Antimicrobials for acute otitis media? a review from the international primary care network

Increasing worldwide resistance of bacteria to antimicrobial drugs is causing a crisis, manifested by higher morbidity, mortality, and costs.1 In 1992 the Institute of Medicine in the United States warned of the growing threat posed by resistant bacteria,2 and in 1994 the Centers for Disease Control in Atlanta initiated a prevention strategy,3 linked to a global plan by the World Health Organisation.4 Proposed remedies include development of new antimicrobials, improved sanitation, and educating patients not to ask for antimicrobials when they are not useful and physicians to prescribe them conservatively.5 About 30% of British children under the age of 3 visit their general practitioner for acute otitis media each year6 and 97% receive antimicrobials.7 In America it is the most common reason for outpatient antimicrobial use. Because this use has uncertain benefits, it merits reconsideration. Increasing resistance to antimicrobial agents has been reported for the three most common bacterial causes of otitis media ( Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis ), but rates differ between countries.8 9 In England and Wales in 1990-5, resistance to penicillin by S pneumoniae increased from 1.5% to 3.9% and to erythromycin from 2.8% to 8.6%.10 Except in the Netherlands, antimicrobials are standard treatment for acute otitis media in most developed countries.7 11 Although type and duration vary between countries, generally ampicillin, amoxycillin, or co-amoxiclav (amoxycillin-clavulanate) are preferred, with co-trimoxazole a low cost alternative.7 In the Netherlands, treatment of symptoms without antimicrobials has been adopted as routine initial treatment for otitis media,12 and this policy is associated with decreased emergence of resistance among organisms commonly found in otitis media.13 14 This approach also is being adopted in Iceland.15 Seven randomised blinded studies have compared antimicrobials with placebo in patients with acute otitis …