Diagnosis and treatment of acute otitis media: An assessment

Objective. To assess compliance with the Centers for Disease Control and Prevention (CDC) evidence-based guidelines for the judicious use of antimicrobials in children with acute otitis media (AOM). Methods. Compliance with CDC's recommended diagnostic criteria and antimicrobial treatments for management of AOM was assessed by chart review and self-report for 29 community pediatricians in St. Louis, Missouri. For each physician, a simple random sample of AOM visits was selected and reviewed by trained reviewers. In addition, each physician completed a questionnaire. Results. Compliance with recommended diagnostic criteria was 38% (95% confidence interval: 34%-42%; n = 573) by chart audit and 41% (95% confidence interval: 24%-61%; n = 29) by self-report. Antimicrobial selection assessed by chart audit was consistent with CDC guidelines in 68% (95% confidence interval: 64%-72%) of visits for a new infection, 63% (95% confidence interval: 47%-78%) of visits for treatment failure, and 50% (95% confidence interval: 33%-67%) for recurrent disease. Self-reported compliance with treatment guidelines for new infection was 100% (95% confidence interval: 88%-100%) and 83% (95% confidence interval: 64%-94%) for treatment failure. Noncompliance was most frequently attributable to overuse of broad-spectrum antimicrobials. Most patients treated with amoxicillin received a 10-day course (98%). Subtherapeutic dosing occurred in 26% of patients treated with amoxicillin. Conclusions. Overdiagnosis of AOM is common. Efforts to improve the judicious use of antimicrobials for AOM should focus on improving diagnostic accuracy, limiting the use of broad-spectrum antimicrobials to cases where they offer clinical benefit, and ensuring that amoxicillin dosing regimens are optimal.