We are witnessing history today. What could be more historic (pediatrically) than a paradigm shift in the management of the infection encountered almost hourly by the pediatrician, otitis media? This shift, and the rationale behind it, is spelled out clearly in the article by Richard Rosenfeld in this month's Pediatric Annals and in his commentary in the November 2004 issue of Pediatrics. J Other excellent articles in this issue, organized by Dr. David Darrow, provide additional insights regarding hearing loss and the draining ear in children.
The big story (and a long awaited and overdue one, in my opinion) is sanction of the option for initial observation without antibiotics of acute otitis media (AOM), particularly in children at least 2 years old with nonsevere symptoms or with an uncertain diagnosis of AOM. It is estimated that about two-thirds of the tonnage of antibiotics prescribed to treat AOM can be avoided; this should result in less antibiotic-related diarrhea, vomiting, rashes, and allergic reactions, including anaphylaxis.
The major benefit to society of this strategy should be to reduce the pressure on our microbial flora to develop antibiotic resistance and to increase the likelihood that when serious bacterial infections occur they are caused by less resistant organisms. This strategy has become official policy in the Netherlands and Sweden, and more recently in the state of New York. It contributes substantially to the very low rates of pneumococcal resistance to beta-lactam agents, for example, in the Netherlands.
The pipeline for the development of new classes of antibiotics is rather slim at this time. The reasons are complex but include the fact that pharmaceutical companies can bring in much more money with a new lipid-lowering agent or antihypertensive. It is a fact that new antimicrobial agents may not be available to deal with some infections, if increasing resistance patterns continue to evolve. Eliminating unnecessary antibiotics for patients with uncomplicated viral illnesses and identifying situations in which there are high rates of spontaneous resolution (as in AOM) should help to reduce somewhat our need for new classes of antimicrobial agents.
Because very few earrelated stamps are available, I instead have selected four stamps with an antiAIDS theme -December 1 being World AIDS Day. Two of the stamps feature very unusual shapes. The triangular and round stamps are from the Ivory Coast (West Africa), from 2003. They portray a symbolic AIDS or HIV under attack, "Ensemble contra le SIDA" or "All against AIDS." The Indonesian stamp and the one from Wallis and Fortuna also exhort people to protect themselves against AIDS.
1. Rosenfeld RM. Otitis, Antibiotics, and the Greater Good. Pediatrics 2004; 114 (5): 1333-1 335.