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Treatment of Acute Otitis Media With a Shortened Course of Antibiotics A Meta-analysis

Anita L. Kozyrskyj, BScPhm, MSc; G. Elske Hildes-Ripstein, MD; Sally E. A. Longstaffe, MD; J. Leigh Wincott, MD; Daniel S. Sitar, BScPhm, PhD; Terry P. Klassen, MD, MSc; Michael E. K. Moffatt, MD, MSc
JAMA. 1998;279(21):1736-1742. doi:10.1001/jama.279.21.1736.
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Objective.— To conduct a meta-analysis of randomized controlled trials of antibiotic treatment of acute otitis media in children to determine whether outcomes were comparable in children treated with antibiotics for less than 7 days or at least 7 days or more.

Data Sources.— MEDLINE (1966-1997), EMBASE (1974-1997), Current Contents, and Science Citation Index searches were conducted to identify randomized controlled trials of the treatment of acute otitis media in children with antibiotics of different durations.

Study Selection.— Studies were included if they met the following criteria: subjects aged 4 weeks to 18 years, clinical diagnosis of acute otitis media, no antimicrobial therapy at time of diagnosis, and randomization to less than 7 days of antibiotic treatment vs 7 days or more of antibiotic treatment.

Data Extraction.— Trial methodological quality was assessed independently by 7 reviewers; outcomes were extracted as the number of treatment failures, relapses, or reinfections.

Data Synthesis.— Included trials were grouped by antibiotic used in the short course: (1) 15 short-acting oral antibiotic trials (penicillin V potassium, amoxicillin [-clavulanate], cefaclor, cefixime, cefuroxime, cefpodoxime proxetil, cefprozil), (2) 4 intramuscular ceftriaxone sodium trials, and (3) 11 oral azithromycin trials. The summary odds ratio for treatment outcomes at 8 to 19 days in children treated with short-acting antibiotics for 5 days vs 8 to 10 days was 1.52 (95% confidence interval [CI], 1.17-1.98) but by 20 to 30 days outcomes between treatment groups were comparable (odds ratio, 1.22; 95% CI, 0.98 to 1.54). The risk difference (2.3%; 95% CI,−0.2% to 4.9%) at 20 to 30 days suggests that 44 children would need to be treated with the long course of short-acting antibiotics to avoid 1 treatment failure. This similarity in later outcomes was observed for up to 3 months following therapy (odds ratio, 1.16; 95% CI, 0.90-1.50). Comparable outcomes were shown between treatment with ceftriaxone or azithromycin, and at least 7 days of other antibiotics.

Conclusion.— This meta-analysis suggests that 5 days of short-acting antibiotic use is effective treatment for uncomplicated acute otitis media in children.

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Figure 1.—Treatment outcomes at 8 to 19 days, 20 to 30 days, 30 to 40 days, and 90 days following initiation of therapy with more than 48 hours (5 days) or at least 7 days or more of treatment with a short-acting antibiotic. Summary and individual study odds ratios (ORs), including 95% confidence intervals, are plotted. The number of children assessed is specified in brackets. Odds ratios greater than 1 favor treatment with at least 7 days or more.
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Figure 2.—Funnel plot of the odds ratios vs sample size for studies included in the meta-analysis of primary outcomes (≤1 month), excluding 1 trial with 17 children and an odds ratio of 13.34.



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