By Hal B. Jenson, MD, FAAP

Dr. Jenson is Dean, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI.

Dr. Jenson reports no financial relationships relevant to this field of study.

Synopsis: Nationally, nonblack children with otitis media more frequently receive broad-spectrum antibiotics than black children do. The majority of children with otitis media in the United States receive inappropriate treatment with broad-spectrum antibiotics.

Source: Fleming-Dutra KE, Shapiro DJ, Hicks LA, Gerber JS, Hersh AL. Race, otitis media, and antibiotic selection. Pediatrics 2014;134:1059-1066.

Two large, national, publicly available databases at the Centers for Disease Control and Prevention were used to compare otitis media visits between black and nonblack children <=14 years of age during 2008 to 2010. There were 4,178 ambulatory visits for otitis media by children <=14 years of age during this period that were evaluated. Patients were excluded from analysis if there was a concomitant diagnosis also requiring antibiotic treatment.

Although otitis media visits per 1000 population were not different between black and nonblack children (253 vs 321, P = 0.12), the percentage of all visits resulting in a diagnosis of otitis media was 30% lower among black children compared with nonblack children (7% vs 10%, P = 0.004).

For children diagnosed with otitis media and for which antibiotics were prescribed, black children were less likely to receive broad-spectrum antibiotics (e.g., macrolides such as azithromycin, â-lactam/â-lactamase inhibitor combinations, quinolones, lincomycin derivatives such as clindamycin, and second- and third-generation cephalosporins) than nonblack children (42% vs 52%, P = 0.01). Multivariable analysis showed the black race/ethnicity was negatively associated with broad-spectrum antibiotic prescribing (odds ratio 0.59; 95% CI, 0.40-0.86), even after adjusting for age, sex, geographic region, insurance, setting of care, metropolitan area, and year.

COMMENTARY

Otitis media is the most common diagnosis that results in antibiotic prescriptions among children younger than 5 years of age. There is no evidence that treatment of otitis media with broader- versus narrower-spectrum antibiotics results in better outcomes and fewer complications. Amoxicillin-clavulanate is recommended if amoxicillin fails initially and for children with a history of amoxicillin-resistant infections. This study could not distinguish between initial and follow-up visits.

This analysis of data from large, representative databases demonstrated differences in the diagnosis and management of otitis media for black children compared to nonblack children. Even though these results found that the percentage of visits resulting in a diagnosis of otitis media was 30% lower in black children compared to nonblack children, it does not appear that the true incidence of otitis media is lower in black children. The difference in rate of otitis media across some studies appears to be confounded by differences in access to care rather than differences in racial/ethnic predisposition.

Black children diagnosed with otitis media were more likely to receive narrow-spectrum antibiotics (e.g., amoxicillin) than nonblack children. The observed difference more likely represents overtreatment of otitis media among nonblack children rather than undertreatment of otitis media among black children. Parent expectations for antibiotics vary by race/ethnicity, and physician perceptions of parental expectations can influence physician antimicrobial prescribing. Such factors likely contribute to the differences found in this study. Whatever the root cause, overuse of antibiotics among children with respiratory tract infections and otitis media is costly and also a significant contributing factor to the increased prevalence of antimicrobial resistance generally.