Home' Australian Pharmacist : Australian Pharmacist April 2012 Contents 310 Australian Pharmacist April 2012 I ©Pharmaceutical Society of Australia Ltd.
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EVIDENCE IN PATIENT CARE
with amoxycillin with clavulanate was
associated with better outcomes than
placebo in children aged six to 35
months.18,19 In these trials, antibiotics were
associated with better outcomes than in
previous trials in terms of effectiveness.
For example, in the study by Tahitinen
et al.,19 the number of children needed
to treat for one child to benefit was four
compared to 16 in the Cochrane review.9
This difference in apparent effectiveness
probably relates to the strict diagnostic
criteria for AOM used in the trials -- only
children who met the stringent diagnostic
criteria, which do not necessarily reflect
actual practice, were included in the
trial. It should also be noted that while
children in the placebo groups of these
trials could receive 'rescue' treatment with
antibiotics, the trials did not compare
immediate antibiotic use to observation
with or without a delayed prescription
for antibiotics after 24--48 hours as
recommended in Australian guidelines.
Overall, these findings do not suggest
that all children with AOM require
antibiotics, rather they highlight the
importance of better identifying children
who do require antibiotics for AOM.
Role of the community
In the case described above, the
pharmacist should reinforce the GP's
recommendations to delay the use of
antibiotics. It may be helpful to advise
Jane that the symptoms of AOM generally
resolve within 24 hours (around two-
thirds of children will be pain-free within
24 hours) and that the initial step in
the treatment of mild cases of AOM in
children should be regular analgesics.
With adequate control of pain and fever,
the outcomes of AOM should not be
substantially different whether antibiotics
are administered or not in most cases. If
symptoms persist beyond two days, the
use of amoxycillin can be reconsidered.
There is a role for pharmacists to reinforce
appropriate messages regarding
treatment of AOM from GPs to parents
and also to promote the evidence-based
approach that the first-line treatment of
AOM is generally analgesics.
1. Damoiseaux RAJM, Rovers MR. Acute Otitis Media in Children.
BMJ Clin Evid. 2011; 05(301).
2. Rovers MM, Schilder AG, Zielhuis GA, et al. Otitis Media. Lancet.
3. van Buchem FL, Dunk JH, van't Hof MA. Therapy of Acute Otitis
Media: Myringotomy, Antibiotics, or Neither? A Double-Blind
Study in Children. Lancet. 1981; 2(8252):883--7.
4. Vergison A, Dagan R, Arguedas A, et al. Otitis Media and Its
Consequences: Beyond the Earache. Lancet Infect Dis. 2010;
5. Therapeutic Guidelines. eTG Complete: Antibiotic. 2011.
6. Hoberman A, Paradise JL. Acute Otitis Media: Diagnosis
and Management in the Year 2000. Pediatric Annals. 2000;
7. Kontiokari T, Koivunen P, Niemela M, et al. Symptoms of Acute
Otitis Media. Pediatr Infect Dis J. 1998; 17(8):676--9.
8. Teele DW, Klein JO, Rosner B. Epidemiology of Otitis Media
During the First Seven Years of Life in Children in Greater Boston:
A Prospective, Cohort Study. J Infect Dis. 1989; 160(1):83--94.
9. Sanders S, DGlasziou PP, Del Mar CB, et al. Antibiotics for Acute
Otitis Media in Children. Cochrane Database of Systematic
Reviews 2010, Issue 9. Art. No.: CD000219.
10. Froom J, Culpepper L, Jacobs M, et al. Antimicrobials for Acute
Otitis Media? A Review from the International Primary Care
Network. BMJ. 1997; 315(7100):98--102.
11. Lahikainen EA. Clinico-Bacteriologic Studies on Acute Otitis
Media Aspiration of the Tympanum as a Diagnostic and
Therapeutic Method. Acta Oto-laryngologica. Supplementum.
12. Goossens H, Ferech M, Vander Stichele R, et al. Outpatient
Antibiotic Use in Europe and Association with Resistance: A
Cross-National Database Study. Lancet. 2005; 365(9459):579--87.
13. Del Mar C, Glasziou P, Hayem M. Are Antibiotics Indicated as
Initial Treatment for Children with Acute Otitis Media? A Meta-
Analysis. BMJ. 1997; 314(7093):1526--9.
14. Marcy M, Takata G, Chan LS, et al. Management of Acute Otitis
Media. Evidence Report/Technology Assessment. 2000; (15):1--4.
15. 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;
16. Rovers MM, Glasziou P, Appelman CL, et al. Antibiotics for Acute
Otitis Media: A Meta-Analysis with Individual Patient Data.
Lancet. 2006; 368(9545):1429--35.
17. Spurling GK, Del Mar CB, Dooley L, et al. Delayed Antibiotics
for Respiratory Infections. Cochrane Database of Systematic
Reviews 2007, Issue 3. Art. No.: CD004417.
18. Hoberman A, Paradise JL, Rockette HE, et al. Treatment of Acute
Otitis Media in Children under 2 Years of Age. NEJM. 2011;
19. Tahtinen PA, Laine MK, Huovinen P, et al. A Placebo-Controlled
Trial of Antimicrobial Treatment for Acute Otitis Media. NEJM.
1. Which of the following statements
about acute otitis media is
a) Diagnosis of acute otitis media is likely
if there is a history of acute onset of
earache and bulging and redness of
the tympanic membrane.
b) Streptococcus pyogenes is one of the
most common bacterial pathogens
causing acute otitis media.
c) Acute otitis media always involves
perforation of the tympanic
d) Obtaining an accurate diagnosis is very
straightforward because functional
testing of the tympanic membrane can
be performed consistently in practice.
2. In what proportion of cases of
acute otitis media do the symptoms
resolve within 24 hours?
3. WITHOUT antibiotic treatment, what
proportion of cases of acute otitis
media will be resolved within three
4. The risk of which of the following
treatment outcomes is reduced with
antibiotic use in acute otitis media?
a) The risk of perforation.
b) The proportion of children experiencing
pain within the first 24 hours.
c) The proportion of children
experiencing pain between days two
and seven following the onset of
d) The risk of hearing loss.
5. If 100 children with acute otitis
media were treated with antibiotics
compared to placebo, how many
fewer children would experience
pain between days two and seven
following the onset of symptoms
with antibiotics according to a
recent Cochrane review?
A score of 4 out of 5 attracts 1 CPD credit.
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