Diagnosis and Treatment of Acute Otitis Media: an Assessment

Objective: To assess compliance with the Centers for Disease Control and Prevention (CDC) evidence-based guidelines for the judicious use of antimicrobials in children with acute otitis media (AOM).

Methods: Compliance with CDC's recommended diagnostic criteria and antimicrobial treatments for management of AOM was assessed by chart review and self-report for 29 community pediatricians in St. Louis, Missouri. For each physician, a simple random sample of AOM visits was selected and reviewed by trained reviewers. In addition, each physician completed a questionnaire.

Results: Compliance with recommended diagnostic criteria was 38% (95% confidence interval: 34%-42%; n = 573) by chart audit and 41% (95% confidence interval: 24%-61%; n = 29) by self-report. Antimicrobial selection assessed by chart audit was consistent with CDC guidelines in 68% (95% confidence interval: 64%-72%) of visits for a new infection, 63% (95% confidence interval: 47%-78%) of visits for treatment failure, and 50% (95% confidence interval: 33%-67%) for recurrent disease. Self-reported compliance with treatment guidelines for new infection was 100% (95% confidence interval: 88%-100%) and 83% (95% confidence interval: 64%-94%) for treatment failure. Noncompliance was most frequently attributable to overuse of broad-spectrum antimicrobials. Most patients treated with amoxicillin received a 10-day course (98%). Subtherapeutic dosing occurred in 26% of patients treated with amoxicillin.

Conclusions: Overdiagnosis of AOM is common. Efforts to improve the judicious use of antimicrobials for AOM should focus on improving diagnostic accuracy, limiting the use of broad-spectrum antimicrobials to cases where they offer clinical benefit, and ensuring that amoxicillin dosing regimens are optimal.