Poor adherence to antibiotic prescribing guidelines in acute otitis media—obstacles, implications, and possible solutions

Abstract

Many countries now have guidelines on the clinical management of acute otitis media. In almost all, the public health goal of containing acquired resistance in bacteria through reduced antibiotic prescribing is the main aim and basis for recommendations. Despite some partial short-term successes, clinical activity databases and opinion surveys suggest that such restrictive guidelines are not followed closely, so this aim is not achieved. Radical new solutions are needed to tackle irrationalities in healthcare systems which set the short-term physician–patient relationship against long-term public health. Resolving this opposition will require comprehensive policy appraisal and co-ordinated actions at many levels, not just dissemination of evidence and promotion of guidelines. The inappropriate clinical rationales that underpin non-compliance with guidelines can be questioned by evidence, but also need specific developments promoting alternative solutions, within a framework of whole-system thinking. Promising developments would be (a) physician training modules on age-appropriate analgesia and on detection plus referral of rare complications like mastoiditis, and (b) vaccination against the most common and serious bacterial pathogens.

Acute mastoiditis in children in Sweden 1993–2007—No increase after new guidelines

“…Bearing in mind the lack of increase in the incidence of AM, this may indicate previous overdiagnosis and overtreatment of AOM. Declining consumption of antibiotics and patients consultations in cases of suspected AOM have also been reported from other countries together with poor compliance with guidelines for treating AOM [24][25][26].…”

Antibiotic use in infants in the first year of life in five European countries

“…However, studies reviewed by Haggard et al. (30) have shown that the adherence of physicians to these guidelines is poor in Europe. In the Netherlands, OM is primarily treated by general practitioners, who have their own guidelines for the treatment with antibiotics; the Dutch guideline recommends prescribing antibiotics in selected cases of OM, that is, those at risk of complications.…”

Oral antibiotics confer small benefits and small harms in low-risk children with acute otitis media

“…Antibiotics also have known harms and antibiotic resistance is increasing worldwide. Therefore, ‘watchful waiting’ or ‘expectant observation’ is either recommended or considered reasonable in guidelines for the management of uncomplicated AOM in children aged over 2 years in Australia,1 Canada,2 France,2 Germany,2 Scotland,2 Spain,2 the Netherlands,2 UK2 and the USA 3…”