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Abstract
Objectives: Withholding antibiotics in nontoxic children with acute otitis media (AOM) is now recommen-
ded to reduce bacterial resistance rates. Using the National Hospital Ambulatory Medical Care Survey
(NHAMCS), the authors describe the national trends for prescribing antibiotics in children with AOM pre-
senting to emergency departments (EDs) in the United States over the past decade. The authors hypothe-
sized that the rates of prescribing antibiotics would decline over time.
Methods: This was a retrospective study of NHAMCS databases. A national sampling of ED visits for 1996
2005 was used to identify trends in ED prescription of antibiotics to patients with AOM. The National Drug
Code Directory Drug Classes were used to identify type of antibiotic prescribed. Frequency and type of
antibiotic prescription patterns over time were evaluated.
Results: There were 2.6 million and 2.1 million ED visits for AOM during the first and last years of the
study. Children ages 212 years accounted for about 40% of all ED visits for AOM, with another 40% in
the younger than 2 years age group and 20% in the older than 12 years of age group. During the first
and last year of the study, 79.2% and 91.3% of the patients with AOM were prescribed antibiotics, respec-
tively. There was a slight increasing trend in the proportion prescribed antibiotics over time (p = 0.02). The
rates of use of antibiotics for AOM were similar in all three age groups.
Conclusions: There was a slight increase in the percentage of children with AOM who were prescribed
antibiotics in the ED between 1996 and 2005. There was also no change in the patterns of prescribing
antibiotics.
ACADEMIC EMERGENCY MEDICINE 2007; 14:11721175 2007 by the Society for Academic Emergency
Medicine
Keywords: acute otitis media, antibiotics, selective, prescriptions
T
he most common diagnosis for which antibiotics to those patients who fail to improve at the end of the ob-
are prescribed for children in the United States servation period or whose condition worsens during the
remains acute otitis media (AOM).1,2 At least 15 observation period. As a result of this policy, the percent-
million prescriptions for antibiotics are written every age of patients given antibiotics for AOM in The Nether-
year.3 AOM, however, is a disease with a high rate of lands is approximately 31%.8
spontaneous resolution.47 For more than 20 years, phy- Excessive and inappropriate use of antibiotics has
sicians in The Netherlands have used a treatment strat- been linked to a rising prevalence of penicillin-resistant
egy for selected patients with AOM that withholds Streptococcus pneumoniae.8 Rates of penicillin-resistant
antibiotics for an initial observation period of two to S. pneumoniae increased from 27.5% in 1995 to 43.8% in
three days, during which time treatment is restricted to 1997.9 In contrast, in The Netherlands, the rate of penicillin
analgesics and antipyretics. Antibiotics are only given resistance to S. pneumoniae still remains less than 1%.10,11
Although historically the standard of care for the treat-
ment of AOM in the United States has been to administer
From the Department of Emergency Medicine, Stony Brook Uni- antibiotics for all cases, concern over the rising rates of
versity Medical Center (TF, AJS, CL, HCT), Stony Brook, NY. bacterial resistance and the success of the Dutch experi-
Received May 1, 2007; revision received June 26, 2007; accepted ence with initial antibiotic withholding has led to a shift
July 9, 2007. in the treatment paradigm for AOM. In the late 1990s,
Presented at the SAEM NY Regional Conference, New York, NY, the New York State Department of Health assembled a
March 28, 2007. committee of physicians whose purpose was to formu-
Contact for correspondence and reprints: Adam J. Singer, MD; late a more judicious approach to the use of antibiotics
e-mail: adam.singer@stonybrook.edu. for AOM. The culmination of the committees work was
a treatment strategy called the observation option that calculate national estimates of number of ED visits. An-
was based closely on the Dutch model.12 The observation tibiotic use was determined within age groups for the
option has been endorsed by the American Academy of pediatric population (younger than 2 years, 212 years,
Pediatrics (AAP) and the American Academy of Family 1317 years) and the adult population (18+ years of
Physicians (AAFP) and can be found on their Web sites.13 age) for comparative purposes. We calculated the age-
We hypothesized that, given the changes in treatment specific percentages of AOM visits resulting in a pre-
strategies for AOM, we would see a gradual decline in scribed antibiotic overall and stratified by gender,
antibiotic prescribing for cases of AOM seen in the emer- race, and geographic region. Estimates included the
gency department (ED). Antibiotic prescribing patterns number of visits and the percentage of visits with anti-
for AOM have been analyzed before, but to our knowl- biotics. Confidence intervals (CIs) were calculated for
edge, this is the first study to analyze antibiotic prescrib- percentages using standard errors, which were esti-
ing patterns for AOM in patients presenting to the ED. mated using the methods described by NHAMCS sur-
vey documentation. Trends were computed across all
METHODS years using weighted linear regression to account for
the sampling scheme used in the NHAMCS survey;
Study Design weights were the inverse of the variance estimates cal-
We analyzed the ED component of the 19962005 Na- culated from the standard errors. Analyses were per-
tional Hospital Ambulatory Medical Care Survey formed using SPSS for Windows 13.0 (SPSS Inc.,
(NHAMCS).14 The study was ruled exempt from in- Chicago, IL).
formed consent by our institutional review board. Although the 2005 NHAMCS data were accessible at
the time of this writing, the documentation necessary to
Study Setting and Population calculate standards errors and weights used in analyses
Briefly, NHAMCS encompasses a national probability was not available, so data from 2005 were only partially
sample of visits to U.S. hospital emergency and outpa- included in these analyses. Results for 2005 that did not
tient departments by the Division of Health Care Statis- require testing or CIs are presented here.
tics of the National Center for Health Statistics, Centers
for Disease Control and Prevention; only the ED data
were used in these analyses. The survey uses a four-stage
RESULTS
sampling design, covering geographic primary sampling
units, hospitals with EDs within primary sampling units, There were 2.6 million and 2.1 million ED visits for AOM
emergency service areas within EDs, and patient visits during the first (1996) and last (2005) years of the study.
within emergency service areas. Patient visits are re- Children aged 212 years accounted for approximately
corded using a systematic random sample selected over 40% of all ED visits for AOM during our study period,
a randomly assigned four-week reporting period. with another 40% in the younger than 2 years age group;
5% of all ED visits for AOM were in the age group 1317
Study Protocol years, and 15% were adults. The age distribution of
Visit sampling and data collection were recorded on patients with AOM was similar across years during
patient record forms by hospital staff or by field represen- the ten-year period (Figure 1).
tatives from the U.S. Census Bureau. Data collection During the first and the next to last (2004) years of the
methods do not indicate that data recording by hospital study, 79.2% (95% CI = 74.9 to 83.5) and 85.7% (95% CI =
staff was performed prospectively; data recording by 81.8 to 89.6) of all pediatric patients (younger than 18
field representatives was performed as a medical chart re- years) with AOM were prescribed antibiotics, respec-
view. Therefore, this study should be considered (conser- tively. There was a slight increasing trend in the propor-
vatively) as a retrospective chart review. Data processing tion of pediatric patients prescribed antibiotics over time
and coding were performed by an external source. (p = 0.02; Figure 2); in 2005, the percent of pediatric pa-
We identified an AOM case if it had International Clas- tients receiving antibiotics was consistent with this trend,
sification of Diseases, Ninth Revision, Clinical Modifica- because 91.3% received antibiotics. The rates of use of
tion (ICD-9-CM) code 382.9 in the primary diagnosis antibiotics for AOM were similar in patients younger
field. Over the ten annual surveys, between six (1996 than 2 years, 212 years, and older than 12 years; most
2002) and eight (20032005) medications were recorded age-year specific rates were between 79% and 89% in
per encounter; all recorded medications were considered the pediatric age groups over the study period. Patients
in the analyses. Up to three National Drug Class codes older than 18 years generally were prescribed antibiotics
were provided for each medication.15 Antibiotic use at a rate about ten percentage points lower than that of
was identified on the basis of any of the following drug pediatric patients (Figure 3). There was no change in an-
class codes: penicillins, cephalosporins, lincosamids or tibiotic use by patient gender, race, or geographic region
macrolides, polymyxins, tetracyclines, chloramphenicol in pediatric patients across years.
or derivatives, aminoglycosides, sulfonamides or related Types of antibiotics prescribed were similar for each
compounds, antibacterials miscellaneous, or quinolones year over the study period. Approximately two thirds
or derivatives. of patients received prescriptions for penicillins, another
15% received prescriptions for erythromycins, and 12%
Data Analysis received prescriptions for cephalosporins. Some patients
Population visits and visit rates were computed by were prescribed more than one antibiotic (e.g., amoxicil-
using the population weights used by NHAMCS to lin and amoxicillin clavulanate).
1174 Fischer et al. TRENDS IN ED ANTIBIOTIC RX FOR ACUTE OTITIS MEDIA IN CHILDREN
the childs condition worsened. Of all patients, 105 (73%) 2. McCaig LF, Hughes JM. Trends in antimicrobial drug
recovered without complications without ever receiving prescribing among office-based physicians in the
oral antibiotics.17 United States. JAMA. 1995; 273:2149.
It would seem, therefore, that a treatment strategy for 3. McCaig LF, Besser RE, Hughes JM. Trends in antimi-
AOM using the initial withholding of antibiotics can, in crobial prescribing rates for children and adoles-
fact, be safely and effectively implemented in the ED in cents. JAMA. 2002; 2878:3096102.
patients with nonsevere infections and good follow-up 4. Rosenfeld RM. Natural history of untreated otitis
and will likely result in a significant decrease in the num- media. Laryngoscope. 2003; 113:164557.
ber of antibiotic prescriptions given. 5. Del Mar C, Glaszion PP, Hayer M. Are antibiotics
Over the study period, the number of patients present- indicated as initial treatment for children with acute
ing with AOM declined by roughly half a million per otitis media? A meta-analysis. Br Med J. 1997; 314:
year. While we have no clear explanation for this decline, 15269.
this finding might also influence the interpretation of our 6. LeSaux N, Gaboury I, Baird M, et al. A randomized,
data. It may be possible that practitioners changed their double-blind, placebo-controlled, noninferiority trial
diagnosis (and resultant coding) practices to take into ac- of amoxicillin for clinically diagnosed acute otitis me-
count their treatment patterns. That is, physicians may dia in children 6 months to 5 years of age. CMAJ.
have given patients who they treated with antibiotics 2005; 172:33541.
the diagnosis otitis media (unspecified) (382.9), while 7. Damoiseaux RA, van Balen FA, Hoes AW, Verheij TJ,
giving patients who they did not treat with antibiotics deMelker RA. Primary care based randomized, dou-
the diagnosis acute serous otitis media (381.01). Thus, ble blind trial of amoxicillin versus placebo for acute
it is possible that over the study period, coding improved otitis media in children aged under 2 years. Br Med
and antibiotic therapy was, indeed, better targeted to the J. 2000; 320:3504.
patients who more clearly needed antibiotics. 8. Gurmaney H, Spor D, Johnson DG, Propp R. Diag-
Although we did not observe a downward trend in the nostic accuracy and the Observation Option in acute
rate of antibiotic prescribing for AOM over the years we otitis media: the Capital Region Otitis Project. Int J
studied, it is entirely possible that a downward trend may Pediatr Otorhinolaryngol. 2004; 68:131525.
be detected in future years as the treatment paradigm for 9. Doern GV, Pfaller MA, Kugler K, Freeman J, Jones
AOM more firmly shifts toward the direction of initial RN. Prevalence of antimicrobial resistance among
observation without antibiotics. respiratory isolates of S. pneumoniae in North
America: 1997 results from the Sentry Antimicrobial
LIMITATIONS Surveillance program. Clin Infect Dis. 1998; 27:
76470.
A significant limitation of our study was that the docu-
10. Hermans PW, Sluijter M, Elzenaar K, et al. Penicillin-
mentation of antibiotics in the visit form does not trans-
resistant Streptococcus pneumoniae in the Nether-
late necessarily to the actual filling of the prescription
lands: results of a 1 year molecular epidemiologic
by the patient. It is entirely possible that some emergency
survey. J Infect Dis. 1997; 175:141322.
physicians already aware of the concept of initially with-
11. Schito GC, Debbia EA, Marchese A. The evolving
holding antibiotics may have, in fact, chosen a delayed
threat of antibiotic resistance in Europe: new data
prescription strategy. However, it was not possible to de-
from the Alexander Project. J Antimicrob Chemo-
termine this distinction from the NHAMCS data forms,
ther. 2000; 46(Suppl T1):39.
which were completed at the point of care. We also can-
12. Observation Option Toolkit for Acute Otitis Media.
not determine the severity of the clinical presentation.
State of New York, Department of Health, Publication
Thus, the rates of antibiotic prescription may be higher
#3893, Mar 2002.
in the ED than in other clinical settings, because mostly
13. Subcommittee on Management of Acute Otitis Me-
children with more severe infections present to the ED.
dia. Diagnosis and management of acute otitis media.
Pediatrics. 2004; 113:145165.
CONCLUSIONS
14. McCaig LF, McLemore T. Plan and operation of the
The rate of antibiotic prescribing for cases of AOM seen National Hospital Ambulatory Medical Care Survey.
in the ED slightly increased between 1996 and 2005. Al- National Center for Health Statistics. Vital Health
though there is evidence that initial observation without an- Stat. 1994; 34:178.
tibiotics is both safe and effective in selected patients, this 15. Koch H, Campbell WH. The collection and process-
evidence has not been recognized or endorsed by any na- ing of drug information: National Ambulatory Medi-
tional professional body of emergency medicine and has cal Care Survey, United States, 1980. National
only recently been endorsed by the AAP and the AAFP. Center for Health Statistics. Vital Health Stat. 1982;
Any detectable decrease in ED antibiotic prescribing pat- 90:190.
terns for AOM as hypothesized will likely have to await a 16. Spiro DM, Tay KY, Arnold DH, Dziura JD, Baker
broader national consensus endorsing such a policy. MD, Shapiro ED. Wait-and-see prescription for the
treatment of acute otitis media. JAMA. 2006; 296:
References 123541.
17. Fischer TFX, Singer AJ, Chale S. Observation Option
1. Dagan R. Treatment of acute otitis media: challenges trial for acute otitis media in the emergency depart-
in the era of antibiotic resistance. Vaccine. 2000; ment [abstract]. Acad Emerg Med. 2006; 13(Suppl
19(Suppl 1):S916. 1):S1712.