Is azithromycin or amoxicillin-clavulanate preferred for the treatment of children with persistent or recurrent otitis media?

According to this POEM – there is no difference between Azithomycin and Amox-Clav in the treatment of otitis media.

Bottom line
For every 10 children with persistent or recurrent otitis media who get high-dose azithromycin for 3 days instead of high-dose amoxicillin-clavulanate for 10 days, there is one additional clinical cure at 1 month and 1 less episode of diarrhea. There is no difference, however, in clinical success at 2 weeks. (LOE = 1b)

But where's the placebo group?  The study referenced above

A reminder that Chris Cates' EBM website has excellent resources on otitis media. 

It's odd – because I do recall seeing many cases of recurent otitis when I was in residency – and even when I was at the Albany Medical Center residency program – where I was on the faculty.  But in my current practice, my  colleagues and I are so conservative with antibiotics that we rarely treat kids who present initially.  We're seeing fewer cases overall – and fewer cases of resistant otitis and VERY few cases of recurrent otitis.  I can't think of the last kid I referred to ENT. 

Questions for the literature:

  • Do delayed prescriptions reduce antibiotic prescriptions?  Yes
  • Is there a way to clinically predict which organism is causing an episode of otitis? YES (cool!) (viruses?)
  • Why does AOM cause persistent OME?
  • Are there well established international guidelines?  No

No antibiotics for ear infections

It's that time of year again … and we're seeing kids in the office with otitis media. With each pasing year, more parents seem to understand that antibiotics for acute otitis media in children are largely unnecessary.

Several years ago, I developed a guideline that was part of a regional effort to reduce antibiotic overuse.   I still print out the patient information that we developed as part of this project, but these days I find that parents already know much of the contents.

When making the decision of how to treat a child with otitis these days, I find myself sharing the decision with the parents. 

JMR:  "Well .. 80% of kids in this situation will get better by themselves."

Mom: "Yes .. it seemed to work last time.  Johnny got better in 2 days .. but the time before that, he needed the antibiotics."

JMR: "Well, that's the problem .. we don't yet have a way to twll which kids are going to be that 20%"

Mom: "Let's wait and see.  I'll call you in 2 days if he's not better."

On Fridays and before holidays, I usually write the prescription, and ask the parents to hold on to it for a day or two.  It's not uncommon that they bring it back to demonstrate proudly all was well without the antibiotics.

In this process, I always focus on the concept that otitis media, like sinusitis, is a problem with obstruction .. rather than one of infection.  There's a nice monograph on this topic.   Te bugs are there anyway.  A little H. flu, S. Pneumo and Moraxella are components of the normal flora of the nasopharynx and therefore the eustacian tube.

But as the mucosa thickens in the context of a cold, the bugs are trapped.  A system that is usually dynamic and flushed on an ongoping basis .. is now stagnant.  Warm, moist place with bacteria.  Infection?  Duh.  But as with any abcess .. we need to enhance drainage FIRST .. not necessarily treat with antibiotics.

Too bad we can't just pop open the eustacian tubes with a remote control.  Hmm … maybe I'm not the only one with this idea.

Reviewing the last 20 cases of otitis media that I saw in the office .. I wrote prescriptions for antibiotics in 6 of them within 48 hours of the visit.  Many of these prescriptions were on Fridays .. so I don't really know how many kids actually got the antibiotics.   I wonder how Chris Bradley or Enoch  or Bhavesh handle this in urgent care settings. 

In our area .. urgent care and ERs have been the biggest problems for us in curbing antibiotic oversue.  Patients seem to get what they ask for in such settings .. which then builds the expectation that antibiotics are indicated for sinusitis, otitis or bronchitis … and of course, this is a concept that I don't agree with.

In the context of the recent flu scares .. and a rather persistent "flu-like-illness" that has been quite prevalent in the past 2 weeks (though waning now, it seems) … I spoke on the phone with a friend in the ER the other day:

JMR: "How are you guys dealing with this high-fever/cough viral thing going around?"

ERDOC: "Man .. it's bad.  Clearly not flu .. but most people think it is … which is just semantics, I guess.  The worst part is that many of the urgent care docs are prescribing Azithromycin for it … so the patients come here 3 days later because the z-pak isn't working and they want us to give them a stronger antibiotic"

JMR: "yikes."

Antibiotics: less is more

Well, in the context of writing not one but TWO prescriptions for antibiotics in the last 24 hours (long-time readers will recall that I am a fanatic about the overuse of antibiotics and I write for them very rarely)

This time, I had a reason.

Our local version of the pertussis outbreak has become signifiant.  With 21 confirmed cases in a high school about 4 miles from our office, I treated a coughing student from that school this morning after consultation with the health department.   But last night's customer was a textbook case.  The PCR's will be back in a few days. We'll see.

In realted news …

This study in JAMA confirms that a shorter duration of antibiotics may be better in the ICU:

  • CONTEXT: The optimal duration of antimicrobial treatment for ventilator-associated pneumonia (VAP) is unknown.
  • Shortening the length of treatment may help to contain the emergence of multiresistant bacteria in the intensive care unit (ICU).
  • RESULTS: Compared with patients treated for 15 days, those treated for 8 days had neither excess mortality (18.8% vs 17.2%; difference, 1.6%; 90% confidence interval [CI], -3.7% to 6