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Am Fam Physician. 2008;77(4):516-521

Background: In 2004, The American Academy of Pediatricians and the American Academy of Family Physicians jointly issued guidelines for the treatment of acute otitis media (AOM). These guidelines included a watchful waiting option for children six months to two years of age if the symptoms are not severe and the diagnosis is uncertain, and for those two years or older with nonsevere symptoms or an uncertain diagnosis. In addition, the guidelines recommend using high-dose amoxicillin (80 to 90 mg per kg per day) as initial treatment for mild disease, and amoxicillin/clavulanate (Augmentin; 80 to 90 mg per kg per day) for severe disease, such as moderate to severe otalgia or a fever of 102.2°F (39°C) or greater. A survey of a network of practice-based physicians was conducted six months after the guidelines were issued to determine physician adherence. This study summarized the findings of a follow-up survey conducted two years after the publication of the guideline.

Methods: The survey was sent to physicians in a practice-based network, which included pediatricians (76.9 percent), family physicians (22.1 percent), and other subspecialists (1.0 percent). The survey assessed their opinions and practice habits regarding the guidelines' observation option. It also sought to determine antibiotic prescribing practices in response to four representative AOM scenarios: nonsevere, severe, AOM that failed amoxicillin, and AOM that failed amoxicillin/clavulanate.

Results: Of 489 mailed surveys, 299 were completed (response rate = 62.7 percent). Of these, 207 responses were by physicians who had participated in the original survey. Although 83.3 percent of respondents believed in the appropriateness of the observation option, only 15 percent had chosen it in the previous three months of practice, and approximately one in 10 physicians reported using the option in at least one half of patients presenting with AOM. In addition, the acceptance rate of the watchful waiting option did not change significantly between 2004 and 2006. In the subset of respondents who completed the initial and follow-up surveys, there was a statistically significant decline in acceptance, from 90.2 to 84.3 percent.

The most important barrier to adherence cited was parental pressure (i.e., discomfort with the observation option and demand for antibiotics), with 64.7 percent of physicians listing this as the primary reason for rejecting the observation option. Less important was the perception that follow-up for watchful waiting was logistically difficult. Finally, there was a decline in adherence to the guidelines' antibiotic recommendations, with fewer physicians prescribing high-dose amoxicillin in favor of standard-dose amoxicillin or other antibiotics as first-line therapy, and fewer physicians prescribing high-dose amoxicillin/clavulanate for severe disease compared with prescribing habits reported in 2004.

Conclusion: Adherence to the AOM guidelines has not improved, with a decline in the two years since publication. Although parental unwillingness was cited as the most important barrier, there is good evidence that many parents are open to watchful waiting when it is appropriately presented. Use of a back-up prescription might alleviate logistic barriers, meaning that if the child has not improved within 48 to 72 hours, the parent can fill the antibiotic prescription. Regarding antibiotic choice, physicians may be prescribing regular rather than higher doses of amoxicillin because of a belief that the heptavalent pneumococcal conjugate vaccine (Prevnar) is sufficiently protective. Regular amoxicillin, rather than amoxicillin/clavulanate, may be used because of the recognition that the latter does not provide additional coverage for non-typeable Haemophilus influenzae and Moraxella catarrhalis, and severe AOM is most likely caused by Streptococcus pneumoniae, for which clavulanate is not helpful. Physicians may also prefer to reserve amoxicillin/clavulanate for second-line treatment. Physicians are also choosing other antibiotics (e.g., cefdinir [Omnicef], azithromycin [Zithromax]) that are the same as or less effective than amoxicillin/clavulanate. More research is needed to explain the gap remaining between guidelines and clinical practice.

editor's note: One of the more recent articles demonstrating the appropriateness of the watchful waiting option was a randomized trial of children six months to 12 years of age that also documented equivalent parental satisfaction with antibiotic treatment or watchful waiting.1 A comprehensive multi-practice survey of patients and physicians paints a somewhat less positive picture of parental attitudes, with 40 percent of parents objecting to the idea of watchful waiting.2 Parental concerns correlated with lower educational levels, and parental acceptance correlated with increased knowledge about antibiotics and the problem of resistance. Of note, a similar percentage of physicians also do not use, or rarely use, the watchful waiting option. Fewer years in practice (e.g., younger physicians), family medicine specialization, individual beliefs, and community concern about antibiotic resistance correlated positively with choosing to ‘wait and see.’ Ultimately, these studies confirm the disconnect between guideline recommendations and clinical practice.—c.w.

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