Acute Otitis Media in Children – There Are Guidelines but Are They Followed?

Abstract

Aims: To determine whether guidelines relating to the diagnosis and treatment of acute otitis media (AOM) in children are followed in a tertiary paediatric emergency department (ED).

Methods: A literature search was undertaken to identify national and international guidelines relating to the diagnosis and management of AOM in children. The guidelines were assessed for their applicability to UK practice. A retrospective case note audit was undertaken. Children presenting to the ED with a discharge diagnosis of AOM over a two month period were identified from the ED computer discharge system. The notes were analysed for compliance with the identified guidelines.

Results: 50 children were identified (age range three months to 11 years). Eighty-six per cent of children received antibiotics. Fifty-two per cent of children had documented signs of AOM. Twenty- five of these children received antibiotics (22 in accordance with guidelines, three not in accordance with guidelines, antibiotic not documented in one case). Thirty-nine per cent of children received antibiotics inappropriately. In all cases, the antibiotic dosage was below the dose recommended in all guidelines.

Conclusion: There is poor compliance with national (and international) guidelines for the management of AOM in this ED. National guidelines must be introduced into the department by direct teaching at senior house officer and middle grade level, a re-audit must be carried out and regular reviews of the notes of patients diagnosed with AOM must be undertaken to ensure compliance with guidelines is maintained.

Key words: Otitis Media; Practice Guidelines; Anti-bacterial Agents; Great Britain

Introduction

Acute otitis media (AOM) is the commonest bacterial infection in children,1 with 25 per cent of all children experiencing an episode of AOM before the age of 10 years.2 AOM is primarily a disease of childhood, with a peak incidence of between six and nine months.3 The earlier the onset, the greater the likelihood of recurrence, with studies indicating that children presenting with AOM before the age of two years are likely to have two or more recurrences within two years.4 AOM is increased in children whose parents smoke,5 in children who attend day care,3 in boys3 and in children who are bottle-fed.6

It is often difficult to obtain a microbiological diagnosis in AOM but the major pathogens have not altered over the past 25 years and are similar in children and adults.7 The commonest organism responsible for AOM is Streptococcus pneumoniae (40 per cent), followed by Haemophilus influenzae (25 per cent), Moraxella catarrhalis (10 per cent), Group A Streptococcus (2 per cent) and Staphylococcus aureus (2 per cent).8 In about 30 per cent no bacterial pathogens are identified.9

Internationally, there are different approaches to the management of AOM, with some countries routinely using antibiotics and other countries instituting symptomatic treatment initially and using antibiotics only if there is no improvement in the child’s clinical condition.10

Concerns about increasing bacterial resistance and the increasing costs of antibiotic prescriptions have led a number of countries to develop evidence-based guidelines for the management of AOM. This audit aimed to identify relevant national and international guidelines and to compare current emergency department prescribing practice with recommended guidelines.

Methods

This was a retrospective audit from the ED of an inner city tertiary referral paediatric hospital serving a multicultural population with an annual attendance of 52 000 children.

A literature search of Medline (Ovid interface), PubMed, the Cochrane library, CINAHL and Embase was undertaken in order to identify published clinical guidelines relevant to the management of AOM in the United Kingdom (UK). Seven guidelines were identified as being applicable to clinical practice in the UK: Alberta Clinical Practice Guidelines 2000,” American Academy of Pediatrics Guidelines 2000,12 British Columbia Guidelines and Protocols Advisory Committee 2002,13 National Guideline Clearinghouse 2002,14 Cochrane Review 2003,15 SIGN Guidelines 2003,16 and PRODIGY Guidelines 2004.17

TABLE I

IDENTIFIED GUIDELINES

These guidelines, and their applicability to standard UK practice, were reviewed and standards for audit were derived from the guidelines (see Table I for summary of guidelines). The notes were examined for the following:

(1) Documented symptoms and signs of AOM: fever (>38.5C), pain, irritability, bulging red eardrum, poorly mobile eardrum, perforation

(2) Early antibiotic treatment in children < two years, in children with temperature >38.5C, in children with bilateral AOM

(3) Recommendation to ‘watch and wait’ for 72 hours if >two years

(4) First line treatment of 40mg/kg/day amoxycillin for five days (or macrolide)

(5) Second line treatment with Augmentin if no better after three days without antibiotics or with three days of first line treatment.

The notes of 50 consecutive children presenting to the ED, with a discharge diagnosis of acute otitis media, between May and July 2004 were identified using computer generated discharge coding. The ED notes were analysed against the ‘best practice’ as defined by the guidelines. The analysis was divided into children under the age of two years and children over the age of two years as the guidelines suggest that these two groups should be managed differently.

Results

Twenty of the 50 children were aged less than two years. Eleven had documented AOM (55 per cent), two had a temperature greater than 38.5C (10 per cent) and 17 children received antibiotics (85 per cent). Of the 11 children identified as having signs of AOM, 10 received antibiotics. In the 11th child it was not possible to determine from the notes whether this child received antibiotics. Nine out of the 10 correctly received amoxycillin, the 10th child received Augmentin as first line treatment (against the recommendations). Six children (30 per cent) received antibiotics for AOM, despite the absence of signs of AOM.

TABLE II

RESULTS OF AUDIT

Thirty of the children were aged more than two years (age range two to 11 years). Fifteen had documented AOM (50 per cent), five had a temperature greater than 38.5C (17 per cent) and 26 children received antibiotics (87 per cent). All 15 children with documented AOM received antibiotics. Twelve correctly received amoxycillin (80 per cent), one received topical Otomize and two incorrectly received Augmentin. Eleven children (42 per cent) received antibiotics for AOM, despite the absence of signs of AOM.

In all children, documentation of duration of antibiotics was inadequate and all children received doses of amoxycillin below the dose recommended by the guidelines.

Discussion

AOM (which may be bacterial or viral) is one of the most common presenting complaints seen in primary and secondary care. In the United Kingdom, approximately 25 per cent of all children have one episode of AOM before their 10th birthday (peak incidence three to six years).18 In the United States, the figures are higher, with an estimated 66 per cent of children having an episode of AOM before their third birthday (peak incidence six to 24 months).9 However, although it is difficult to quantify, it is likely that AOM is over- diagnosed in the United States.19,20 The indiscriminate use of broad- spectrum antibiotics is associated with increasing bacterial resistance19,21 and in the Western world most cases of AOM remit spontaneously without complications.15

In this study, it is likely that the over-diagnosis of AOM was a common reason for the unnecessary prescription of antibiotics. The over-diagnosis may occur for a number of reasons. Firstly, there is no universal definition of acute otitis media. Generally, the term AOM is used to describe short-term inflammation of the middle ear characterised by earache, which may be preceded by upper respiratory tract symptoms. Secondly, otoscopy may be difficult in children because of the presence of wax, the narrowness and tortuosity of their ear canals and their poor co-operation. Otoscopic appearances typical of AOM include: (1) fullness or bulging of the tympanic membrane (best predictor22); (2) changes in the membrane colour (typically red or yellow); and (3) perforated tympanic membrane which may be discharging.

TABLE III

DIAGNOSTIC FEATURES OF AOM AND OME

Thirdly, pneumatic otoscopy, often used to confirm the diagnosis by demonstrating reduced or absent mobility of the tympanic membrane is not widely available in the ED. Fourthly, and perhaps the most difficult task of all, is the need to differentiate between AOM and otitis media with effusion (OME)(see Table III).16 Misdiagnosing OME for AOM may result in the over-prescription of antibiotics. Conversely, failure to diagnosis AOM in younger children may lead to reducing hearing, delayed speech development and reduced cognitive function.23 In the very young child (less than two months), the presence of AOM increases the risk of the development of bacteraemia and subsequent septicaemia.24 An additional factor influencing the over-diagnosis of AOM may be the paucity of undergraduate otolaryngology training. This is an issue that needs addressing as many newly qualified doctors will undertake training in specialties where \examination of the ear, nose and throat is necessary (general practice, emergency medicine, paediatrics including paediatric surgery, otolaryngology, anaesthetics).

The other finding in this study was poor documentation of dose and duration of treatment. Although antibiotics were prescribed inappropriately in 39 per cent of children, the drugs used in those children requiring treatment were appropriate in 85 per cent of children. The dose of antibiotics prescribed is important but is poorly documented. The recommendations for dosage in low risk children is 40mg/kg/day amoxycillin and in high risk children 90mg/ kg/day amoxicyllin. The recommended doses are derived from the pharmacokinetic and pharmacodynamic properties of antibiotics. Penicillins, cephalosporins and macrolides demonstrate time- dependent killing.25 This means that optimum microbial killing for penicillin and cephalosporins occurs when the antibiotic concentration exceeds the minimal inhibitory concentration (MIC) for more than 40 per cent and 50 per cent of the dosing interval respectively. Using this model, amoxycillin is most effective against AOM caused by Streptococcus pneumoniae and Haemophilus influenzae.26 In high risk children (less than two years of age, in day care or received antibiotics recently) who are likely to have drug-resistant Streptococcus pneumonia (resulting from excessive antibiotic use) increasing the dose of amoxycillin to 80-90mg/kg/ day increases the likelihood that the drug concentration will exceed the MIC for more than 40 per cent of the time. Failure to respond to amoxycillin suggests that the child is infected with beta-lactamase producing organisms and Augmentin (amoxycillin/clavulanate) is the treatment of choice in these circumstances.

In the United States the duration of treatment has typically been 10-14 days,27 whilst in the UK the duration of treatment is usually 5-7 days.28 Unfortunately, there is no consensus of opinion. The shorter course used in the UK may be appropriate in children older than two years of age with little risk of treatment failure.29 Children with recurrent disease or anatomical/immunological disorders should receive 10-14 days of treatment.

Limitations of audit

This was a retrospective case notes review of only 50 children.

Conclusion

Despite a number of guidelines specifying the clinical diagnostic criteria for AOM, the situation under which antibiotics should be prescribed, the antibiotics (and the dose) that should be used and the duration of treatment, there was still a high proportion (39 per cent) of children in both age groups who received inappropriate treatment for AOM, despite the lack of clinical signs of AOM. The number of children in this audit is very small but it is clear that ED staff need education about the national guidelines pertaining to the diagnosis and management of AOM. Following this audit, a similar audit is currently underway in another paediatric ED. Guidelines for the management of AOM in children will be drawn up and disseminated to both paediatric EDs, in one via senior house officer/middle grade teaching and the written departmental-based guidelines; and in the other via senior house officer/middle grade/nurse practitioner teaching and the web-based ED handbook.30 A re-audit will be undertaken following the introduction of the guidelines. The difficulty will be sustainability. Spot note checks will occur in the second department as part of clinical governance but the underlying difficulty lies with the core knowledge of otolaryngology. In order to sustain a change in clinical practice, education at undergraduate level needs to be addressed.

Recommendations

(1) Make correct diagnosis of AOM

Fever, irritability

Bulging, reddened tympanic membrane

Poorly mobile tympanic membrane

(2) Stratify risk for individual child

High risk children:

Children in day care

Children under two years of age

Children with bilateral AOM

Children with systemic symptoms (i.e. temp > 38.5C)

Children with older siblings

Children whose parents smoke

Children who present with hearing or behavioural difficulties

Low risk children

(3) If child is high risk, give antibiotics

(4) If child is low risk, watch and wait for 48-72 hours

(5) Prescribe antibiotics according to guidelines

Amoxycillin (or macrolide) as first line treatment

Augmentin (or different macrolide) as second line treatment

* National and international guidelines exist for the treatment of acute otitis media in children

* This study illustrates that in United Kingdom practice there is poor compliance with guidelines when children present to emergency departments with acute otitis media

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S L WOOLLEY, FFAEM, D R K SMITH, MRCS*

From the Bristol Royal Infirmary, Bristol, and the * University Hospital of Wales, Cardiff, Wales.

Accepted for publication: 25 February 2005.

Address for correspondence:

Dr S L Woolley FFAEM

Consultant, Emergency Department

Bristol Royal Infirmary/Bristol Children’s Hospital

Upper Maudlin Street

Bristol, UK

Fax: 0044 117 928 2713

E-mail: woolley_s@hotmail.com

Dr S Woolley takes responsibility for the integrity of the content of the paper.

Competing interests: None declared

Copyright Royal Society of Medicine Press Ltd. Jul 2005