This editorial in CMAJ is wonderful.  The authors summarize a recent paper in that jornal that found a small difference in outcomes between patients who received amoxicillin and those who received placebo.  86% of patients who received placebo – and 92% of those who received amoxicillin had resolution of disease.  The editorial appropriately points out that this small difference should not cause us to think that antibiotics are appropriate for first-line treatment of AOM.  The NNT remains ~ 11 for treatment of AOM with antibiotics.  Do we really want those 10 extra kids treated? …  No.  of course not.

For those of you who have been reading this weblog for a long time, you have probably noticed that one of my primary clinical interests is otitis media and it's closely related cousins: Sinusitis and bronchitis.  These conditions are the cause of the most frequent visits to physicians at children and adults in this country (aside from well-child care and prenatal visits).

These conditions may also represent the vast majority of antibiotic prescriptions that are written in this country and since all three of these conditions can usually be successfully treated without the use of antibiotics, appropriate diagnosis and deliberate management is important.

I say "deliberate management" because many patients care physicians medical students and residents think that when condition is not treated with an antibiotic, it isn't treated.  For example, in our electronic medical record, there is a template entry next to "upper respiratory infection" where the user has two choices: "Treat with antibiotic" and "no treatment."  

Of course, neither is appropriate care.  We need to give our patients to best tools that we can for the management of these perplexing problems. 

• Good information. 
• Good recommendations for symptomatic treatment including appropriate analgesics for otitis media and symptomatic relief for nasal congestion or persistent cough
• Access to care if symptoms worsen or don't improve after a given period of time

Today I found a few articles related to otitis media that seem interesting albeit somewhat concerning:

Augmentin causes autism this seems like a rather poorly done study which I hope no one at USA Today decides to write a feature article on.

In this review of acute mastoiditis, over 200 cases were reviewed during a 10 year period.  It's interesting to note that the average age was 16 and more of the patient's who presented with mastoiditis were being treated with antibiotics and those who were not.  Of course, we can't draw any conclusions about this because of the timeframe of the study (for most of this period, Antibiotics were the treatment of choice for otitis media) and because there certainly can't be any causality established with a retrospective study like this.

This study is an unfortunate and rather detailed review of the microbiology observed in a number of cases of patient's with sinusitis or otitis media.  The problem with this study is that it is clearly focused on disease oriented evidence rather than patient oriented evidence.   There is in fact no clinical correlation mentioned, and the conclusion of the study: The amoxicillin clavulanic acid should be used for the treatment of these conditions – is inherently suspect.

Respiratory syncytial virus is a common cause of otitis media and young children.

Pneumococcal vaccine will likely help in reducing the emergence of resistant pneumococcus.

This one deserves a bit of reformatting so that we can interpret the abstract a little more easily.

Pathogens:

• Streptococcus pneumoniae
• Haemophilus influenzae non-type b
• Moraxella catarrhalis
• Streptococcus pyogenes
• Staphylococcus aureus

So far, this isn't news ..

"Resistance to the eight antimicrobial agents used was found in 37 instances in the AOM group as compared to 99 instances in the ROM group (P < 0.005). "

OK .. we still haven't learned anything new …

The difference between AOM and ROM was significant with Streptococcus pneumoniae resistance to amoxicillin (P < 0.005), to amoxicillin/clavulanate (P < 0.005), to trimethoprim/sulfamethoxazole (P < 0.01), to cefixime (P < 0.01) and to azithromycin (P < 0.01), and for H. influenzae resistance to amoxicillin (P < 0.025).

So the take-home message is clearly that treatment with antibiotics leads to the emergence of resistant organisms.  No kidding.

This paper caught my eye .. I'll include the whole abstract

Acute Otitis Media Caused by Drug-resistant Bacteria: Correlation with Antibiotic Treatment.

Objective Although acute otitis media (AOM) is the commonest infectious disease of childhood, the emergence of drug-resistant bacteria has dramatically changed its clinical outcome. Here, we report the trend of AOM due to drug-resistant Staphylococcus pneumoniae (DRSP) and beta-lactamase-negative ampicillin-resistant Haemophilus influenzae (BLNAR), and the relation between antibiotics used for the management of AOM and the isolation of bacterial pathogens. Material and Methods Bacterial isolation and susceptibility tests were performed on specimens from children with AOM. Clinical information, including antibiotic treatment within the previous 30 days, was analyzed. Results DRSP was detected in 59.3% of Pneumococci isolates and BLNAR in 26.0% of H. influenzae isolates. As expected, the incidence of AOM caused by such drug-resistant bacteria has been increasing year on year, and 32% of cases have been treated with inappropriate antibiotics. In contrast, 32% of cases of AOM caused by DRSP and 50% caused by BLNAR were given antibiotics with high susceptibility to drug-resistant bacteria. Conclusion In order to ensure the most appropriate use of antibiotics, clinicians should consider performing tympanocentesis or myringotomy, with subsequent submission of the middle ear fluid for susceptibility testing. Furthermore, these results suggest that, as well as the selection of antibiotics, the dosage and period of dosing should also be considered in the management of AOM. In addition, other factors, in particular horizontal transmission from other infants in day care or nursery school, may affect the rapid spread of such drug-resistant bacteria.

Cousin "CityKitty" .. mother of Paul .. recently called about his second bout of otitis media.    It's so hard.  In the context of good research that demonstrates how most cases of AOM resolve spontaneously, physicians are not only prescribing plenty of antibiotics .. but second-line agents as well .. hmm.