Spiro DM, Tay KY, Arnold DH, Dziura JD, et al. Wait-and-see prescription for the treatment of acute otitis media: a randomized controlled trial. JAMA. 2006 Sep 13;296(10):1235-41. PMID: 16968847

 

What we already know: The most common diagnosis for which antibiotics are prescribed in the pediatric population is acute otitis media (AOM). Two previous randomized trials that looked at “wait-and-see prescription” (WASP) antibiotics excluded children with severe AOM, and neither were performed in an emergency department. AOM often resolves on its own, and complication rates are similar whether antibiotics are prescribed or not.

 

Why this study is important: It is important to evaluate the outcomes of optional antibiotics in a disease that frequently resolves spontaneously, especially since antibiotics carry side effects, and antibiotic resistance is growing. Although there have already been trials evaluating WASP outcomes, those were done in office settings, where the parent already had a relationship with the provider, unlike in an ED.

 

Brief overview of the study:

  • RCT
  • Children aged 6 months – 12 years diagnosed with AOM in 1 urban peds ED
    • 283 patients randomized to WASP or “standard prescription” (SP)
  • Objectives:
    • Determine whether treatment of AOM using WASP reduced use of antibiotics compared to SP
    • Evaluate the effects of the intervention on clinical symptoms and adverse antibiotic-related effects
  • 62% of WASP prescriptions were not filled compared to 13% not filled in SP group
  • No difference between groups in frequency of subsequent fever, otalgia, or unscheduled medical visits. No serious adverse events.
  • Rx filling associated with fever and otalgia in both groups

 

Limitations:

  • AOM diagnosis made by attending; may have practice variability.
    • 52 patients diagnosed with AOM were “not enrolled by attending physician discretion” – unclear what that means.
  • The WASP and SP groups were not blinded since parents were aware they were participating in a study about WASP, which may have altered their behavior (consider Hawthorne effect).
  • Outcome data were self reported via phone call.
  • May not be generalizable since limited to a single academic PED.

 

Take home message: Wait-and-see prescription of antibiotics is a safe option for the treatment of acute otitis media in the pediatric population.