Weighing the risks and benefits of withholding antiobiotic treatment for acute otitis media.
The American Academy of Pediatrics (AAP) guidelines on acute otitis media (AOM) urge clinicians to instruct parents to weigh the disadvantages and advantages of withholding antibiotics for AOM. Potential costs, or risks, of using fewer antibiotics include extra sick days, hospitalizations for treatment of supurative complications, and monetary costs. Potential benefits include fewer adverse drug events and a slowing of development of antimicrobial resistance. For a parent to favor implementing the AAP guidelines, any adverse outcomes from doing so need to be offset by at least the benefits of using fewer antibiotics. This includes the combined child-, family-, and community-level benefits of decreasing the likelihood of additional resistance.
Using various modeling techniques, a study predicted the difference in AOM outcomes (benefits and costs) using AAP guidelines compared with AOM outcomes using a baseline strategy. Outcomes were antibiotic use, mild and severe adverse events, and antibiotic resistance. Costs were sick days, mastoitiditis hospitalizations, and dollar costs (largely dependent on missed parental work days). For a parental perspective on the value of antibiotic use, investigators also expressed each of these AOM outcomes using a common denominator of quality-adjusted life-days (QALDs), once again comparing outcomes using AAP guidelines and baseline strategy.
The study estimated that for the benefits of the AAP guidelines to at least balance the risks, parents would need to value the benefit of decreased antibiotic resistance resulting from one fewer antibiotic prescription using the AAP guidelines at from ~0.3 to 4 QALDs, depending on the child's age. Put another way, the study suggests a trade-off of ~0.3 to 4 QALDs (7 to 96 hours) to avoid one course of antibiotics (Meropol SB: Pediatrics 2008;121:669).
I am not going to lie; this math problem is over my head. But the point of this article is that recommendations like the OM practice guideline are made with broad public policy/community health considerations in mind. Parents look at these recommendations from a different point of view, asking, "What is the cost and benefit of this recommendation to me, my family, and my child?" You assist your families in making that calculation every day.
DR. BURKE, section editor for Journal Club, is chairman of the department of pediatrics at Saint Agnes Hospital, Baltimore. He is a contributing editor for Contemporary Pediatrics. He has nothing to disclose in regard to affiliations with, or financial interests in, any organization that may have an interest in any part of this article.