0910 Antibiotics, otitis media and mastoiditis

The medical literature abounds with studies comparing outcomes of treatment strategies for children with otitis media (acute and chronic), with much of the debate around a wait-and-see approach vs. the prescription of antibiotics. Interestingly, from a recent study published in Pediatrics it would appear that over a 16-year period (1990-2006) UK primary care practitioners reduced antibiotic prescription rates from 77% to 58%. These statistics can be regarded as being fairly accurate and valid since they were derived from a database covering >2.5 million children (aged between 3 months and 15 years). By comparison, and acknowledging that the time period was shorter (2001-2003), a US-based study of the population covered by Medicaid did not show any change in rates of prescription of antibiotics. It would be interesting to know the rate of antibiotic prescription for acute otitis media in South Africa, but impressions are that it would not be as low as the 58% cited in the UK study. Having noted these statistics, the actual purpose of the UK study was to assess whether the reduced rate of antibiotic prescription was associated with an increased risk and rate of diagnosis of subsequent mastoiditis. Results were that a) mastoiditis incidence was low (around 1.2 cases per 10 000 child years) and remained stable over the study period whereas acute otitis media rate declined; b) most cases (two-thirds) of mastoidits were not preceded by otitis media; and c) non-treatment of otitis media increased the mastoidits risk by a factor of 2. The authors nevertheless conclude that this does not make the case for universal treatment of otitis media because of the large number of treatments required (~5000) to prevent one case of mastoiditis. Returning to the finding of the reduction in incidence of otitis media over the study period, one explanation is that it is due to the introduction of pneumococcal vaccine. This aspect was covered in summary 336 of this series, making the point that the key feature of vaccination is early and repeated immunization in healthy infants and toddlers rather than on later immunization after presentation with disease.

Read more:
Pediatrics 2009; 123: 424-30
Fam Med 2009; 41: 182-7
BMC Pediatrics 2009; 9: 14 (Epub)