Prescribing Patterns and Retreatment Rates in Patients With Otitis Media

T.I. Shireman and K.A. Kelsey

Clin Drug Invest. 2002;22(5) 

In This Article

Abstract and Introduction

Objective: To explore factors leading to the treatment of acute-onset otitis media (OM) and determine the effect of antibiotic choice on retreatment rates in a paediatric Medicaid population.
Design/setting: A retrospective cohort review of Ohio Medicaid medical and prescription claims.
Patients: The study population included continuously enrolled children 7 years of age or younger with a new onset diagnosis of acute nonsuppurative or suppurative OM during a 3-month period and followed for 30 days post-diagnosis. Claims were screened for the presence of other upper respiratory infections (URI) and chronic OM.
Main outcome measures: Primary outcome measures included antibiotic treatment rates, likelihood of receiving amoxicillin as initial treatment, and retreatment, and were modelled using logistic regression analysis.
Results: Over 75% of the 9177 cases were treated empirically with an antibiotic prescription. The most commonly prescribed antibiotic was amoxicillin. African-American children [confidence interval for adjusted odds (CI) 1.04-1.43], children with a suppurative diagnosis (CI 1.83-2.24), and those with a concurrent URI (CI 1.36-1.86) were more likely to receive an antibiotic. Furthermore, African-American (CI 1.46-1.95) and Hispanic children (CI 1.04-2.18) were more likely to receive amoxicillin. Retreatment rates declined with age (CI 0.89-0.93) and were lower for African-Americans (CI 0.61-0.83) and children who received a sulfa drug (CI 0.64-0.95) or amoxicillin (CI 0.62-0.79).
Conclusion: The decision to use antibiotics in the treatment of OM was primarily influenced by the type of OM diagnosis. Amoxicillin and sulfa drugs were the most effective agents. These results were consistent with and strongly supported the United States national guidelines to avoid empirical antibiotic treatment or to choose narrow-spectrum agents like amoxicillin for initial treatment of acute-onset OM.

Otitis media (OM) is one of the most common diagnoses to be treated with antimicrobials in the paediatric population, accounting for over 25% of the oral antibiotics prescribed annually.[1,2,3] Within the United States, where physicians prescribe antibiotics for the majority of ambulatory visits for OM, antibiotic choices vary widely.[4,5] Provider factors (specialty, practice setting or region) and patient factors (age, race and gender) have been shown to influence antibiotic choice for OM cases.[4,5,6,7,8] Over the last decade, a few newer, broad-spectrum antibiotics have become available, expanding the antibiotic choices for treatment of OM.[9,10] These agents are four to ten times more expensive than amoxicillin,[6] but their added expense is not necessarily indicative of better outcomes.[7,11]

The Drug-Resistant Streptococcus Pneumoniae Therapeutic Working Group established updated United States-based national guidelines for acute otitis media in early 1999 and recommended the use of amoxicillin in children with acute OM who had not received an antibiotic recently.[12] Amoxicillin was still a primary choice for those who had received an antibiotic in the preceding 4 weeks, but the Working Group also included amoxicillin/clavulanic acid or cefuroxime as first-choice alternatives in this situation. Previous national guidelines from the Agency for Health Care Policy and Research (now known as the Agency for Healthcare Research and Quality) for otitis media with effusion recommended avoiding antibiotics altogether or use of narrow-spectrum agents such as amoxicillin, if necessary.[13] In light of the increased availability of a number of new antibiotics between the release dates of these sets of guidelines, updated information on antibiotic prescribing patterns was needed.

The purposes of this study were to explore factors leading to empirical treatment of children with acute-onset OM and antibiotic choice, and to determine the effect of antibiotic choice on short-term retreatment rates in a paediatric Medicaid population. While this analysis was similar to previous reports, we included newer, broad-spectrum agents adopted since those previous studies.[4,5,6,7] Cases studied included acute nonsuppurative and suppurative OM diagnoses, and the analysis controlled for the effect of chronic OM and concurrent upper respiratory tract infections on antibiotic choice and outcomes.