To the Editor: In his Clinical Crossroads article about a 15-month-old child with recurrent otitis media, Dr Paradise1 concluded that it would be "injudicious" to withhold antibiotics from patients with acute otitis media (AOM). However, he did not consider important evidence necessary to place the discussion in its proper context.
Although antibiotics appear to have some beneficial effect in the treatment of AOM, the magnitude of benefit appears small. A recent review of studies designed to address this question found no reduction in pain at 24 hours and only a 5% absolute reduction in the number of patients with pain after 2 to 7 days.2 This means that approximately 17 children must be treated with antibiotics to prevent 1 child from having pain during the same period. One of the studies cited by Paradise noted about a 13% absolute reduction in symptoms at day 4 in children younger than 2 years,3 but even this minimal benefit would require 7 to 8 children with AOM to receive antibiotics to prevent 1 child from having symptoms at the fourth day.
Paradise also suggested that antibiotics are necessary to help prevent mastoiditis. However, there is no conclusive evidence that withholding antibiotics in children with AOM would increase the incidence of mastoiditis.2 ,4 There appear to be only 2 additional cases of mastoiditis per 100 000 children in countries with lower rates of antibiotic use for AOM.4 However, the data do not prove causation because mastoiditis rates in some areas are similar despite significantly higher rates of antibiotic prescribing for AOM. As many as 2500 children with AOM would need to be treated with antibiotics to prevent a single case of mastoiditis.4 This small reduction in the absolute risk of mastoiditis would be accompanied by the adverse effects of antibiotics and the tremendous public health problem of antimicrobial resistance. One study concluded that countries with less antibiotic use for AOM issue 7800 fewer prescriptions per 100 000 children, resulting in 1600 fewer adverse effects.4 In addition, data indicate that in 1998, 24% of invasive Streptococcus pneumoniae isolates in the United States were resistant to penicillin, a nearly 20% increase over 1995.5
Withholding antibiotics may not be reasonable in all children with AOM, and evidence is needed to identify subgroups of patients in whom antibiotics are necessary. A reevaluation of the current approach to AOM is in order, considering the disadvantages and the apparently minimal benefit of prescribing antibiotics for AOM.
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal
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