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Wait-and-See vs. Standard Prescriptions for AOM

Am Fam Physician. 2007 Jan 15;75(2):250-251.

Background: Acute otitis media (AOM) is the most common reason for antibiotic prescriptions in children. However, symptomatic treatment of AOM without the use of antibiotics has a high rate of resolution and a similar incidence of complications. Spiro and colleagues conducted a randomized controlled trial in an emergency department setting to determine if AOM treatment using a “wait-and-see prescription” approach reduced antibiotic use and adverse effects compared with a “standard prescription” approach.

The Study: The study population was composed of 283 children six months to 12 years of age who were diagnosed with AOM. Treating physicians made the diagnoses using standard diagnostic criteria, and patients were randomized into the wait-and-see or standard prescription groups. All participants were given a written prescription for an antibiotic chosen by the physician. Participants in the wait-and-see group were given written and verbal instructions not to fill the prescription unless their child was not better or was worse 48 hours after the visit. Those in the standard group were instructed to fill the prescription and give the antibiotic to the child following the visit. All participants received free supplies of ibuprofen (Motrin) and otic analgesia to be used for symptomatic relief.

Telephone interviews were conducted with a parent or guardian at four to six, 11 to 14, and 30 to 40 days after the diagnosis. The primary outcome measured was the proportion of each group that filled the antibiotic prescription. Secondary outcomes included clinical course of illness, adverse effects of medications, unscheduled medical visits, days of work or school missed, and comfort of parents with managing future occurrences of AOM without antibiotics.

Results: Prescriptions were not filled in 62 percent of the wait-and-see group and 13 percent of the standard group. The parents in the wait-and-see group who did fill the prescription reported their reasons for doing so were fever (60 percent), otalgia (34 percent), or fussy behavior (6 percent). No serious adverse events were reported for any patients in the study. There was a statistically significant difference between the wait-and-see and standard groups in total days of otalgia at four- to six-day intervals (2.4 and 2.0 days, respectively). Diarrhea was more common in the standard group (23 percent) compared with the wait-and-see group (8 percent). There were no statistically significant differences in rash, otorrhea, or unscheduled medical visits between the two groups. There also was no difference in the willingness of parents to withhold antibiotics in future occurrences of AOM.

Conclusion: The authors concluded that wait-and-see prescriptions can be a successful treatment strategy for AOM even when the patients do not have an established relationship with the physician. The wait-and-see approach interrupts the cycle of parental expectations of antibiotic use and of antibiotic prescriptions for AOM. Furthermore, it reduces the costs and adverse effects associated with unnecessary antibiotic use.

Source:

Spiro DM, et al. Wait-and-see prescription for the treatment of acute otitis media: a randomized controlled trial. JAMA. September 13, 2006;296:1235–41.

editor's note: This study demonstrates that a wait-and-see prescription approach for AOM is a successful treatment strategy even when patients are unfamiliar with their physicians. The finding that parents accepted a delayed-prescription approach in an emergency department setting suggests that the wait-and-see approach could have a wide-spread application outside primary care.1,2 Adoption of this approach for uncomplicated AOM in various clinical settings could serve to decrease antibiotic resistance as well as the adverse effects associated with unnecessary antibiotic use.—r.b.s.

 

REFERENCES

1. McCormick DP, Chonmaitree T, Pittman C, Saeed K, Friedman NR, Uchida T, et al. Nonsevere acute otitis media: a clinical trial comparing outcomes of watchful waiting versus immediate antibiotic treatment. Pediatrics. 2005;115:1455–65.

2. Little P, Gould C, Williamson I, Moore M, Warner G, Dunleavey J. Pragmatic randomised controlled trial of two prescribing strategies for childhood acute otitis media. BMJ. 2001;322:336–42.


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