University of Michigan
Department of Pediatrics
Evidence-Based Pediatrics Web Site

Question

• Does watchful waiting versus immediate treatment with antibiotics in AOM reduce antibiotic resistance by decreasing overall amount of antibiotics taken without compromising patient care?

Clinical Bottom Lines

1. When patients with nonsevere acute otitis media were given symptomatic treatment and parents were told to return if their symptoms got worse, there was an overall reduction in amount of antibiotic prescriptions filled and a reduction in antibiotic resistance when compared to patients given immediate antibiotic prescriptions at diagnosis.
2. Parent satisfaction between the two groups was not statistically different.
3. There were no adverse outcomes documented with the watchful waiting group.

Summary of Key Evidence

1. 223 Subjects were enrolled: 73% were nonwhite, 57% were <2yr old, 47% attended day care, 82% had prior AOM.  112 were randomized to the immediate antibiotic group and 111 were randomized to the watchful waiting group.  94% were followed through the 30 day end point.¹
2. Parent satisfaction with AOM care was not different between the 2 treatment groups at either day 12 or day 30.
3. Compared to the WW group, symptom scores on days 1 to 10 resolved faster in subjects treated with immediate antibiotics.  Parents in the immediate antibiotic group gave their children fewer doses of pain medication than patients in the WW group.
4. Patients in the antibiotic group experienced 16% fewer failures than subjects in the WW group.
5. 66% of patients in the WW group completed the study without antibiotics.
6. Although a majority of the children in the antibiotic group had eradication of S pneumoniae initially, on day 12, cultures were more likely to be multi-drug resistant than strains from children in the WW group.
7. More antibiotic-related adverse events were noted in the antibiotic group compared with the WW group.  No serious AOM-related adverse events were observed in either group.
8. Office and ED visits, phone calls, and days of work/school missed were not different between groups.
9. Prescriptions for antibiotics were reduced by 73% in the WW group compared with the antibiotic group.

Additional Comments

• Parent satisfaction and reporting of symptoms may have been influenced by personal beliefs and preconceptions about the advantages and disadvantages of abx treatment.
• Although physicians accept the idea of watchful waiting, they perceive a barrier to its implementation is parental reluctance, however, this has been shown in this study and other studies to not be the case.

Citation

1. McCormicj DP, Chonmaitree T, Pittman C, Saeed K, Friedman NR, Uchida T, Baldwin CD. Nonsevere Acute Otitis Media: A Clinical Trial Comparing Outcomes of Watchful Waiting Versus Immediate Antibiotic Treatment. Pediatrics 2005;115;1455-65.

CAT Author: Kate Bower, MD

CAT Appraisers: Francis McBee Orzulak, MD

Date appraised: February 13, 2007