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Wait-and-See Program Reduces Antibiotic Use for Acute Otitis Media

The only (minor) downside is about a half-day-longer duration of otalgia.

Although acute otitis media (AOM) has a high rate of spontaneous resolution and is generally treated expectantly in Europe, it remains the most frequent provocation for antibiotics in the U.S., accounting for approximately 15 million prescriptions per year. In a randomized controlled trial, researchers assessed the effects of a wait-and-see prescription (WASP) approach on antibiotic use, symptoms, and adverse effects.

Children ages 6 months to 12 years who were diagnosed with AOM at an urban pediatric emergency department were randomized to receive standard prescriptions or WASP. Antibiotic type, dose, and duration of therapy were chosen by the clinician; prescriptions expired 3 days after the ED visit. Children were excluded if they had intercurrent bacterial infection, appeared "toxic," were hospitalized, were immunocompromised, had received antibiotics in the preceding week, or had myringotomy tubes or a perforated tympanic membrane.

Parents of the 145 patients in the standard-prescription group received written and verbal instructions to "fill the antibiotic prescription and give the antibiotic to your child after today’s visit." Parents of the 138 patients in the WASP group received instructions "not to fill the antibiotic prescription unless your child either is not better or is worse 48 hours (2 days) after today’s visit." All patients received bottles of ibuprofen suspension and otic analgesic drops.

Significantly more parents in the WASP group than in the standard-prescription group did not fill the prescription (62% vs. 13%). At telephone follow-up at 4 to 6 days, the incidence of otalgia did not differ between groups, but the duration of otalgia was significantly longer in the WASP group (2.4 vs. 2.0 days). The incidence of diarrhea was significantly higher in the standard-prescription group than in the WASP group at 4 to 6 days (23% vs. 8%) and at 11 to 14 days (24% vs. 12%).

Comment: The WASP approach reduced the use of antibiotics by 56%, with no real difference in clinical outcome. The incidence of diarrhea was almost three times as great in the standard-prescription group as in the WASP group. This study should help dissuade practitioners and parents who believe that antibiotics are necessary for AOM. The adverse effects of antibiotics and greater resistance to bacterial pathogens constitute a significant price to pay for what is, in most cases, a self-limited illness.

— John A. Marx, MD, FAAEM, FACEP

Published in Journal Watch Emergency Medicine October 20, 2006

Citation(s):

Spiro DM et al. Wait-and-see prescription for the treatment of acute otitis media: A randomized controlled trial. JAMA 2006 Sep 13; 296:1235-41.

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