Is treatment of acute otitis media with once-a-day amoxicillin feasible? Results of a pilot study

Once or twice daily versus three times daily amoxicillin with or without clavulanate for the treatment of acute otitis media

BACKGROUND

Acute otitis media (AOM) is a common problem in children, for which amoxicillin, with or without clavulanate, is frequently prescribed as a treatment of choice. The conventional recommendation is either three or four daily doses. However, nowadays it is frequently prescribed as once or twice daily doses. If once or twice daily amoxicillin, with or without clavulanate, is as effective for acute otitis media as three or four times a day, it may be more convenient to give the medication once or twice a day to children and hence improve compliance.

OBJECTIVES

To compare the effectiveness of one or two daily doses with three or four daily doses of amoxicillin, with or without clavulanate, for the treatment of AOM in children; and to compare complication rates and adverse reactions.

SEARCH METHODS

We searched CENTRAL 2013, Issue 2, MEDLINE (January 1950 to March week 1, 2013), EMBASE (1974 to March 2013) and the Science Citation Index (2001 to March 2013).

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of children aged 12 years or younger with AOM, diagnosed by acute ear pain (otalgia) and inflamed ear drum (confirmed by positive tympanocentesis or tympanogram of type B or C).

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data on treatment outcomes from individual trials and assessed trial quality based on selection bias, performance bias and detection bias, attrition bias, reporting bias and other biases. We defined the quality grading as low risk of bias, high risk of bias or unclear risk of bias. We summarised the results as risk ratio (RR) with 95% confidence intervals (CI).

MAIN RESULTS

We included five studies with 1601 children in the review. Pooled analysis demonstrated that the following outcomes were comparable between the two groups: clinical cure at the end of therapy (RR 1.03, 95% CI 0.99 to 1.07); during therapy (RR 1.06, 95% CI 0.85 to 1.33) and at follow-up (RR 1.02, 95% CI 0.95 to 1.09); recurrent AOM (RR 1.21, 95% CI 0.52 to 2.81); compliance rate (RR 1.04, 95% CI 0.98 to 1.10) and overall adverse events (RR 0.92, 95% CI 0.52 to 1.63). When we performed subgroup analysis separately for trials with amoxicillin only and amoxicillin/clavulanate only, it showed that all important outcomes were comparable between once or twice daily groups and the three times daily group. The risk of bias amongst the five included studies was as follows: for random sequence generation we graded two studies as low and three unclear risk of bias; for allocation concealment all studies were at unclear risk of bias; for blinding (performance and detection bias) we graded four as high and one as unclear risk of bias; for incomplete outcome data (attrition bias) we graded two low, two high and one as unclear risk of bias; for reporting bias four were at low and one at high risk; and for 'other' bias four were at low and one at unclear risk of bias.

AUTHORS' CONCLUSIONS

This review showed that the results of using once or twice daily doses of amoxicillin, with or without clavulanate, were comparable with three doses for the treatment of AOM.

Optimal intervention intensity

Empirical evidence exists for many of the different interventions in speech-language pathology. However, relatively little is known about the optimal intensity of those interventions. In order for speech-language pathology services to be both effective and efficient speech-language pathologists need to know how to faithfully administer ideal doses of the active ingredients of interventions, in what forms, how often and for how long. This is the lead paper to a scientific forum on this fundamental yet under-studied issue of clinical practice. Borrowing from the work of Warren, Fey, and Yoder, the concept of intervention intensity is described. Issues involved in establishing the optimal intensity of interventions are identified, including what and how intervention goals are targeted. Given that speech-language pathology interventions can involve the delivery of therapeutic inputs (e.g., conversational recasts, questions) and/or clients carrying out an act (e.g., speech production, voice production, comprehending, naming, swallowing), a framework is proposed for measuring all potential inputs and acts that might contribute to the calculation of an intervention intensity. Client-, clinician-, condition-, and service-related variables that could influence the investigation and practical application of an optimal intervention intensity are also discussed.

Short-course antibiotics for acute otitis media

BACKGROUND

Acute otitis media (AOM) is a common illness during childhood, for which antibiotics are frequently prescribed.

OBJECTIVES

To determine the effectiveness of a short course of antibiotics (less than seven days) in comparison to a long course of antibiotics (seven days or greater) for the treatment of AOM in children.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2009, issue 4) which contains the Acute Respiratory Infections Group's Specialised Register, MEDLINE, EMBASE, MEDLINE In-Process & Other Non-Indexed Citations, CINAHL, BIOSIS Previews, OCLC Papers First and Proceedings First, Proquest Dissertations and Theses (inception to November 2009); International Pharmaceutical Abstracts, the NLM Gateway, ClinicalTrials.gov and Current Controlled Trials (inception to August 2008).

SELECTION CRITERIA

Trials were included if they met the following criteria: participants aged one month to 18 years; clinical diagnosis of ear infection; no previous antimicrobial therapy; and randomisation to treatment with less than seven days versus seven days or more of antibiotics.

DATA COLLECTION AND ANALYSIS

The primary outcome of treatment failure was defined as the absence of clinical resolution, relapse or recurrence of AOM during one month following initiation of therapy. Treatment outcomes were extracted from individual studies and combined in the form of a summary odds ratio (OR). A summary OR of 1.0 indicates that the treatment failure rate following less than seven days of antibiotic treatment was similar to the failure rate following seven days or more of treatment.

MAIN RESULTS

This update included 49 trials containing 12,045 participants. Risk of treatment failure was higher with short courses of antibiotics (OR 1.34, 95% CI 1.15 to 1.55) at one month after initiation of therapy (21% failure with short-course treatment and 18% with long-course; absolute difference of 3% between groups). There were no differences found when examining treatment with ceftriaxone for less than seven days (30% failure in those receiving ceftriaxone and 27% in short-acting antibiotics administered for seven days or more) or azithromycin for less than seven days (18% failure in both those receiving azithromycin and short-acting antibiotics administered for seven days or more) with respect to risk of treatment failure at one month or less. Significant reductions in gastrointestinal adverse events were observed for treatment with short-acting antibiotics and azithromycin.

AUTHORS' CONCLUSIONS

Clinicians need to evaluate whether the minimal short-term benefit from longer treatment of antibiotics is worth exposing children to a longer course of antibiotics.

Once or twice daily versus three times daily amoxicillin with or without clavulanate for the treatment of acute otitis media

BACKGROUND

Acute otitis media (AOM) is a common problem in children, for which the antibiotic amoxicillin, with or without clavulanate, is frequently prescribed.

OBJECTIVES

To compare the effectiveness of one or two daily doses with three or four daily doses of amoxicillin, with or without clavulanate, for the treatment of AOM in children.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2008, issue 1), which contains the Acute Respiratory Infections (ARI) Group's Specialized Register; MEDLINE (January 1950 to March 2008); EMBASE (1974 to March 2008); the Science Citation Index (2001 to March 2008); and NLM Gateway (HSRProj) (March 2008).

SELECTION CRITERIA

We included studies if they met the following criteria: randomized controlled trials (RCTs) of children aged 12 years or younger with AOM, diagnosed by the following explicit criteria: acute ear pain (otalgia) and inflamed ear drum (confirmed by positive tympanocentesis or tympanogram of type B or C).

DATA COLLECTION AND ANALYSIS

We extracted data on treatment outcomes from individual trials. We assessed quality based on selection bias, performance bias, attrition bias and sample size calculation. The quality grading was defined as low risk of bias, moderate risk of bias or high risk of bias. The results were summarized as risk ratio (RR) and 95% confidence intervals (CI).

MAIN RESULTS

We included six studies with 1601 children in the review. Although the clinical cure rates at the end of therapy and at the follow-up periods of each study were shown to be comparable between the two groups, we did not perform pooled data analysis because of moderate to high risk of biases in the included studies. Most of the children were aged 2 months to 12 years. None of the studies had any consistently significant results either for benefit or harm. The outcomes were assessed at the end of therapy (often 10 days) and this may have been too late to measure any differences.

AUTHORS' CONCLUSIONS

This review showed insufficient evidence to judge whether once or twice daily doses of amoxicillin, with or without clavulanate, were comparable with three or four daily doses for the treatment of AOM. The evidence appears to be biased and therefore no firm conclusions can be drawn.

Comparison of study designs for acute otitis media trials

BACKGROUND

A framework for evaluating the efficacy of antibiotics in development as well as those currently approved for acute otitis media (AOM) is needed.

OBJECTIVE

Review strengths and limitations of various antibiotic trial designs and their outcome measures.

METHODS

A review of 157 published trials involving 36,710 subjects for the treatment of AOM.

RESULTS

AOM trials have three designs: (1) clinical, clinical diagnosis and assessment of outcomes; (2) single tympanocentesis, microbiologic diagnosis (by middle ear fluid culture) and clinical assessment of outcomes; and (3) double tympanocentesis, microbiologic diagnosis and microbiologic outcome assessment. Identifiable strengths and limitations of each design are reviewed. Case definitions for entry of children in trials of AOM vary widely. The lack of stringent diagnostic criteria in a clinical design allows for inclusion of a significant proportion of children with a non-bacterial etiology (i.e., viral AOM or otitis media with effusion). Tympanocentesis increases diagnostic accuracy at study entry; however, the procedure is confounding because of its potentially therapeutic benefit and the procedure is not performed in a uniform manner. A second tympanocentesis allows a high sensitivity to detect microbiologic eradication, but it does not correlate with clinical outcomes in half of the cases. The timing of outcome assessment also varies widely among trials.

CONCLUSIONS

Improved clinical diagnosis criteria for AOM are needed to enhance specificity; emphasis on a bulging tympanic membrane has the best evidence base. Tympanocentesis within study designs has merits. At study entry it assures diagnostic accuracy but may alter outcomes and it is useful to document microbiologic outcomes but lacks specificity for clinical outcomes. For all designs, test of cure assessment 2-7 days after completion of therapy seems most appropriate.

Acute otitis media in children

Acute otitis media (AOM) is the most common reason parents bring children into the primary care physician's office. It is diagnosed by clinical symptoms of otalgia and often fever and irritability and by clinical otoscopy. Organisms common to the nasopharynx usually cause AOM. Many episodes of AOM resolve spontaneously. Because it is uncertain how many and which children will resolve without therapy, it is reasonable to treat all children with AOM with antibiotics. The first choice of antibiotics is amoxicillin. Other choices rest on a variety of factors.

An evidence-based approach to treating otitis media

More than 20 years ago, a shrewd clinician remarked, "There is little evidence that those antimicrobial agents which hypothetically or in vitro are more effective ... are superior in the treatment of otitis when compared to penicillin alone." Several hundred clinical trials later, the advantages of broad spectrum drugs remain unproved, and questions remains as to whether antibiotics are required for most episodes of AOM. Further, antibiotics have been demoted to the status of optional therapy for OME. This situation is unlikely to change as new studies with new antibiotics proliferate. What is clear, however, is that accelerated patterns of bacterial resistance mandate an evidence-based approach to managing otitis media. Bacteria have an uncanny ability to learn new mechanisms of antibiotic resistance. A large part of bacterial "education" has undoubtedly been fueled by antibiotic prescriptions from well-intentioned physicians, with unrealistic expectations of drug efficacy. A judicious approach to antibiotic treatment of otitis media can result only from knowing the spontaneous course of the disorder and incremental effect of antibiotics on clinical outcomes. In this article, a series of unifying concepts are developed to help practicing clinicians with an evidence-based approach to managing otitis media. Critical review of the published evidence suggests that the most favorable outcomes from medical treatment will occur if practitioners: appreciate the favorable natural history of untreated otitis media realize that OME may take months to resolve following a single AOM episode modify risk factors to improve the odds of spontaneous resolution use pneumatic otoscopy and confirmatory tympanometry to diagnose OME recognize the limited impact of antibiotic therapy on treatment and prevention balance the benefits of antibiotics against the risk of accelerated bacterial resistance avoid repetitive, prolonged, or prophylactic antibiotic treatment of chronic OME avoid ineffective therapy, such as antihistamine/decongestant preparations An important aspect of management is helping caregivers understand the natural history of otitis media and the impact of medical treatment on shortterm and long-term outcomes. Realistic expectations on the part of all involved parties should facilitate rational decisions about watchful waiting, medical therapy, and the need for surgical intervention.