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Guidelines for treating ear infections imply greater willingness to treat children older than 2 years with antibiotics

There is growing concern about increasing antibiotic resistance by the organisms that cause children's ear infections (acute otitis media, AOM), the most common bacterial illness in children. The American Academy of Pediatrics (AAP) guidelines for AOM were developed to address this issue and the uncertainty regarding which children should receive antimicrobial therapy. A new study has found that the guidelines reduce antibiotic use for children under age 2 with AOM, but at a relatively high cost of sick days and parental missed work days.

Researchers used decision analysis to compare the AAP guidelines' three-criteria strategy for diagnosing and treating AOM with a commonly used and less restrictive two-criteria strategy and a "watch and wait" strategy. In the AAP three-criteria strategy, all children are diagnosed with AOM if they satisfy illness acuity, tympanic membrane inflammation, and middle ear fluid buildup criteria. The two-criteria strategy includes the first two factors but excludes fluid buildup.

All children diagnosed with AOM under the first two strategies receive antibiotic (amoxicillin) treatment. By contrast, the watch and wait strategy monitors all children following the initial visit for 2 days without antibiotic therapy. The researchers found an age inconsistency in the results of following the AAP guidelines for children younger than 2 years and children older than 2 years. For children under 2 years, the researchers predicted that the three-criteria strategy resulted in 21 to 26 percent less antibiotic use, 13 to 14 percent more sick days, and 23 to 28 percent fewer adverse drug events (ADEs) than the two-criteria strategy. However, for children 2 to 12 years, the results predicted were 67 percent less antibiotic use, 4 percent more sick days, and 68 percent fewer ADEs.

Using the two-criteria strategy vs. the AAP guidelines, 1.2 to 1.4 children under age 2 would need to be treated to avoid a sick day, compared with 6.3 children older than 2 years who would need to be treated to avoid a sick day if using the AAP guidelines vs. the watch and wait strategy. Thus, based on the AAP criteria, the willingness to use antibiotics to avoid sick days for older children is considerably higher than for younger ones.

The authors conclude that the AAP guidelines may be more cost effective for older children than for children under 2 years of age. This study was supported in part by a Center for Education and Research on Therapeutics (CERT) grant from the Agency for Healthcare Research and Quality (HS10399). For more information on the CERT program, please visit www.ahrq.gov

See "Age inconsistency in the American Academy of Pediatrics guidelines for acute otitis media," by Sharon Meropol, M.D., M.S.C.E., Henry A. Glick, Ph.D., and David A. Asch, M.D., in the April 2008 Pediatrics 121, pp. 657-666.

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