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A Watchful Waiting Prescription for Otitis Media



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Am Fam Physician. 2004 Apr 1;69(7):1788.

Growing concern about antibiotic resistance and the small benefit of treating acute otitis media (AOM) with antibiotics have made initial observation an attractive treatment option in children with ear infections. However, parents often want antibiotics for their children and believe that antibiotic treatment is necessary for ear infections. A physician in England implemented the concept of a safety-net antibiotic prescription (SNAP). Parents were given an antibiotic prescription but were asked not to fill it unless the child's symptoms persisted for a day or more. Using this strategy, the physician was able to lower the total number of antibiotics used by his patients by 20 percent. Siegel and colleagues conducted a study to determine the acceptability of a SNAP policy in a multicenter pediatric research group in Cincinnati, Ohio.

Children one through 12 years of age with otitis media were enrolled in the study. Exclusion criteria related to greater severity of disease or perceived problems with follow-up. Parents were instructed not to fill the SNAP unless symptoms worsened or did not improve after 48 hours. Pain medicines such as ibuprofen, acetaminophen or antipyrine/benzocaine drops were given in the office at no cost. A follow-up telephone call determined whether the prescription had been filled.

A total of 194 patients were enrolled, and 90 percent of them completed the follow-up interview. Of the 175 families, 120 (69 percent) did not fill the prescription, and 117 said they were willing to use pain medications without antibiotics in the future. Of the 55 families who did fill the prescription, 33 filled the prescription within 48 hours of diagnosis. A large proportion of these parents cited continued pain or fever as the reason. Of the variables considered in trying to distinguish between parents who did and did not fill the prescription, the only predictive variable was previous episodes of AOM. After a child had two or more AOM episodes, parents were significantly more likely to fill the prescription than parents of a child with one or no AOM episodes.

Most parents believe that antibiotics are necessary to treat AOM, even though research has shown that there is little or no benefit in treating this infection with antibiotics. In this study, the majority of parents did not fill the SNAP and expressed a willingness to avoid antibiotics if their children had AOM in the future. There were no adverse events associated with watchful waiting. However, one child who received antibiotics after 48 hours developed mastoiditis in the opposite ear six weeks after treatment. The authors note that limitations of their study included lack of minority representation and exclusion of severe disease.

Siegel RM, et al. Treatment of otitis media with observation and a safety-net antibiotic prescription. Pediatrics. September 2003;112:527–31.


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