Antibiotic Duration for Acute Otitis Media Exceeds Guidelines

Acute otitis media (AOM) is typically treated with 10 days of antibiotics, according to a new study in the Journal of the Pediatric Infectious Diseases Society (JPIDS).¹ Notably, the investigators find the duration excessive, citing US and international guidelines advising 5 to 7 days, if antibiotics are indicated, but there is often no indication when the etiology is viral, they mention. The shorter course of antibiotics for AOM is not only consistent with stewardship practices to reduce antibiotic-associated adverse events and development of treatment-resistant bacteria, but is supported by evidence of effectiveness, lead author Sophie Katz, MD, from the Division of Infectious Diseases in the Department of Pediatrics at Vanderbilt University Medical Center (VUMC), in Nashville, Tennessee, and colleagues emphasize.

"Studies suggest that for most children with uncomplicated AOM (defined as AOM without otorrhea), the risk of treatment failure does not differ between those who receive 5 days of therapy and those who receive 7 or more days of therapy. Additionally, 5-day regimens provide similar rates of clinical cure and bacterial eradication for children ages 2 years and older compared to traditional 10-day regimens," Katz and colleagues wrote.

To ascertain duration of antibiotic courses prescribed for AOM, the investigators accessed records from 135 care locations of 2 large health systems for more than 73,000 outpatients aged 2 to 17 years with a diagnosis of AOM from 2019-2022. Both systems, at the VUMC and at Washington University, were noted to have robust outpatient antimicrobial stewardship programs.

Katz and colleagues found that an antibiotic prescription was provided to 61,612 (84%) of these children, with most (45,689; 75%) for a 10-day duration. Seven days of antibiotics were prescribed for 12,060 (20%); and the guideline-recommended 5-day course of treatment was prescribed for only 5% (3144) of the studied cohort.

A higher proportion of encounters at VUMC resulted in an antibiotic prescription (90%) than at Washington University (81%).Antibiotic selection was similar between health systems; with amoxicillin was the most commonly prescribed. Non-first line antibiotics, most commonly cefdiir, were prescribed in approximately 30% of cases.

Treatment failure, AOM recurrence, adverse drug events, hospitalizations, and office, emergency department or urgent care visits for AOM within 30 days after the index visit were characterized as "rare."

The investigators calculated that if the 10-day prescriptions had been written for 7 or 5 days, 34,267 or 57,111 antibiotic-days per year would have been avoided, respectively. They posit that such a reduction would have produced broad cost-savings, not only in direct drug costs, but in costs related to antibiotic resistance, adverse effects and potential school/daycare and workdays missed.

In a related ID Consultant column of the JPIDS, titled "Give Me Five,"² Katz and colleagues urge practitioners to overcome the "academic imprinting" that contributes to maintaining long-standing practices despite countervailing evidence.

"Prescribers in the United States should overcome academic imprinting and follow international trends to reduce antibiotic durations for common acute respiratory tract infections, where 5 days is a safe and efficacious course when antibiotics are prescribed," Katz and colleagues advise.

Compliance with guideline course durations of antibiotics is particularly beneficial with AOM, as it is the indication for approximately 25% of all antibiotics prescribed to children annually, Katz and colleagues noted.

"Given the burden of antibiotic prescriptions written for AOM annually in the United States, decreasing the 'default' antibiotic duration to 5-days could have significant impact on overall outpatient antibiotic use," Katz and colleagues declare.

References
1.Katz SE, Jenkins TC, Stein AB, et al. Durations of antibiotic treatment for acute otitis media and variability in prescribed durations across two large academic health systems.J Pediatric Infect Dis Soc 2024 July 26; piae073.Online ahead of print. doi:10.1093/jpids/piae073.
2. Feghaly RE, Jaggi P, Katz SE, Poole NM. "Give Me Five": The case for 5 days of antibiotics as the default duration for acute respiratory tract infections. J Pediatric Infect Dis Soc 2024; 13:328-333.