No therapy: use, abuse, efficacy, and morbidity--the European versus the Third-World experience

Historical controls documented a marked reduction in complications from acute otitis media (AOM) and chronic suppurative otitis media (CSOM) with the introduction of antibiotic therapy in the period 1930 to 1950s amongst other changes that occurred in North American and Western European society. Today, the natural history of spontaneous remission in AOM in over 80% of children within 24 hours of presentation questions the raison d'etre for the routine prescription of antibiotics for what may essentially be a self-limiting condition. Metaanalyses of numerous antibiotic versus placebo trials in the treatment of AOM have demonstrated little difference in clinical outcome, as have treatment stratagems where antibiotics have been initially withheld. More judicious use of antibiotic therapy in AOM appears to have been associated with a decline in antimicrobial resistance in countries such as the Netherlands and Iceland. It is difficult to know, however, whether the direct savings from decreased antibiotic use will ultimately lead to an actual decrease in the other direct and indirect costs associated with AOM. Unfortunately, children in the third world have not experienced a corresponding decline in ear disease. Significant loss of disability-adjusted life years (DALYs) continues to occur from otitis media. Withholding antibiotic therapy in the treatment of AOM would more than likely impose greater morbidity and mortality on an already disadvantaged population. Nevertheless, the experience of the Thai Rural Ear Nose and Throat Foundation has been seminal in documenting and affecting change in both the morbidity and mortality patterns of AOM and CSOM during Thailand's transition toward developed nation status. This article analyzes these issues and provides a review of the literature available.