Individualized treatment approach urged for AOM

Pichichero M. Pediatr Infect Dis J. 2013;doi:10.1097/INF.0b013e3182862b57.

  • Infectious Diseases in Children, March 2013

More stringent diagnostic criteria of acute otitis media applied by validated otoscopist pediatricians, evidence-based selection of antibiotics may reduce ear tube surgery six-fold and future AOM episodes five-fold, according to study results published online.

Infectious Diseases in Children Editorial Board member Michael E. Pichichero, MD, director of Rochester General Hospital Research Institute at Rochester General Hospital, and colleagues reported data on 254 children who were enrolled in a longitudinal, prospective study conducted from July 2006 to July 2011. Children in the control group were enrolled at aged 6 months and were recruited by co-author Janet R. Casey, MD, from Legacy Pediatrics, a middle-class, suburban sociodemographic pediatric practice in Rochester, N.Y.

Michael Pichichero, MD 

Michael E. Pichichero

The researchers reported data on three groups of children: those who were diagnosed using more stringent criteria for AOM than those advocated by the AAP, had tympanocentesis to identify the infecting bacteria and antibiotic tailored to the pathogen – the group they labeled “individualized care”; community controls, whom the researchers defined as having AOM according to AAP guidelines diagnosed by pediatricians with routine pediatric training and treated according to AAP guidelines; and “Legacy” controls, who “were diagnosed with the same diagnostic criteria by the same physicians as the individualized care group and received the same empiric amoxicillin/clavulanate (80 mg/kg of amoxicillin component) but no tympanocentesis or change in antibiotic.”

The community controls were most likely to have a reoccurrence of AOM (27.3%) vs. 14.4% of those in the Legacy control group. Better diagnostic training and better empiric treatment reduced recurrent AOM nearly in half. Adding tympanocentesis drainage and individualized antibiotic treatment resulted in only 5.9% of children experiencing recurrent AOM.

Therefore, the researchers said that this study shows individualized care consisting of accurate diagnosis by validated otoscopists, use of tympanocentesis and directed antibiotic therapy does result in fewer children becoming classified as otitis prone. Therefore, the reduction in the diagnosis of recurrent AOM resulted in reduced use of antibiotics and tympanostomy surgery.

“We expect there will be those who cannot support changes toward the management paradigm our paper advocates. Our findings strike at the core of inadequate pediatric residency and post graduate training in diagnosis of AOM (a long-held opinion of Drs. Jerry Klein, Sylvan Stool, Phil Kaleida and others),” Pichichero and Casey told Infectious Diseases in Children. “It raises the question whether residents and practicing physicians should be better trained in diagnosis of AOM and become validated otoscopists by having their diagnosis confirmed or refuted by tympanocentesis in a sequence of test patients. It challenges the forthcoming AAP AOM guideline regarding its endorsement of high dose amoxicillin rather than amoxicillin/clavulanate as the best empiric treatment of choice.”

Disclosure: Pichichero and Casey report no relevant financial disclosures.

Michael E. Pichichero, MD, can be reached at Rochester General Health System, 1425 Portland Ave., Rochester, N.Y.  14621.

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