Family Practice Vol. 20, No. 4, 417-419
© Oxford University Press 2003
Clinical Research |
Acute otitis media—a brief explanation to parents and antibiotic use
Family Medicine Department, Sial Research Center for Family Medicine and Primary Care, Division of Community Health, Ben-Gurion University of the Negev, Clalit Health Services, 84105 Beer-Sheva, Israel.
Correspondence to Dr Yacob Pshetizky; E-mail: family{at}bgumail.bgu.ac.il
Pshetizky Y, Naimer S and Shvartzman P. Acute otitis media—a brief explanation to parents and antibiotic use. Family Practice 2003; 20: 417–419.
 |
Abstract |
|---|
 Top Abstract IntroductionMethodsResultsDiscussionConclusionReferences |
|---|
Background. Acute otitis media (AOM) is a common self-limiting disease in children. Antibiotic use is controversial. Physicians in the USA and in Israel prescribe antibiotics almost universally, while physicians in other countries report good outcome without any treatment. Parents’ expectation is an important factor influencing a physician’s decision to prescribe antibiotics.
Objectives. Our aim was to assess whether a brief explanation to parents regarding the self-limited nature of AOM and the controversy regarding antibiotic prescription for the disease will influence the parents’ decision regarding antibiotics use.
Methods. Parents of the children participating in the study in two primary care clinics belonging to HMO–Clalit Health Services (CHS) in the southern district of Israel were randomly assigned to an intervention (44) and control (37) group. The intervention group received the brief explanation. The two groups received prescription for antibiotics. The subjects comprised 81 children aged 3 months to 4 years visiting the family practice clinics and diagnosed with AOM. The rate of antibiotics purchase, using the prescription given and the factors influencing the decision were evaluated.
Results. Fewer parents administered antibiotics to their children in the intervention group compared with the control group (37% versus 63%, respectively, P < 0.0001). Mother’s education level was the only factor found to be significantly lower in the group that eventually purchased antibiotics (P < 0.05).
Conclusions. In children with AOM, a brief explanation by the family physician to the child’s parents about the disease and the expected spontaneous recovery could decrease antibiotic use by 
50%.
Keywords. Acute otitis media, antibiotics, children, intervention, treatment.
|
Introduction |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionConclusionReferences |
|---|
Acute otitis media (AOM) is common in children between the ages of 6 and 36 months. Symptoms consist mainly of otalgia, fever, irritability, anorexia and diarrhoea.1 It is usually a self-limiting disease; complications are rare, and antibiotics are usually not necessary, unless the course is irregular.2,3 Amoxicillin, trimethoprim plus sulfamethoxazole, or erythromycin plus sulfasoxazole are the first-choice antibiotics for AOM. Early treatment with antibiotics might reduce the severity of pain, but the majority of children feel better within 24 h, regardless of antibiotic treatment.4,5 The efficacy of antibiotics remains controversial.3
Patient and parent expectations have a major influence on the doctor’s decision to prescribe antibiotics. Most patients with respiratory tract symptoms believe that the illness is caused by infection, and that antibiotic treatment is needed.6 This inadvertently influences antibiotic dispensing, and sharing the uncertainty about prescribing antibiotics may reduce their use.7
The aim of this study was to assess whether a brief explanation to parents regarding the self-limited nature of AOM and the controversy regarding antibiotic prescription will influence the parents’ decision regarding antibiotics use.
|
Methods |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionConclusionReferences |
|---|
An ethics committee approval according to the Declaration of Helsinki was obtained for the study. The study took place during the winter of 1998–1999 in two primary care clinics belonging to ‘Clalit’ Health services in the southern district of Israel. Consecutive children aged 3 months to 4 years diagnosed with AOM [high fever (>38°C), purulent ear discharge, or opacity or bulging of the eardrum] were enrolled in the study and randomized to one of two groups.
The randomization process included pre-prepared closed envelopes assigning each child to the different groups. One group received a prescription for antibiotics as part of the routine care, without a patient education component. The second group received a structured explanation and a prescription for antibiotics to be used if symptoms did not improve within 48 h.
The explanation was short and included the following points: (i) AOM is part of an upper respiratory tract infection; (ii) it has been well established that in most cases children will recover regardless of antibiotic prescription; (iii) dangerous late complications from AOM unfortunately may occur regardless of whether antibiotics were or were not delivered in the course of the acute illness; and (iv) parents were recommended in cases of high fever or severe pain to administer paracetamol prescribed according to the child’s weight.
Children exhibiting a toxic child appearance, a temperature of 
39.5°C, extreme restlessness/irritability or vomiting, or where there was uncertainty of the diagnosis were excluded from the study.
At the initial visit, all parents received a prescription for antibiotics to be administered (amoxicillin or trimethoprim sulfamethoxazole, for 7 days) if there was no improvement or a worsening in the child’s condition over the next 24–48 h. It was the parents’ decision whether to use the prescription or not. All parents participating in the study had previous acquaintance with their family physician and were able to contact him at any time.
One week after the visit, the parents were contacted and interviewed by phone using a structured questionnaire by a blinded interviewer.
|
Results |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionConclusionReferences |
|---|
The study population included 44 children whose parents received an explanation and 37 who did not. No significant differences were found between the socio-demographic variables of the children and parents in both groups.
Among the group of parents that received a structured explanation regarding the benefits and disadvantages of antibiotics treatment, significantly fewer parents (37%) administered antibiotics to their children compared with the group of parents that received the routine care (63%) (P < 0.0001). In the group of parents that received no explanation, most of the children received the antibiotics on the first day (77%, P < 0.0001) (Table 1
).
|
Only the mother’s education level was found to be significantly associated with the decision to administer antibiotics (P < 0.05). None of the other variables evaluated (parent’s age, gender, past experience with AOM, previous illness and expectation from the visit) were found to be significant. This might be due to the small group size (44).
|
Discussion |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionConclusionReferences |
|---|
In this study, two homogenous groups of children, in terms of age, gender, past AOM and parents’ education, were evaluated for the effect of a short explanation in one group regarding the benefits and disadvantages of antibiotic treatment. The main finding of our study is that in the group of parents that received an explanation, only 37% of children were treated with antibiotics versus the group of parents that did not receive an explanation, where 63% of children were treated with antibiotics (P < 0.0001).
We know that parents are worried when their child presents with an acute febrile illness and fear the possibility of a serious disease such as meningitis.8 We are also aware of the fact that most parents of children with upper respiratory tract illnesses are interested in antibiotic treatment.9 Some recent data suggest that the receipt of antibiotics for a respiratory infection is not in itself associated with increased patient satisfaction. This suggests that patients do believe in the effectiveness of antibiotics for specific illnesses.6,7 It has also been found that most patients expect and desire prescription of antibiotic medication.10 On the other hand, we realize that AOM is a disease that in most cases will clear up without intervention. Any dire consequences of these infections are unrelated to the treatment policy adopted early in the course of the disease.3 In this study, we have shown that a brief explanation to the parents about the possibility of self-cure without antibiotics, although time consuming, is time well spent. An explanation regarding pain treatment and fever helps to alleviate anxiety and significantly decreases the use of antibiotics. Both groups of patients were similar in both socio-demographic and illness characteristics.
Since this observation is based on only two practices, questions regarding generalizability could be raised, although it is well known anecdotally that there are countries such as The Netherlands that do not prescribe antibiotics for AOM as first-line treatment.3
|
Conclusion |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionConclusionReferences |
|---|
In children with AOM, a brief explanation by the family physician to the child’s parents about the disease and its expected spontaneous recovery could significantly decrease antibiotic use by
50%.
|
Acknowledgments |
|---|
We wish to thank Dr Selma Weinstoke for her assistance in the data collection stage.
|
References |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionConclusionReferences |
|---|
1 Del Mar C, Glasziou P, Hayem M. Are antibiotics indicated as initial treatment for children with acute otitis media? Br Med J 1997; 314: 1526–1529.
2 Little P, Gould C, Williamson I, Moore M, Warner G, Dunleavey J. Pragmatic randomized controlled trial of two prescribing strategies for childhood acute otitis media. Br Med J 2001; 322: 336–342.
3 Froom J, Culpepper L, Grob P et al. Diagnosis and antibiotic treatment of acute otitis media: report from International Primary Care Network. Br Med J 1990; 300: 582–586.[ISI][Medline]
4 Lagace E. Antibiotic treatment for AOM [letter]. J Fam Pract 1997; 45: 202–203.[Medline]
5 Little P, Gould C, Moore M, Warner G, Dunleavey J, Williamson I. Predictors of poor outcome and benefits from antibiotics in children with acute otitis media: pragmatic randomized trial. Br Med J 2002; 325: 22–27.
6 Mainous AG III, Zoorob RJ, Oler MJ, Haynes DM. Patient knowledge of upper respiratory infections: implications for antibiotic expectations and unnecessary utilization. J Fam Pract 1997; 45: 75–83.[ISI][Medline]
7 Macfarlane J, Holmes W, Gard P, Thornhill D, Macfralane R, Hubbard R. Reducing antibiotic use for acute bronchitis in primary care: blinded, randomized controlled trial of patient information leaflet. Br Med J 2002; 324: 91.
8 Kai J. What worries parents when their preschool children are acutely ill, and why: a qualitative study. Br Med J 1996; 313: 983–986.
9 Hamm RM, Hicks RJ, Bemben DA. Antibiotics and respiratory infections: are patients more satisfied when expectations are met? J Fam Pract 1996; 43: 56–62.[ISI][Medline]
10 Macfarlane J, Holmes W, Macfarlane R, Britten N. Influence of patients’ expectations on antibiotic management of acute lower respiratory tract illness in general practice: questionnaire study. Br Med J 1997; 315: 1211–1214.
CiteULike 
Connotea 
Del.icio.us What's this?
This article has been cited by other articles:
|
|
 |
|
  D. Merenstein, M. Diener-West, A. Krist, M. Pinneger, and L. A. Cooper An Assessment of the Shared-Decision Model in Parents of Children With Acute Otitis Media Pediatrics, December 1, 2005; 116(6): 1267 - 1275. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 Other articles noted: 25 Jul 03 to 7 Nov 03 Evid. Based Nurs., January 1, 2004; 7(1): e1 - 1. [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||