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Sept. 13, 2006 — 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 the Journal of the American Medical Association.
Acute otitis media (AOM; ear infection) 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, M.D., M.P.H., 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. Phone 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 to the SP group (62 percent vs. 13 percent). There was no statistically significant difference between the groups in the frequency of subsequent fever, otalgia (ear ache), 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 percent), otalgia (34 percent), or fussy behavior (6 percent). No serious adverse events were reported for patients in the study.
"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," the authors conclude.
In an accompanying editorial, Paul Little, M.B.B.S., M.D., F.R.C.G.P., of the University of Southampton, Aldermoor Health Centre, Southampton, U.K., comments 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."