The push for health care providers to prescribe antimicrobials prudently has hit the professional press again. But this time, the effort has gone beyond the clinical realm. A bill introduced to the House in June 20131 proposes the amendment of Section 319E of the Public Health Service Act2 with the goal of reducing antimicrobial resistance and addressing the paucity of new antimicrobials developed to combat “superbugs.” However, my interest lies not expressly with this piece of legislation but rather—and perhaps more pertinently—with the tools we already have in our armamentarium to prevent that resistance in the first place.
In a recent blog posting titled “First Do No Harm,”3 Lori Kestenbaum, MD, recalled her medical school days when she was required to “name the diseases, then the bugs that can cause that disease, then the drugs that can treat those bugs.” Furthermore, she noted (as have others in recently published columns and articles), “Antibiotics have a reputation as being mild, potentially harmless medications that can only bring benefit.” I cannot agree more: This summer, I knew more adults who were taking antibiotics (and the big-guns ones at that) and who did not appreciate the risk for resistance to bugs they might face in future.
But I want to discuss the use—or should I say nonuse?—of the tools available to us. Like Dr. Kestenbaum, I too was taught to identify the disease, the potential organism, and the drug that could kill the bug. But, and I think just as essential, I was also taught the importance of acquiring a complete history of an illness and utilizing the techniques of a thorough physical examination.
So an article published earlier this year by Pediatric News4 was quite a shocker for me. The headline read, “Tympanic membrane now keys otitis media diagnosis.” Hmm, I thought, didn’t it always? Apparently not for some practitioners, since the impetus for the article was the American Academy of Pediatrics’ (AAP) revision of its guidelines for diagnosis and treatment of acute otitis media (AOM).5 The AAP’s revised guidelines include pneumatic otoscopy as a “standard tool” for diagnosis.
I was intrigued that the AAP needed to emphasize this information. For me, pneumatic otoscopy was always included when I was examining a child with the typical presenting symptoms of AOM (fever, fussiness, and ear pain)—not easily, either, as I recall trying to examine many a squirmy, screaming child!
I remember one instance when I dismissed the pneumatic otoscopy because I could not quite hold the otoscope and maneuver the bulb while the child screamed and squirmed. “The tympanic membranes are red and bulging,” I informed my preceptor, a seasoned pediatrician. His response was, “Did the tympanic membranes move?” I shrugged; I had not been able to fully evaluate them. The lesson I learned that day was not only the importance of determining the mobility of the tympanic membranes, but also how to calm a screaming child.
The AAP guidelines include the “tincture of time” approach to treatment, which has been borne out in the research as satisfactory. Over the past 30 years, results from placebo-controlled trials of AOM treatment have consistently demonstrated that most children do well without antibiotics, without adverse sequelae.5 The benefit to this approach is avoidance of unnecessary use of antibiotics. More importantly, it reduces the risk for drug reactions, drug resistance, and the unpleasant side effects that can accompany antibiotic use.
“Watchful waiting,” as some call it, which entails observation for worsening of symptoms or failure to improve in a 48- to 72-hour period, is recommended. (However, pain management may be necessary for otalgia associated with otitis media with effusion, to help the child and the parent ride out the observation period.) It is the perfect opportunity to educate parents about the risks and adverse effects that accompany any medication use. The caveat is that the clinician and the parent must share in the decision to observe the symptomatology. This approach requires that a system be in place to ensure prompt follow-up, should the child’s condition worsen.
The marriage of three elements is the foundation for a positive diagnosis of AOM: rapid onset of symptoms, middle ear effusion, and evidence of middle ear inflammation. The problem is that few providers consistently use pneumatic otoscopy and as a result lose (or never had) the dexterity to perform that part of an exam. Truth be told, it is not an easy maneuver. But we need to reinforce its importance, as it reduces the uncertainty of the diagnosis and the unnecessary use of antimicrobials.