Introduction: the challenge of marginal efficacy
Antibiotic resistance—the driver for change
Guidelines: formulation and presentation
Guideline | Scope | First-line treatment |
---|---|---|
American Academy of Pediatrics and American | Pain management, initial observation versus antibacterial treatment, appropriate choices of antibacterials, and preventive measures | Analgesia |
Academy of Family Physicians (AAP/AAFP 2004) [5] | Following certain diagnosis | |
<2 years: antibiotics; | ||
>2 years; watchful waiting | ||
Scottish Intercollegiate Guidelines Network (SIGN 2003) [88] | Detection, management, referral and follow-up of AOM and OM with effusion | Analgesia first-line |
Delayed antibiotic treatment after 72 h | ||
National Institute of Clinical Excellence, UK (NICE 2008) [70] | Clinical effectiveness and cost effectiveness of antibiotic management strategies for respiratory tract infections | AOM—no antibiotic or delayed antibiotics |
And/or antibiotics for severe cases | ||
Bilateral AOM in children younger than 2 years | ||
AOM in children with otorrhoea | ||
Agence Française de Sécurité Sanitaire des Produits de Santé (AFSSAPS 2005) [2] | Best use of antibiotics for respiratory tract infection | <2 years: antibiotics |
>2 years: watchful waiting unless symptoms are severe then use antibiotics | ||
And/or delayed treatment after re-evaluation at 48–72 h | ||
Ontario Guidelines Advisory Committee 2002 [71] | Antibiotic treatment in OM | For purulent OM with effusion or minimally symptomatic AOM |
Amoxicillin prescription to be filled within a week at the parent’s discretion, if symptoms are worsening | ||
Or deferred treatment following phone call to physician | ||
Guidelines of the German society for pediatric infectious diseases [36] | Treatment of AOM | Symptomatic treatment (analgesia, nose drops) and watchful waiting for 24–72 h if second look is assured. Antibiotics first line (amoxicillin) in severe disease, age < 6 months, risk factors |
Nederlands Huisarts Genootschap (NHG) [69] | Treatment of AOM | Analgesia (paracetamol) |
In case of worsening disease or children <2 year with bilateral acute OM: amoxicillin for 1 week (recommended alternatives azithromycin for 3 days or cotrimoxazole for 5–7 days) | ||
Spanish Pediatric Association [23] | Treatment of AOM | Symptomatic treatment (paracetamol, ibuprofen) |
Children >2 years without poor prognostic factors, analgesic with reassessment after 48 h | ||
Antibiotic is recommended treatment for: | ||
Mild or moderate condition: amoxicillin, then amoxicillin-clavulanate (if clinical failure at 48–72 h of treatment) | ||
Severe conditions or less than 6 months: amoxicillin-clavulanate then if clinical failure at 48–72 h of treatment, tympanocentesis and treatment according to results of Gram staining and antibiotic sensitivity | ||
Previous treatment failure (lack of clinical response): | ||
amoxicillin-clavulanate then ceftriaxone, then tympanocentesis and treatment, according to Gram stain, culture, and sensitivity |
Are guidelines alone effective in changing practice?
Reasons for non-adherence
Multi-dimensional cultural differences and the vicious spiral
Parental pressure: the burden of OM on the family
Physician inertia
Conflicts of interest
Fears over the adverse consequences of restricted prescribing
Diagnosis of OM versus severity and persistence of disease
Possible contributions to a solution
Risk factor reduction
Training and role evolution for physicians
Decision support
Incentives and related structural changes to manage care
Public information campaigns
Vaccination
Conclusions
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Strengthening physician education, training, and continuing professional training towards prevention and explanation, integrated with clinical decision support and feedback; also encouraging continuity of care to manage irrational demand downwards, while providing assurance and monitoring risk
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Two specific training modules for generalist pediatricians and family practitioners promoting age-appropriate analgesia and the efficient early identification and management of symptomatic mastoiditis
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Vaccination against the most serious pathogens for OM, shifting the clinical emphasis away from prophylaxis against serious complications, and from low-effectiveness, especially in high-prescription countries of older first-line treatments. The shift in perceived risk following high-coverage vaccination against OM should help to break the vicious spiral, but opportunities should be seized to test this conjecture, and to document the a priori partnership whereby improved adherence to guidelines would decrease replacement pressures and so ease the vaccine development and updating cycle