TORONTO — A strategy of watchful waiting reduced antibiotic use and was well accepted by parents of children diagnosed with acute otitis media in the emergency department in a randomized trial of 223 children.
Previous trials have evaluated a management strategy for otitis media in which the use of antibiotics was optional, but most were conducted in office settings in which parents had an established relationship with their providers.
A more recent study in the emergency department (ED) found a 56% reduction in antibiotic use when parents of children with acute otitis media were given a prescription but asked not to fill it unless the child's condition remained unchanged or worsened in 48 hours (JAMA 2006;296:1235–41).
The current study looked at parental acceptance of such a policy in the ED, Dr. Jennifer Chao said at the annual meeting of the Pediatric Academic Societies.
The American Academy of Family Physicians and American Academy of Pediatrics 2004 practice guidelines suggest minimizing antibiotic side effects by giving parents of select children the option of fighting the infection on their own for 48–72 hours, then starting antibiotics if the symptoms do not improve.
The investigators randomized 232 children, aged 2–12 years, diagnosed with acute otitis media who met AAP criteria for delayed antibiotic treatment to a watchful-waiting strategy that included pain medications and no antibiotic prescription, or to safety net antibiotic protocol (SNAP) that included pain medications and an antibiotic prescription.
Watchful-waiting parents had to return to the ED or to the child's provider if symptoms persisted for 2 or 3 days, whereas SNAP parents had to fill their prescription if symptoms persisted for 2 or 3 days. A research assistant, blinded to group assignment, conducted telephone surveys with parents 7–10 days after the ED visit. One hundred watchful-waiting parents and 106 SNAP parents completed follow-up. The mean age of the children was 5 years.
During the 2–3 day observation period, 87% of the watchful-waiting group adhered to the management protocol and did not use antibiotics, vs. 62% of the SNAP group, Dr. Chao and colleagues of the Jacobi Medical Center, N.Y., reported. During the 7–10-day follow-up period, 81% and 53%, respectively, did not use antibiotics.
Both watchful waiting and SNAP were well accepted by parents, with 91% vs. 95% of parents “very” or “extremely satisfied” with the protocol. The difference was not statistically significant.
Both groups were equally willing to consider observation therapy in the future (65% vs. 62%). “Observation therapy without a prescription substantially improves adherence and reduces antibiotic exposure,” Dr. Chao said.
In a logistic regression analysis, predictors of parental adherence to observation therapy included assignment to therapy, duration of fever before and after the visit, height of fever, and physician predictions of adherence.
No complications were reported. Antibiotics were used in 9 patients who reported fever for more than 4 days and in 16 patients reporting pain longer than 4 days. Data on patients who returned to the ED and/or went to see another provider were not available, said Dr. Chao, who is now with the State University of New York Downstate Medical Center in Brooklyn.