Acute otitis media (AOM) is a common diagnosis in outpatient pediatrics that often results in antibiotic prescriptions. In 2013, revised clinical practice guidelines for AOM by the American Academy of Pediatrics (AAP) recommended reserving antibiotics and a watchful waiting (WW) approach in most scenarios; amoxicillin +/-clavulanate as 1st-line agents if treating; and courses of >7 days to be clearly indicated only in severe cases in those ≤2 years old. Adherence to AOM guidelines amongst pediatric providers, especially in non-academic outpatient settings, has not been well characterized.
In a large community-based sepsis point prevalence study, diagnosis, antibiotic prescription, and other data were collected from all patients aged 0 to 18 years seen on 9/5/16, 12/5/16, 3/6/2017, and 6/5/17, in the Emergency Department (ED) of the Women and Children’s Hospital of Buffalo, 11 primary pediatric (PMD) offices, and 2 private urgent care centers (UCC) in Buffalo, NY. For this secondary analysis, all children with a provider diagnosis of acute otitis media (AOM) were identified. Adherence to AAP AOM guidelines were analyzed and compared relative to clinical care setting.
Of 2062 sick visits, 6% (121) were diagnosed with AOM, and in 82% of these antibiotics were prescribed: 91% (39/43) in ED; 70% (21/30) in UCC; 83% (40/48) in PMD, p=0.071. When prescribed, 69% of antibiotics were 1st-line agents. In UCC and PMD, oral 3rd generation cephalosporins were the most common non-1st line agents, followed by azithromycin (20% and 8% of all antibiotic prescribed cases respectively). 90% of antibiotic courses were ≥ 7 days. There were no differences in prescribing practices between outpatient settings
A recent study found that WW is clinically appropriate in >50% of pediatric AOM and overall cost-effective. However, in our analysis, antibiotics are still being prescribed in 4 out of 5 cases. Non-1st line agents, which are excessively broad and/or suboptimal in targeting the main pathogens for pediatric AOM, are given in over a quarter of prescriptions. Increasing awareness and adherence to AOM guidelines, in various outpatient settings, should be a major target of pediatric antibiotic stewardship efforts.
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