ABSTRACT: Watchful waiting management of nonsevere acute otitis media (AOM) can reduce the use of antibiotics, but it requires a reliable means of assessing clinical severity.
We present the development of a pocket AOM card with which the clinician can rapidly assess total AOM severity.
The components of the pocket card consisted of a faces scale, to assess parent perception of severity, and a standard set of tympanic membrane photographs, with which the pediatrician can grade the severity of tympanic membrane inflammation. The components of the pocket card were tested for validity, reliability and responsiveness with the use of data from parents, pediatricians and pediatric otolaryngologists.
Instruments were assessed for concurrent correlation, sequence validity and reliability against previously published questionnaires with the use of Spearman correlation. Responsiveness was calculated with the use of enrollment, day 12 and day 30 data from a randomized clinical trial.
The components of the pocket AOM card demonstrated excellent sequence validity, concurrent correlation and reliability (r = 0.58-0.99). Total AOM card severity, consisting of the sum of the 2 scales, demonstrated better responsiveness to change than any of the scales taken individually.
The AOM card combines a parent assessment of symptoms and the clinician assessment of the tympanic membrane to provide an assessment of total AOM severity that can be used to facilitate shared decision making between parent and clinician. The combined score of the AOM card was more responsive to change than any of the instruments used alone. The AOM card provides a useful tool for teaching and research.
The Pediatric Infectious Disease Journal 03/2006; 25(2):101-7. · 3.58 Impact Factor
ABSTRACT: The widespread use of antibiotics for treatment of acute otitis media (AOM) has resulted in the emergence of multidrug-resistant pathogens that are difficult to treat. However, it has been shown that most children with nonsevere AOM recover without ABX. The objective of this study was to evaluate the safety, efficacy, acceptability, and costs of a non-ABX intervention for children with nonsevere AOM.
Children 6 months to 12 years old with AOM were screened by using a novel AOM-severity screening index. Parents of children with nonsevere AOM received an educational intervention, and their children were randomized to receive either immediate antibiotics (ABX; amoxicillin plus symptom medication) or watchful waiting (WW; symptom medication only). The investigators, but not the parents, were blinded to enrollment status. Primary outcomes included parent satisfaction with AOM care, resolution of symptoms, AOM failure/recurrence, and nasopharyngeal carriage of Streptococcus pneumoniae strains resistant to ABX. Secondary outcomes included medication-related adverse events, serious adverse events, unanticipated AOM-related office and emergency department visits and telephone calls, the child's absence from day care or school resulting from AOM, the parent's absence from school or work because of their child's AOM, and costs of treatment. Subjects were defined as failing (days 0-12) or recurring (days 13-30) if they experienced a higher AOM-severity score on reexamination.
A total of 223 subjects were recruited: 73% were nonwhite, 57% were <2 years old, 47% attended day care, 82% had experienced prior AOM, and 83% had not been fully immunized with heptavalent pneumococcal vaccine. One hundred twelve were randomized to ABX, and 111 were randomized to WW. Ninety-four percent of the subjects were followed to the 30-day end point. Parent satisfaction with AOM care was not different between the 2 treatment groups at either day 12 or 30. Compared with WW, symptom scores on days 1 to 10 resolved faster in subjects treated with immediate ABX. At day 12, among the immediate-ABX group, 69% of tympanic membranes and 25% of tympanograms were normal, compared with 51% of normal tympanic membranes and 10% of normal tympanograms in the WW group. Parents of children in the ABX group gave their children fewer doses of pain medication than did parents of children in the WW group. Subjects in the ABX group experienced 16% fewer failures than subjects in the WW group. Of the children in the WW group, 66% completed the study without needing ABX. Immediate ABX resulted in eradication of S pneumoniae carriage in the majority of children, but S pneumoniae strains cultured from children in the ABX group at day 12 were more likely to be multidrug-resistant than strains from children in the WW group. More ABX-related adverse events were noted in the ABX group, compared with the WW group. No serious AOM-related adverse events were observed in either group. Office and emergency department visits, phone calls, and days of work/school missed were not different between groups. Prescriptions for ABX were reduced by 73% in the WW group compared with the ABX group. Costs of ABX averaged $47.41 per subject in the ABX group and $11.43 in the WW group.
Sixty-six percent of subjects in the WW group completed the study without ABX. Parent satisfaction was the same between groups regardless of treatment. Compared with WW, immediate ABX treatment was associated with decreased numbers of treatment failures and improved symptom control but increased ABX-related adverse events and a higher percent carriage of multidrug-resistant S pneumoniae strains in the nasopharynx at the day-12 visit. Key factors in implementing a WW strategy were (a) a method to classify AOM severity; (b) parent education; (c) management of AOM symptoms; (d) access to follow-up care; and (e) use of an effective ABX regimen, when needed. When these caveats are observed, WW may be an acceptable alternative to immediate ABX for some children with nonsevere AOM.
PEDIATRICS 06/2005; 115(6):1455-65. · 4.47 Impact Factor
ABSTRACT: Prior studies have shown that bullous myringitis (BM) accounts for <10% of acute otitis media (AOM) cases, and that the distribution of viral and bacterial pathogens in BM is similar to that in AOM without BM, except for a relative increase in the proportion of Streptococcus pneumoniae in BM. We studied 518 cases of AOM in children aged 6 months to 12 years. Using tele-otoscopy to assist the diagnosis, we identified 41 cases (7.9%) with BM. Children who had AOM with BM were older than AOM patients without BM (median age: 4.3 years vs 18 months). We compared 41 cases of AOM with BM to 41 control cases of age-, race-, and gender-matched AOM patients without BM. When compared with this matched control group, children with BM had more severe symptoms at the time of diagnosis and were more likely to have bulging of the tympanic membrane in the quadrants that were not obscured by the bulla. Children with AOM and BM may require aggressive pain management. Although parents and clinicians may agree that a watchful waiting approach is appropriate for older children with mild AOM, children experiencing painful AOM with BM may not be successful candidates for a watchful-waiting approach, because parents may resist postponement of antibiotic therapy in children who are more symptomatic.
PEDIATRICS 10/2003; 112(4):982-6. · 4.47 Impact Factor