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National Trends in Emergency Department

Antibiotic Prescribing for Children with Acute

Otitis Media, 19962005
Thomas Fischer, MD, Adam J. Singer, MD, Christopher Lee, MD, Henry C. Thode Jr., PhD

Objectives: Withholding antibiotics in nontoxic children with acute otitis media (AOM) is now recommen-
ded to reduce bacterial resistance rates. Using the National Hospital Ambulatory Medical Care Survey
(NHAMCS), the authors describe the national trends for prescribing antibiotics in children with AOM pre-
senting to emergency departments (EDs) in the United States over the past decade. The authors hypothe-
sized that the rates of prescribing antibiotics would decline over time.
Methods: This was a retrospective study of NHAMCS databases. A national sampling of ED visits for 1996
2005 was used to identify trends in ED prescription of antibiotics to patients with AOM. The National Drug
Code Directory Drug Classes were used to identify type of antibiotic prescribed. Frequency and type of
antibiotic prescription patterns over time were evaluated.
Results: There were 2.6 million and 2.1 million ED visits for AOM during the first and last years of the
study. Children ages 212 years accounted for about 40% of all ED visits for AOM, with another 40% in
the younger than 2 years age group and 20% in the older than 12 years of age group. During the first
and last year of the study, 79.2% and 91.3% of the patients with AOM were prescribed antibiotics, respec-
tively. There was a slight increasing trend in the proportion prescribed antibiotics over time (p = 0.02). The
rates of use of antibiotics for AOM were similar in all three age groups.
Conclusions: There was a slight increase in the percentage of children with AOM who were prescribed
antibiotics in the ED between 1996 and 2005. There was also no change in the patterns of prescribing
ACADEMIC EMERGENCY MEDICINE 2007; 14:11721175 2007 by the Society for Academic Emergency
Keywords: acute otitis media, antibiotics, selective, prescriptions

he most common diagnosis for which antibiotics to those patients who fail to improve at the end of the ob-
are prescribed for children in the United States servation period or whose condition worsens during the
remains acute otitis media (AOM).1,2 At least 15 observation period. As a result of this policy, the percent-
million prescriptions for antibiotics are written every age of patients given antibiotics for AOM in The Nether-
year.3 AOM, however, is a disease with a high rate of lands is approximately 31%.8
spontaneous resolution.47 For more than 20 years, phy- Excessive and inappropriate use of antibiotics has
sicians in The Netherlands have used a treatment strat- been linked to a rising prevalence of penicillin-resistant
egy for selected patients with AOM that withholds Streptococcus pneumoniae.8 Rates of penicillin-resistant
antibiotics for an initial observation period of two to S. pneumoniae increased from 27.5% in 1995 to 43.8% in
three days, during which time treatment is restricted to 1997.9 In contrast, in The Netherlands, the rate of penicillin
analgesics and antipyretics. Antibiotics are only given resistance to S. pneumoniae still remains less than 1%.10,11
Although historically the standard of care for the treat-
ment of AOM in the United States has been to administer
From the Department of Emergency Medicine, Stony Brook Uni- antibiotics for all cases, concern over the rising rates of
versity Medical Center (TF, AJS, CL, HCT), Stony Brook, NY. bacterial resistance and the success of the Dutch experi-
Received May 1, 2007; revision received June 26, 2007; accepted ence with initial antibiotic withholding has led to a shift
July 9, 2007. in the treatment paradigm for AOM. In the late 1990s,
Presented at the SAEM NY Regional Conference, New York, NY, the New York State Department of Health assembled a
March 28, 2007. committee of physicians whose purpose was to formu-
Contact for correspondence and reprints: Adam J. Singer, MD; late a more judicious approach to the use of antibiotics
e-mail: for AOM. The culmination of the committees work was

ISSN 1069-6563 2007 by the Society for Academic Emergency Medicine

1172 PII ISSN 1069-6563583 doi: 10.1197/j.aem.2007.07.011
ACAD EMERG MED  December 2007, Vol. 14, No. 12 1173

a treatment strategy called the observation option that calculate national estimates of number of ED visits. An-
was based closely on the Dutch model.12 The observation tibiotic use was determined within age groups for the
option has been endorsed by the American Academy of pediatric population (younger than 2 years, 212 years,
Pediatrics (AAP) and the American Academy of Family 1317 years) and the adult population (18+ years of
Physicians (AAFP) and can be found on their Web sites.13 age) for comparative purposes. We calculated the age-
We hypothesized that, given the changes in treatment specific percentages of AOM visits resulting in a pre-
strategies for AOM, we would see a gradual decline in scribed antibiotic overall and stratified by gender,
antibiotic prescribing for cases of AOM seen in the emer- race, and geographic region. Estimates included the
gency department (ED). Antibiotic prescribing patterns number of visits and the percentage of visits with anti-
for AOM have been analyzed before, but to our knowl- biotics. Confidence intervals (CIs) were calculated for
edge, this is the first study to analyze antibiotic prescrib- percentages using standard errors, which were esti-
ing patterns for AOM in patients presenting to the ED. mated using the methods described by NHAMCS sur-
vey documentation. Trends were computed across all
METHODS years using weighted linear regression to account for
the sampling scheme used in the NHAMCS survey;
Study Design weights were the inverse of the variance estimates cal-
We analyzed the ED component of the 19962005 Na- culated from the standard errors. Analyses were per-
tional Hospital Ambulatory Medical Care Survey formed using SPSS for Windows 13.0 (SPSS Inc.,
(NHAMCS).14 The study was ruled exempt from in- Chicago, IL).
formed consent by our institutional review board. Although the 2005 NHAMCS data were accessible at
the time of this writing, the documentation necessary to
Study Setting and Population calculate standards errors and weights used in analyses
Briefly, NHAMCS encompasses a national probability was not available, so data from 2005 were only partially
sample of visits to U.S. hospital emergency and outpa- included in these analyses. Results for 2005 that did not
tient departments by the Division of Health Care Statis- require testing or CIs are presented here.
tics of the National Center for Health Statistics, Centers
for Disease Control and Prevention; only the ED data
were used in these analyses. The survey uses a four-stage
sampling design, covering geographic primary sampling
units, hospitals with EDs within primary sampling units, There were 2.6 million and 2.1 million ED visits for AOM
emergency service areas within EDs, and patient visits during the first (1996) and last (2005) years of the study.
within emergency service areas. Patient visits are re- Children aged 212 years accounted for approximately
corded using a systematic random sample selected over 40% of all ED visits for AOM during our study period,
a randomly assigned four-week reporting period. with another 40% in the younger than 2 years age group;
5% of all ED visits for AOM were in the age group 1317
Study Protocol years, and 15% were adults. The age distribution of
Visit sampling and data collection were recorded on patients with AOM was similar across years during
patient record forms by hospital staff or by field represen- the ten-year period (Figure 1).
tatives from the U.S. Census Bureau. Data collection During the first and the next to last (2004) years of the
methods do not indicate that data recording by hospital study, 79.2% (95% CI = 74.9 to 83.5) and 85.7% (95% CI =
staff was performed prospectively; data recording by 81.8 to 89.6) of all pediatric patients (younger than 18
field representatives was performed as a medical chart re- years) with AOM were prescribed antibiotics, respec-
view. Therefore, this study should be considered (conser- tively. There was a slight increasing trend in the propor-
vatively) as a retrospective chart review. Data processing tion of pediatric patients prescribed antibiotics over time
and coding were performed by an external source. (p = 0.02; Figure 2); in 2005, the percent of pediatric pa-
We identified an AOM case if it had International Clas- tients receiving antibiotics was consistent with this trend,
sification of Diseases, Ninth Revision, Clinical Modifica- because 91.3% received antibiotics. The rates of use of
tion (ICD-9-CM) code 382.9 in the primary diagnosis antibiotics for AOM were similar in patients younger
field. Over the ten annual surveys, between six (1996 than 2 years, 212 years, and older than 12 years; most
2002) and eight (20032005) medications were recorded age-year specific rates were between 79% and 89% in
per encounter; all recorded medications were considered the pediatric age groups over the study period. Patients
in the analyses. Up to three National Drug Class codes older than 18 years generally were prescribed antibiotics
were provided for each medication.15 Antibiotic use at a rate about ten percentage points lower than that of
was identified on the basis of any of the following drug pediatric patients (Figure 3). There was no change in an-
class codes: penicillins, cephalosporins, lincosamids or tibiotic use by patient gender, race, or geographic region
macrolides, polymyxins, tetracyclines, chloramphenicol in pediatric patients across years.
or derivatives, aminoglycosides, sulfonamides or related Types of antibiotics prescribed were similar for each
compounds, antibacterials miscellaneous, or quinolones year over the study period. Approximately two thirds
or derivatives. of patients received prescriptions for penicillins, another
15% received prescriptions for erythromycins, and 12%
Data Analysis received prescriptions for cephalosporins. Some patients
Population visits and visit rates were computed by were prescribed more than one antibiotic (e.g., amoxicil-
using the population weights used by NHAMCS to lin and amoxicillin clavulanate).

Figure 3. Percent of patients within age group receiving

antibiotics in 2004. (Color version of this gure available on-
line at

no such endorsement to date. Furthermore, many physi-

cians may not have been familiar with the observation
option during the study period, because it was only en-
Figure 1. Age distribution of ED patients with acute otitis dorsed by the AAP and the AAFP in 2004, toward the
media by year, 19962005. (Color version of this gure avail- end of the study period. While the observation option
able online at recommended by the AAP is only for children ages 6
months to 2 years with an uncertain diagnosis, the obser-
vation option should be considered even for nonsevere
DISCUSSION certain cases of AOM in children aged 2 years or older.
Another possible explanation for our failure to show a
The results of the current study clearly demonstrate that
decline in antibiotic prescribing rates is that even if emer-
the majority of patients presenting to the ED with AOM
gency physicians are aware of the observation option as
are prescribed antibiotics, regardless of age. Further-
a treatment strategy, they may not believe it is an appro-
more, there has been a slight increase in the proportion
priate strategy for the ED setting. A critical element of
of patients with AOM who are prescribed antibiotics.
the observation option is that close follow-up must be en-
The study also demonstrates that most patients with
sured so that intervention with antibiotic therapy can be
AOM are prescribed a penicillin. The obvious question
initiated in the event that the patients condition worsens
is this: why has there been no decline in the ED antibiotic
or fails to improve at the end of the observation period.
prescribing rates for AOM over the ten years of our
Herein lies a caveat that is of unique concern to the emer-
study period? Several possibilities seem likely.
gency physician. Doubts regarding patient follow-up in
Despite the fact that the concept of initial withholding
general often lead to more cautious diagnostic and ther-
of antibiotics for AOM is a legitimate treatment strategy,
apeutic plans of action than would otherwise be followed
it is unknown how widely accepted this concept is within
in a different setting. Furthermore, it is possible that a
the emergency medicine community. As previously men-
patient with AOM presenting to the ED represents a
tioned, the observation option has been officially en-
more severe form of the disease than one who presents
dorsed by the AAP and the AAFP. However, the
in the primary care setting, thereby making initial obser-
American College of Emergency Physicians has made
vation a less attractive option for the emergency physi-
cian. Therefore, one must fairly ask the question: is
there any evidence that initial observation without pre-
scribing antibiotics is a safe and effective treatment strat-
egy in the ED setting? In fact, there are two recent
studies addressing this very question.
Spiro et al. studied children with AOM aged 6 months to
12 years who presented to the ED and found that 62%
of these patients recovered uneventfully without requir-
ing antibiotics.16 In addition, Spiro et al. observed no inci-
dence of suppurative complications (i.e., mastoiditis or
meningitis) in those patients not given antibiotics and
found overwhelming parental cooperation with this strat-
egy of initially withholding antibiotics.16 We have also
conducted a small observational study in which a conve-
Figure 2. Percentage of pediatric (younger than 18 years) nience sample of 144 children aged 217 years with AOM
patients with acute otitis media who received antibiotics presenting to our ED were treated with analgesics and
in the ED by year, 19962005. (Color version of this gure given a prescription for antibiotics. The parents were
available online at instructed not to fill the prescription for 4872 hours unless
ACAD EMERG MED  December 2007, Vol. 14, No. 12 1175

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A significant limitation of our study was that the docu-
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