Judicious Use of Antibiotics - Otitis Media

Introduction

Decreasing effectiveness of antibiotics has become a worldwide concern. It is generally acknowledged that the increase in drug-resistant bacteria is in large measure a byproduct of inappropriate prescription of antibiotics. Antibiotic resistance occurs when mutant bacteria are selected out by antibiotic use. These mutant bacteria are not eradicated by standard antibiotics.

The New York State Department of Health initiated a focused review of judicious use of antibiotics in upper respiratory infections, and in particular acute otitis media (AOM), in 1997. The review revealed that otitis is responsible for 30 million office visits nationwide per year, with an expenditure of approximately 5 billion dollars. Annually, over eight million excessive antibiotic prescriptions are written, due in part to over-diagnosis of AOM, and to the mistaken idea that antibiotic treatment of otitis media with effusion (OME) might be effective.

Overutilization of antibiotics in otitis and other upper respiratory infections accounts for the 25 to 45% prevalence of drug-resistant Streptococcus pneumonia in the United States, in comparison to the Netherlands where drug resistant Streptococcus pneumonia is only 1%. The Dutch developed and use the "Observation Option without Antibiotics" (OOWA). The use of OOWA on selected children age 2 and older has reduced antibiotic use in the Netherlands to 31% of all children treated for AOM. In contrast, over 95% of children with AOM are treated with antibiotics in the United States.

In 1997 the Department of Health, in collaboration with the health care community, initiated the Capital Region Otitis Project (CROP). Over the course of a year, the CROP committee analyzed evidence-based literature and formulated a multifaceted educational intervention, which took place in October 1998. Subsequently, the CROP committee developed A Practitioner's Guideline for Children Suspected of Having a Middle Ear Infection and a parent brochure, Ear Infections in Children.

The Practitioner's Guideline and the Parent Brochure may be used for guidance and education for clinicians and parents/caregivers in the diagnosis and management of otitis media. The Department of Health and the CROP committee thank Jacob Reider, M.D. of Albany Medical College Department of Family Practice for facilitating the development of the practitioner guideline and Lyn Hohmann, Ph.D., M.D., of Capital District Physicians' Health Plan for facilitating the development of the parent brochure.

Guidelines and Evidence-Based Medicine

This guideline was developed by and for the Capital Region of New York State. Other regions and groups are invited to study, adopt, and/or adapt it as they see fit, after reviewing the evidence-based literature.

We accept the Institute of Medicine's definition of guidelines as "Systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances."

We also agree with Sackett's statement that "Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients."; The three components of evidence based medicine are 1.) individual clinical expertise, 2.) external research evidence, and 3.) patient preference. (Sackett DL et al, BMJ 1996;312:71-72.)

You may address your comments and questions to patientsafety@health.state.ny.us.

Capital Region Otitis Project Committee

  • Harvey Bernard, M.D., NYS Dept of Health, Office of Medicaid Management
  • Susan Birkhead, B.S.N., M.P.H., Child Care Consultant, Troy
  • Samuel Bosco, M.D., Chief, Emergency Medicine, St. Peter's Hospital, Albany
  • John Cahill, NYS Dep't of Health, Bureau of Community Relations
  • Bradley Ford, M.D., MVP Health Plan; Pediatrician, Schenectady
  • Foster Gesten, M.D., NYS Dept of Health, Office of Managed Care
  • Lyon Greenberg, M.D., Pediatric Otolaryngology, Albany
  • Donna Haskin, B.S.N., NYS Dept of Health, Office of Medicaid Management
  • Lyn Hohmann, Ph.D., M.D., Capital District Physicians' Health Plan, Albany
  • Christopher Kus, M.D., M.P.H., NYS Dep't of Health, Center for Community Health
  • Martha Lepow, M.D., Pediatric Infectious Disease, Albany Medical College
  • Sheila McGuire, R.N., C.N.P., Pediatric Nurse Practitioner, Voorheesville
  • Harry Miller, M.D., Kaiser Permanente Health Plan; Pediatrician, Schenectady
  • William O'Dwyer, M.D., Pediatrician, Latham
  • Richard Propp, M.D., NYS Dept of Health, Office of Medicaid Management
  • Pat Pulver, M.P.H., P.A., Physician Assistant Faculty, Albany Medical College
  • Jacob Reider, M.D., Family Practice Faculty, Albany Medical College
  • Denise Spor, B.A., R.N., NYS Dept of Health, Office of Medicaid Management