|
Ear infections in kids: ‘Wait and see
prescription’ best approach
Article in JAMA shows less antibiotic use,
equivalent outcomes with deferred treatment.
For children with acute ear infections seen in an emergency department,
giving parents the option of delaying use of antibiotics resulted in
significantly lower use of antibiotics compared to parents who received
a standard prescription, with little difference in the outcomes for the
children, according to a study in the September 13 issue of
JAMA.
Acute otitis media (AOM) is the most common reason for which an
antibiotic is prescribed to children. Treatment of AOM accounts for an
estimated 15 million antibiotic prescriptions written per year in the
United States, according to background information in the article.
Untreated AOM has a high rate of natural resolution, with similar rates
of complications whether antibiotics are prescribed or withheld.
Resistance to antibiotics is a major public health concern worldwide and
is associated with the widespread use of antibiotics.
David M. Spiro, MD, MPH, formerly of the Yale University School of
Medicine, New Haven, Conn., and colleagues conducted a study to
determine whether treatment of AOM using a "wait-and-see
prescription" (WASP) significantly reduced use of antibiotics
compared with a "standard prescription" (SP), and evaluated
the effects of this intervention on clinical symptoms and adverse
outcomes. Overall, 283 children with AOM aged 6 months to 12 years seen
in an emergency department were randomly assigned to receive either a
WASP (n = 138) or a SP (n = 145). All patients received ibuprofen and
ear analgesic drops for use at home. Telephone interviews were conducted
after enrollment to determine outcomes. The trial was conducted between
July 2004 and July 2005.
The researchers found that the WASP significantly reduced the use of
antibiotics. Substantially more parents in the WASP group did not fill
the antibiotic prescription, compared with the SP group (62% versus
13%). There was no statistically significant difference between the
groups in the frequency of subsequent fever, otalgia (earache), or
unscheduled visits for medical care. The patients in the WASP group
whose parents filled the prescription reported they did so because of
fever (60%), otalgia (34%), or fussy behavior (6%). No serious adverse
events were reported for patients in the study.
The authors added: "This randomized controlled trial has provided
evidence that the WASP strategy significantly reduces the use of
antibiotics in an urban population presenting to an emergency department
and may be an alternative to routine treatment of AOM with antibiotics.
Wait-and-see prescriptions remain controversial as most pediatricians in
the United States have been trained to routinely prescribe antibiotics
for AOM and believe that many parents expect a prescription; a small
minority of practitioners who care for children routinely use watchful
waiting.
"The WASP approach may interrupt the cycle of antibiotic
prescription, the expectation of parents to immediately treat AOM with
an antibiotic, and subsequent medical visits for this illness. The risks
of antibiotics, including gastrointestinal symptoms, allergic reactions,
and accelerated resistance to bacterial pathogens must be weighed
against their benefits for an illness that, for the most part, is self
limited. The routine use of WASP for AOM will reduce both the costs and
adverse effects associated with antibiotic treatment and should reduce
selective pressure for organisms resistant to commonly used
antimicrobials,"
In an accompanying editorial, Paul Little, MBBS, MD, FRCGP, of the
University of Southampton, Aldermoor Health Centre, Southampton, U.K.,
commented on the findings of Spiro and colleagues: "Further
evidence is needed to inform clinicians about when to use delayed
prescribing. Studies are needed to define children at risk of adverse
outcomes. For instance, most severely ill children and children about
whom the physician was concerned for other reasons will not have entered
the trial by Spiro et al. or other trials. Further studies also are
needed to determine the most effective alternatives to antibiotics.
However, given the current evidence base, a reasonable approach would be
as follows. When the child is not systemically ill and the physician has
no major concerns, delayed prescribing can be used. If the physician has
concerns about sicker or at risk patients (e.g., those with systemic
symptoms or comorbidity, infants younger than 6 months), then
antibiotics should be prescribed.
"If parents are given clear information about the timing of
antibiotic use and specific guidelines for signs and symptoms that
should trigger reassessment, delayed prescribing probably has its place,
should be acceptable to parents, appears reasonably safe, and provides a
significant step in the battle against antibiotic resistance."
Web links
Related resources on www.pharmacist.com
Contact the writer: L. Michael Posey,
BPharm, Pharmacy Today
Posted September 12, 2006, 5:15 pm EDT
| Article in JAMA shows less antibiotic use, equivalent outcomes with deferred treatment. |
|
