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Studies investigate watchful waiting over immediate antibiotics for young children with nonsevere ear infections

The widespread use of antibiotics for treatment of acute otitis media (AOM, ear infection) has contributed to the emergence of multidrug-resistant pathogens. Since most children with nonsevere AOM recover without antibiotics, current guidelines recommend that physicians consider watchful waiting rather than antibiotics for children 2 years and older who have uncomplicated, nonsevere AOM.

A new study supported by the Agency for Healthcare Research and Quality (HS10613) examined the effect of watchful waiting and immediate antibiotics on ear infections. A second AHRQ-supported study (HS10247) explored physicians and parents attitudes about watchful waiting for nonsevere AOM. Both studies are described here.

McCormick, D.P., Chonmaitree, T., Pittman, C., and others (2005, June). "Nonsevere acute otitis media: A clinical trial comparing outcomes of watchful waiting versus immediate antibiotic treatment." Pediatrics 115(6), pp. 1455-1465.

This study concluded that immediate antibiotic treatment for nonsevere AOM in children 6 months to 12 years old provided superior early results, but, infection recurrences among children treated with antibiotics resulted in nearly identical outcomes between the antibiotics and watchful waiting groups by day 30 (77 vs. 76 percent cure, respectively). Investigators randomized 112 children to receive immediate antibiotics (amoxicillin plus symptom medication) and 111 children to watchful waiting (symptom medication only). Symptom scores on days 1 to 10 resolved faster in the antibiotics than the watchful waiting group. At day 12, among the immediate antibiotics group, 69 percent of tympanic membranes and 25 percent of tympanograms were normal compared with 51 percent of tympanic membranes and 10 percent of tympanograms among the watchful waiting group.

Two-thirds (66 percent) of the children in the watchful waiting group completed the study without needing antibiotics. Immediate antibiotics resulted in eradication of Streptococcus pneumoniae carriage in the majority of children, but S. pneumoniae strains cultured from children in the antibiotics group at day 12 were more likely to be multidrug-resistant than strains from children in the watchful waiting group. Also, more antibiotics-related adverse events (none serious) were noted in the antibiotics group compared to the watchful waiting group. Parent satisfaction with AOM care was not different between the 2 treatment groups at day 12 or 30. Costs of antibiotics averaged $47.41 per child in the antibiotics group and $11.43 in the watchful waiting group.

Finkelstein, J.A., Stille, C.J., Rifas-Shiman, S.L., and Goldmann, D. (2005, June). "Watchful waiting for acute otitis media: Are parents and physicians ready?" Pediatrics 115(6), pp. 1466-1473.

Few physicians initially try watchful waiting for children with nonsevere acute otitis media (AOM) and many parents have concerns about this option, concludes a study supported by the Agency for Healthcare Research and Quality (HS10247). The investigators surveyed 160 physicians and 2,054 parents of children under age 6 in 16 Massachusetts communities about the acceptability of watchful waiting prior to release of recent guidelines endorsing this strategy.

A majority of physicians reported at least occasionally using watchful waiting, but few used it frequently. For instance, 38 percent of physicians treating children 2 years or older reported never or almost never using watchful waiting, 39 percent reported occasional use, 17 percent sometimes, and 6 percent most of the time. Younger physicians reported more frequent use of watchful waiting than older colleagues. Education that promoted judicious antibiotic use (including information about watchful waiting for AOM) increased use of watchful waiting among doctors but did not significantly affect parental views.

When asked about this approach in a vignette of nonsevere AOM, about one-third (34 percent) of parents reported that they would be somewhat or extremely satisfied if watchful waiting was recommended, another 26 percent would be neutral, and the remaining 40 percent would be somewhat or extremely dissatisfied.

Parents with a high school education or less were half as likely as college-educated parents to be satisfied with initial watchful waiting, and Medicaid-insured parents were about 30 percent less likely than non-Medicaid insured parents to be satisfied with this approach. Higher antibiotic-related knowledge, belief that antibiotic resistance is a serious problem, and feeling included in medical decisions all were independently associated with higher predicted satisfaction with watchful waiting.

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