NY 11201, USA. richrosenfeld@msn.com
Abstract:
Our primary objective was to assess diagnostic accuracy for acute otitis media (AOM) relative to the criterion standard established by the United States Agency for Healthcare Research and Quality: middle-ear effusion (MEE) plus onset in the past 48 h of signs or symptoms of middle-ear inflammation. A secondary objective was to assess the potential reduction in antibiotic usage that could be achieved if clinicians managed AOM according to a consensus guideline developed by the New York Region Otitis Project (NYROP). A convenience sample of primary care practitioners were surveyed after diagnosing AOM in 135 children aged 0.3-11.8 years (median 2.4 years). Clinicians expressed high certainty for AOM diagnosis in 122/135 episodes (90%). The prevalence of true AOM was 70% with a positive predictive value for high certainty of 76%. Of the 40 false-positive diagnoses, 35 did not have MEE and 5 did not have acute signs or symptoms. The relative risk for receiving an antibiotic was 1.50 times higher when clinicians expressed certainty (P=0.005), which produced 31/120 (26%) potentially unnecessary antibiotic prescriptions. Initial antibiotics would not have been prescribed for 29% of episodes using the NYROP guidelines. More judicious use of antibiotics may result if clinicians deferred initial therapy in children without definitive AOM, particularly when the presence of MEE is uncertain.
Insights
Diagnosing acute otitis media (AOM) accurately is crucial. Over-prescription of antibiotics occurs even with high diagnostic certainty, but guidelines like NYROP could reduce unnecessary antibiotic use in children.
Area of Science:
- Pediatrics
- Infectious Diseases
- Diagnostic Accuracy
Background:
- Acute otitis media (AOM) is a common childhood infection.
- Accurate diagnosis is essential to guide appropriate antibiotic treatment.
- Overdiagnosis and overtreatment contribute to antibiotic resistance.
Purpose of the Study:
- To evaluate the diagnostic accuracy of AOM compared to a criterion standard.
- To assess the potential reduction in antibiotic prescribing using the New York Region Otitis Project (NYROP) guidelines.
Main Methods:
- A convenience sample of primary care practitioners diagnosed AOM in 135 children (0.3-11.8 years).
- Diagnostic certainty and presence of middle-ear effusion (MEE) were recorded.
- Comparison with criterion standard: MEE plus acute signs/symptoms within 48 hours.
Main Results:
- Clinicians reported high certainty in 90% of AOM diagnoses.
- True AOM prevalence was 70%; high certainty had a 76% positive predictive value.
- 26% of antibiotic prescriptions were potentially unnecessary; NYROP guidelines could have avoided 29% of initial prescriptions.
Conclusions:
- Clinician certainty in AOM diagnosis does not guarantee accuracy, leading to potential overtreatment.
- Implementing guidelines like NYROP can promote more judicious antibiotic use.
- Deferring therapy when MEE is uncertain may reduce unnecessary antibiotic prescriptions.