Correspondence
Otitis Media
N Engl J Med 2003; 348:363January 23, 2003
- Article
To the Editor:
In the article on otitis media (Oct. 10 issue),1 Hendley's conclusions about the moderate value of antibiotics in acute otitis media are based largely on the results of published meta-analyses.2-4 Selecting studies for inclusion in meta-analyses requires consideration of methodologic issues. Among these is the definition of acute otitis media. Hendley stringently defines acute bacterial otitis media,1 but if studies evaluating the effect of antibiotic therapy have weak definitions (allowing the inclusion of children more likely to have otitis media with effusion than acute otitis media), the response in recipients of placebo will not differ much from that in recipients of an antibiotic. None of the three meta-analyses cited used a stringent definition of acute otitis media.
In the study cited as support for watchful waiting as a management strategy for acute otitis media,5 the dose of amoxicillin was 125 mg three times daily for all children. For a 10-kg child, this dose amounts to 38 mg per kilogram of body weight per day; for a 30-kg child, 12 mg per kilogram per day. In essence, the investigators were comparing placebo with placebo, especially in older children. The evidence in the literature is not sufficient to support the conclusion that antibiotics have a minimal role in most cases of acute otitis media.
5 ReferencesEllen R. Wald, M.D.
University of Pittsburgh School of Medicine, Pittsburgh, PA 15213
ellen.wald@chp. edu 1
Hendley JO . Otitis media. N Engl J Med 2002;347:1169-1174
Full Text | Web of Science | Medline2
Rosenfeld RM ,Vertrees JE ,Carr J , et al. Clinical efficacy of antimicrobial drugs for acute otitis media: metaanalysis of 5400 children from thirty-three randomized trials. J Pediatr 1994;124:355-367
CrossRef | Web of Science | Medline3
Takata GS ,Chan LS ,Shekelle P ,Morton SC ,Mason W ,Marcy SM . Evidence assessment of management of acute otitis media. I. The role of antibiotics in treatment of uncomplicated acute otitis media. Pediatrics 2001;108:239-247
CrossRef | Web of Science | Medline4
Glasziou PP ,Del Mar CB ,Sanders SL ,Hayem M . Antibiotics for acute otitis media in children. Cochrane Database Syst Rev 2002;2:3-35
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;322:336-342
CrossRef | Web of Science | Medline
Author/Editor Response
Wald correctly points out that all trials comparing antibiotics and placebo have used “weak definitions” of otitis media as criteria for enrollment, rather than a “stringent definition” of acute bacterial otitis media (i.e., a bulging tympanic membrane with purulent fluid behind it, or a “pus drum,” as shown in Figure 2B in the article). I recommend immediate treatment of this form of bacterial otitis media with high-dose amoxicillin, whereas the strategy of delayed prescription of an antibiotic would be my choice for all other episodes of acute otitis media.
Wald also notes that in the cited study of the delayed-prescribing strategy for otitis media,1 the dose of amoxicillin was low, particularly in older children. However, the critical finding in the study was that three fourths of the parents in the delayed-prescribing group did not even pick up the antibiotic prescription because of realization that their children's condition was improving by three days with acetaminophen alone. This strategy appears to be a reasonable means to select the small proportion of children (13 percent) with acute otitis media who will benefit from antibiotic therapy.
1 ReferencesJ. Owen Hendley, M.D.
University of Virginia Health System, Charlottesville, VA 22908
joh@virginia.edu 1
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;322:336-342
CrossRef | Web of Science | Medline
