Published online April 1, 2008
PEDIATRICS Vol. 121 No. 4 April 2008, pp. 657-668 (doi:10.1542/peds.2007-1913)
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ARTICLE

Age Inconsistency in the American Academy of Pediatrics Guidelines for Acute Otitis Media

Sharon B. Meropol, MD, MSCEa,b, Henry A. Glick, PhDc,d and David A. Asch, MD, MBAa,c,d,e,f

a Center for Clinical Epidemiology and Biostatistics
b Center for Education and Research on Therapeutics
c Department of Biostatistics and Epidemiology
d Division of General Internal Medicine, Department of Medicine
e Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
f Center for Health Equity Research and Promotion, Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennsylvania

OBJECTIVE. The American Academy of Pediatrics acute otitis media guidelines could reduce antibiotic use. The objective was to compare strategies for diagnosing and treating otitis: (1) a commonly used, 2-criteria strategy, (2) the guidelines’ 3-criteria algorithm, and (3) initially watching without antibiotics.

METHODS. A decision analysis was performed with literature-based parameter. The target population was children presenting to primary care physicians with possible otitis media. Main outcomes were antibiotic use, sick days, mild adverse drug events, and number needed to treat/avoided sick day.

RESULTS. For children 2 to <6 months of age, compared with the 2-criteria strategy, guideline use predicted 21% less antibiotic use, 13% more sick days, and 23% fewer adverse drug events; the number needed to treat for the 2-criteria strategy versus the American Academy of Pediatrics strategy was 1.2 children per avoided sick day. For children 6 to <24 months of age, guideline use, compared with the 2-criteria strategy, predicted 26% less antibiotic use, 14% more sick days, and 28% fewer adverse drug events; the number needed to treat for the 2-criteria strategy versus the American Academy of Pediatrics strategy was 1.4 children per avoided sick day. For children >2 years of age, guideline use, compared with the 2-criteria strategy, predicted 67% less antibiotic use, 4% more sick days, and 68% fewer adverse drug events. The number needed to treat for the guideline strategy versus the watch strategy was 6.3 children per avoided sick day; that for the 2-criteria strategy versus the guideline strategy was 12.3. Guideline use for children <2 years implies that our number needed to treat to avoid a sick day is <1.4; for children >2, guideline use implies we are willing to treat at least 6.3 children to avoid a sick day. Thus, the guidelines imply a greater willingness to treat older children, compared with younger children.

CONCLUSIONS. The American Academy of Pediatrics guidelines are inconsistent in their outcomes across age groups. Guideline implementation under age 2 reduces antibiotic use but at a relatively heavy cost of sick days and parental missed work days. This trade-off may be particularly unfavorable for working parents, who might reasonably prefer greater antibiotic use.

Key Words: antibiotic use • child • cost-effectiveness • guidelines • otitis media

Abbreviations: AAP—American Academy of Pediatrics • ADE—adverse drug event • AOM—acute otitis media • ENT—ear, nose, and throat • MEE—middle ear effusion • NNT—number needed to treat • CI—confidence interval

Accepted Aug 29, 2007.


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