Acute otitis media warrants 10 days of antibiotics

Ear infections remain a top reason for parents to bring their children to the pediatrician-and the top reason for antibiotic prescriptions among pediatric patients. Diagnosis and treatment methods vary, but a new study reveals that a 10-day course of treatment with antibiotics in cases of acute otitis media (AOM) may be the gold standard.

According to the American Academy of Pediatrics (AAP) 2013 guidelines on AOM, generalized otitis media remains the most common reason physicians prescribe antibiotics to children in the United States.

Acute otitis media is diagnosed in children with moderate-to-severe bulging of the tympanic membrane or new onset of otorrhea, recent onset of ear pain, intense erythema of the tympanic membrane, and/or middle ear effusion revealed through pneumatic otoscopy and/or tympanometry. However, methods of diagnosis can vary, resulting in misdiagnosis.

For most middle ear infections, the American Academy of Family Physicians (AAFP) recommends watchful waiting, with a progression to antimicrobial therapy as symptoms worsen. The 2013 AAFP recommendation cites ineffectiveness of antibiotics in some cases, as well as cost and concerns about antimicrobial resistance.

Yet, in acute cases, antibiotics are necessary, although some clinicians have sought to reduce exposure by shortening the course of treatment.

This study set out to determine if a shorter course of antibiotics-aimed at stemming a growing wave of antimicrobial resistance-would have the same results, but researchers found that a longer course of antibiotics was, in fact, significantly more effective in treating AOM without evidence of contributing to increased resistance.

The new study evaluated 520 children aged 6 to 23 months with AOM. Children in the study received either a 10-day course of amoxicillin-clavulanate for 10 days or a 5-day course of antibiotic therapy followed by a placebo for 5 days.

Those treated with the 5-day course were more likely to have clinical failure than those in the 10-day treatment group (34% versus 16%, respectively). According to the study, rates of clinical response were rated by symptom scores of 0 to 14, with higher numbers indicating more severe symptoms.

Mean symptom scores from day 6 through day 14 were 1.61 in the 5-day group compared with 1.34 in the 10-day group, according to the report, and rose to 1.89 versus 1.20 by days 12 to 14. Additionally, children whose symptom scores dropped by more than 50% were greater in the 5-day treatment group than in the 10-day group.

There was no significant difference in recurrence of infection, adverse events, or nasopharyngeal colonization between the 2 groups, the study notes.

The study also found that children with residual fluid in the middle ear were more likely to have recurring infections, regardless of the length of treatment. Children with recurrent infection also were more likely to experience clinical failure on the 5-day course of treatment than on the 10-day course, according to the report.

Alejandro Hoberman, MD, chief of general academic pediatrics, professor of pediatrics and clinical and translational science, vice chair of clinical research at the Children’s Hospital of Pittsburgh, Pennsylvania, and lead author of the study, says the research clearly demonstrates that a 10-day course of treatment is the best course of treatment for children aged younger than 24 months with stringently diagnosed AOM.

“A strategy of reduced-duration treatment-5 days every time the children had an ear infection during the respiratory season-offered no benefits in reducing the likelihood of adverse events or the emergence of bacterial resistance,” Hoberman says. “We are not advocating at all reducing duration of antibiotics given the findings of the study, that a short-course treatment resulted in significantly worse outcomes than the standard duration treatment. It is important to discuss with parents that if AOM is diagnosed using stringent criteria like those used in our study, antimicrobial therapy is beneficial and a 10-day course provides best results.”

Hoberman says he hopes the study will prompt clinicians to sharpen their diagnostic skills in a way that would prevent inadequate use of antibiotics in children who do not have true ear infections, but instead offer the full 10-day course of antibiotics for children who are symptomatic with bulging tympanic membranes.

Ms Zimlich is a freelance writer in Cleveland, Ohio, contributing regularly to Contemporary Pediatrics, Managed Healthcare Executive, and Medical Economics. She has nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.