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Antibiotic Recommendations for Acute Otitis Media and Acute Bacterial Sinusitis

Frost, Holly M., MD; Gerber, Jeffrey S., MD, PhD; Hersh, Adam L., MD, PhD

The Pediatric Infectious Disease Journal: February 2019 - Volume 38 - Issue 2 - p 217
doi: 10.1097/INF.0000000000002085
Letters to the Editor
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Department of Pediatrics, University of Colorado, Denver, CO, Department of Pediatrics, Denver Health and Hospital Authority, Denver, CO

Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, PA

Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah, Salt Lake City, UT

The authors have no funding or conflicts of interest to disclose.

Address for correspondence: Holly M. Frost, MD; E-mail: holly.frost2@dhha.org.

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To The Editors:

Drs Wald and DeMuri provide an excellent summary of the evolution of acute otitis media (AOM) pathogens since the introduction of the pneumococcal conjugate vaccine.1 However, predicting clinical treatment failure rates by in vitro susceptibilities alone has significant shortcomings, and we do not agree that these epidemiologic changes alone are sufficient to justify the recommendation to use amoxicillin-clavulanate as a first-line therapy for all patients.

First, despite the changes in microbial epidemiology, the percentage of patients potentially benefitting from broad-spectrum antibiotic therapy is relatively small. For example, clinical outcomes vary substantially across pathogens; while only 19% of AOM cases caused by Streptococcus pneumoniae self-resolve, 48% of Haemophilus influenzae and 75% of Moraxella catarrhalis cases self-resolve.2 , 3 Thus, it is likely that fewer patients benefit from treatment as the proportion of patients with H. influenzae or M. catarrhalis increases.

Based on the AOM pathogen distribution provided by Drs Wald and DeMuri, the spontaneous resolution rates previously mentioned and an assumption that 35% of H. influenzae produce β-lactamase, we estimate that at least 58% of patients will require no antibiotics, 29% will benefit from amoxicillin and only 13% will benefit from amoxicillin-clavulanate. Furthermore, serious complications from AOM are exceedingly rare and do not differ between patients who receive placebo versus antibiotics.4 A marginal benefit in symptom reduction is achieved with antibiotics; however, the number needed to treat for symptomatic benefit at days 2–3 is 20 patients.4

Second, recent data show that the clinical treatment failure for acute respiratory infections in children is low and does not differ between patients who receive narrow- and broad-spectrum antibiotics (3.1% narrow spectrum vs. 3.4% broad spectrum).5 Unfortunately, post–pneumococcal conjugate vaccine clinical trials evaluating treatment failure rates for AOM specifically, including those by Hoberman, Cohen, Tähtinen, and Pichichero, have exclusively used broad-spectrum antibiotics (amoxicillin-clavulanate or cefpodoxime proxetil) leaving the clinical failure rate of amoxicillin for treatment of AOM in the post–pneumococcal conjugate vaccine era unknown.5

Third, because AOM is, by far, the most common indication for antibiotic use in children, the potential downsides of this recommendation are profound. Broad-spectrum antibiotic use places children at greater risk for adverse drug events,5 selection for antimicrobial resistant organisms and dysbiosis of the microbiome. Additionally, a recent cost-utility analysis by Shaikh et al6 found that the incremental cost-utility ratio for treatment of AOM with amoxicillin-clavulanate compared with amoxicillin was high at $2331.18 per quality-adjusted life-day gained.

While we acknowledge that changes in the microbiology of AOM are important, we would caution the use of in vitro data alone to change treatment recommendations. Further studies evaluating the clinical failure rate of amoxicillin compared with broader-spectrum antibiotics, such as amoxicillin-clavulanate, are needed to inform recommendations. Given the lack of certainty of the benefit of broader-spectrum antibiotic use and the known harms, we are not convinced that the use of amoxicillin-clavulanate as a first-line therapy is justified without additional data.

Holly M. Frost, MD

Department of Pediatrics

University of Colorado, Denver, CO

Department of Pediatrics

Denver Health and Hospital Authority, Denver, CO

Jeffrey S. Gerber, MD, PhD

Division of Pediatric Infectious Diseases

Department of Pediatrics

University of Pennsylvania School of Medicine, Philadelphia, PA

Adam L. Hersh, MD, PhD

Division of Pediatric Infectious Diseases

Department of Pediatrics

University of Utah, Salt Lake City, UT

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REFERENCES

1. Wald ER, DeMuri GP. Antibiotic recommendations for acute otitis media and acute bacterial sinusitis: conundrum no more. Pediatr Infect Dis J. 2018;37:1255–1257.
2. Howie VM, Ploussard JH. Efficacy of fixed combination antibiotics versus separate components in otitis media. Effectiveness of erythromycin estrolate, triple sulfonamide, ampicillin, erythromycin estolate- triple sulfonamide, and placebo in 280 patients with acute otitis media under two and one-half years of age. Clin Pediatr (Phila). 1972;11:205–214.
3. Klein JO. Microbiologic efficacy of antibacterial drugs for acute otitis media. Pediatr Infect Dis J. 1993;12:973–975.
4. Venekamp RP, Sanders SL, Glasziou PP, Del Mar CB, Rovers MM. Antibiotics for acute otitis media in children. Cochrane Database Syst Rev. 2015;(6):CD000219.
5. Gerber JS, Ross RK, Bryan M, et al. Association of broad- vs narrow-spectrum antibiotics with treatment failure, adverse events, and quality of life in children with acute respiratory tract infections. JAMA. 2017;318:2325–2336.
6. Shaikh N, Dando EE, Dunleavy ML, et al. A cost-utility analysis of 5 strategies for the management of acute otitis media in children. J Pediatr. 2017;189:54–60.e3.
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