The alarm has been sounded both in the public and the medical community. Bacterial resistance to antibiotics is a real problem. Common respiratory tract pathogens such as Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis are developing increasing resistance worldwide. Surveillance data from the CDC (1998) demonstrate that more than 50% of all clinical isolates of pneumococci are not susceptible to penicillin. Resistance to multiple antibiotics is common. Studies suggest that overuse of antibiotics is a significant contributor to this increasing resistance. An evaluation of insurance claims in Kentucky during 1992 to 1993 demonstrated that 60% of patients with colds were treated with antibiotics. Resistant infections lead to treatment failures, requiring additional courses of antibiotics which can then create increasing resistance. As resistance increases there are fewer treatment options available. The use of expensive drugs and more aggressive interventions cause costs to rise.

There are several factors which determine whether a physician will prescribe an antibiotic. Physician factors include: the difficulty of distinguishing between a bacterial process and a viral process; a desire to meet patient expectations for a prescription; and a fear of losing patients in a competitive environment. Patients often believe an antibiotic is necessary for treatment of any infection, and parents hope an antibiotic will shorten a child's illness so that fewer days will be loss at work. Unfortunately, some daycare centers will only accept children back if they are receiving an antibiotic.

In 1998, our office participated in a study examining the relationship between antibiotic prescriptions and patient satisfaction.¹ In the study, 306 parents were questioned before and after a visit for an acute illness. Surprisingly, parent satisfaction did not correlate with whether an antibiotic was prescribed or not.

Parents expected the physician to spend time explaining their child's illness, address their concerns and provide a contingency plan. Good communication, not a prescription, led to satisfied parents.

Otitis media is the most common diagnosis for which antibiotics are prescribed in the pediatric population. Acute otitis media is responsible for nearly 30 million office visits per year.² One study of 2,253 infants found that in the first 2 years of life, patients spend an average of 42-49 days each year on antibiotic therapy for acute otitis media.³ Teele discovered that 93% of children have experienced at least one episode of acute otitis media by the age of 7 years.⁴

Before discussing the issue of treatment, it is important to remember that physicians need to do a better job in diagnosing acute otitis media. Over-diagnosing of ear infections results in unnecessary prescriptions for antibiotics, which encourages the development of resistant organisms. An inadequate exam due to cerumen, a red tympanic membrane, and an overreliance on a child's complaint of ear pain often result in over-diagnosis. We must also distinguish between acute otitis media and otitis media with effusion. An ear effusion often persists after a course of antibiotics for acute otitis media and need not be treated with repeated courses of medication. Ear effusions are also often seen with upper respiratory infections and can be observed.

Doctors and parents are now asking: "Do all ear infections need to be treated with antibiotics?" Clearly many of these infections will resolve spontaneously. An analysis of studies conducted from 1966 to 1992 concluded that 81% of acute otitis media resolved without antibiotic therapy. The benefit of antibiotics over placebo was 13.7%. Another analysis discovered that antibiotics resulted in ear pain resolving approximately 2 days sooner than therapy with no antibiotics.

Currently in the Netherlands, children may be treated with analgesia and watched closely. One study of 4860 children with acute otitis media over the age of 2 years and not treated with antibiotics demonstrated that only 126 (3.3%) did not improve in 48 hours.⁵ Similar results were found in a study of younger children.⁶

It should be noted that infections caused by Haemophilus influenzae and Moraxella catarrhalis are more likely to resolve spontaneously than infections caused by Streptococcus pneumoniae. One must also consider the age of the study populations and the possibility of the over-diagnosis of acute otitis media in evaluating these studies. Thus there is evidence that antibiotics offer only a marginal advantage over no antibiotics in the treatment of acute otitis media in healthy children older than 2 years of age.

I would like to propose an alternative to immediate treatment of acute otitis media with antibiotics in all children. In my practice, I commonly find children with ears that appear infected but who are afebrile and experiencing little or no discomfort. I discuss my findings with the parent and suggest two alternatives: 1) we can treat the ear infection for 10 days with a broad-spectrum antibiotic; or 2) we can withhold therapy for 48-72 hours then recheck the ears. If we do not treat the child, it is with the understanding that the parent can call on the phone for treatment at any time if the child becomes febrile or uncomfortable. If the infection has improved at the recheck, no further therapy is required. If the infection has not improved or has worsened, standard antibiotic therapy is instituted. I have found that parents are very happy to have the choice of withholding antibiotics and are comfortable with the contingency plan. My impression is that approximately 50%-60% of the children improve and do not require medication.

Many have expressed the hope that if we can decrease the use of antibiotics, we can significantly reduce the incidence of resistance. In the Netherlands, 6% of Haemophilus influenzae are antibiotic resistant and 1% of Streptococcus pneumoniae are penicillin resistant.⁷ Perhaps with each of us making a small change in our prescription habits, we can have an impact on the big picture.

REFERENCES

1. Mangione-Smith R, McGlynn EA, Elliott MN, Krogstad P, Brook RH. The relationship between perceived parental expectations and pediatrician antimicrobial prescribing behavior. Pediatrics. 1999 Apr;103(4 Pt 1):711-718.

2. Chartrand SA, Pong A. Acute otitis media in the 1990s: the impact of antibiotic resistance. Pediatr Ann. 1998 Feb;27(2):86-95.

3. Paradise JL, Rockette HE, Colborn DK, et al. Otitis media in 2253 Pittsburgh-area infants: prevalence and risk factors during the first two years of life. Pediatrics. 1997 Mar;99(3):318-333.

4. Teele DW, Klein JO, Rosner B. Epidemiology of otitis media during the first seven years of life in children in greater Boston: a prospective, cohort study. J Infect Dis. 1989 Jul;160(1):83-94.

5. van Buchem FL, Peeters MF, van 't Hof MA. Acute otitis media: a new treatment strategy. Br Med J (Clin Res Ed). 1985 Apr 6;290(6474):1033-1037.

6. Damoiseaux RA, van Balen FA, Hoes AW, Verheij TJ, de Melker RA. Primary care based randomised, double blind trial of amoxicillin versus placebo for acute otitis media in children aged under 2 years. BMJ. 2000 Feb 5;320(7231):350-354.

7. Hermans PW, Sluijter M, Elzenaar K, et al. Penicillin-resistant Streptococcus pneumoniae in the Netherlands: results of a 1-year molecular epidemiologic survey. J Infect Dis. 1997 Jun;175(6):1413-1422.