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Abstract & Commentary
Synopsis: Discouraging the use of antibiotics may have a negative side, but the benefits outweigh it (please also see special supplement enclosed with this issue).
Source: Van Zuijlen DA, et al. Pediatr Infect Dis J. 2001;20: 140-144.
In the 1980s, the dutch college of general Practioners published recommendations that children seen and diagnosed with acute otitis media (AOM) should be watched for a few days rather than treated empirically with antibiotics. The exceptions were children younger than 6 months of age, high-risk patients (recurrent otitis media, craniofacial malformations, immunodeficiencies), children 1-2 years of age with continued symptoms after 24 hours, and children up to 14 years with earache or fever for more than 3 days or otorrhea for more than 14 days. There was a remarkable reduction in antibiotic (usually amoxicillin) prescribing for AOM to 31% of cases, according to a report in 1990. This is considerably lower than any other country in Europe or North America, where empiric antibiotic use has been nearly universal.
Van Zuijlen and colleagues investigated the possible effect of this reduced antibiotic use by gathering information on the frequency of hospital discharges of children with a diagnosis of acute mastoiditis. They collected information from Norway, Denmark, the United Kingdom, Canada, the United States, and New York City. They also found population figures to derive an estimate of the incidence of acute mastoiditis of about 3-4 per 100,000 children in The Netherlands, Denmark, and Norway, but only 1 or 2 per 100,000 children in the other countries. They estimated antibiotic use for AOM was nearly 100% for other countries with the exceptions of Denmark, Norway, and The Netherlands, where it was estimated to be 80%, 70%, and 30%, respectively.
There was an inverse correlation between antibiotic use for AOM and acute mastoiditis, with the exception of Norway and Denmark where the mastoiditis frequency was high despite the high use of antimicrobials.
COMMENT BY ALAN d. TICE, MD, FACP
The compliance of the physicians with antimicrobial use guidelines in The Netherlands is remarkable, if true. Not only was physician behavior changed but dramatically so. What has happened since the survey reported in 1990 is not known. It would also be interesting to know the changes that have occurred in AOM prescribing there and in the other countries since then. The success of the campaigns to reduce antibiotic prescribing have had a limited effect in the United States.
The reduction in the use of antibiotics appears to carry some risk. It does appear that the incidence of acute mastoiditis is greater with reduced antibiotic use for AOM. The question then is what to do about it. It is not really feasible to do clinical trials to get better data on the risks and benefits of treating AOM because of the huge numbers that would be needed and the lack of available funding.
This investigation has numerous faults, and the data are getting old. Some of the shortcomings include varying rates of hospitalization for acute mastoiditis among countries, diagnosis coding variations, documentation of actual use of antibiotics for AOM, and consistent population figures. Antimicrobial resistance has also increased dramatically and the vaccine for Hemophilus influenzae has been introduced. The lack of correlation between antibiotic use and mastoiditis in Denmark and Norway is not consistent with the findings in other countries.
The case of an inverse correlation between the use of antibiotics for AOM and acute mastoiditis is not clearly proven, but it does make sense. Any approach to antimicrobial therapy has not only benefits, but risks as well. Mastoiditis would seem much less likely in patients with otitis media who are receiving an effective antibiotic.
This type of epidemiologic study may become more useful in the future as information systems about patient care develop and data are collected in a standardized format. This research may give us better answers to some of the age-old questions. On the other hand, the information on means, medians, and statistical analyses will never replace the need for physician evaluation of the next patient who presents in the office with otitis media. Guidelines and generalizations may not apply (as every individual is unique), and the variables to consider are limitless.
The possibility of reducing the risk of acute mastoiditis by 2 cases per 100,000 children through doubling or tripling the amount of antibiotics used for AOM in The Netherlands must also be weighed. From Van Zuijlen et al’s figures, 2500 Dutch children with AOM would have to be treated with antibiotics to prevent 1 case of acute mastoiditis. They estimate it would take an additional 7800 antibiotic prescriptions per year to accomplish this. Aside from the added cost, this would likely cause amoxicillin-related side effects in 1600 patients and stimulate antibiotic resistance as well.
It seems each decision on antibiotic use has its pros and cons. It will be helpful to have better data and analyses to understand the effect of intervention.