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Educational Objectives:

After evaluating this article, participants will be able to:
1. Incorporate strategies into practice to avoid the unnecessary prescription of antibiotics
2. Implement a wait-and-see approach with antimicrobials
3. Meet parental expectations without necessarily prescribing antibiotics or other unnecessary treatments or diagnostics.
 

Parents and caregivers are becoming more involved in healthcare discussions and the internet era has led to significant concerns for providers as a little knowledge is worse than no knowledge at all. Parents will often have predetermined expectations of what the ED visit should entail and will already have their own differential diagnosis and treatment plan in mind before we have even had a chance to fully evaluate the patient. It is not unusual for parents to feel that their experience in the ED lacked satisfaction with the care provided. Zaffani S et al, discovered that maternal anxiety and physicians’ interpretation of parental expectations are important factors to take into account during the visit. Furthermore, younger mothers, with a lower level of education and less experience were found to require more provider time, information and support. They were also found to be more likely to request a specific therapy, less likely to be satisfied, more easily influenced and more likely to follow mass-media advice, rather than a reliable source of information. (Child Care Health Dev. 2005 Sep;31(5):575-80.)
Many parents demand antibiotics but are not well informed about the risks of wide-spread antibiotic use and many providers feel justified in writing these prescriptions despite the evidence that most of these patients do not benefit from them. This journal club will arm you with some compelling articles that will assist you when dealing with difficult families.


Q1: What is the risk of antibiotic-associated diarrhea (AAD) in the outpatient pediatric population and what are the risk factors for development of AAD?

A: In this study, antibiotic-associated diarrhea was common in these outpatient children, especially for those aged less than 2 years and after the prescription of certain antibiotics, particularly the combination of amoxicillin/clavulanate  

Citation
Turck D, Bernet JP, Marx J et al. INCIDENCE AND RISK FACTORS OF ORAL ANTIBIOTIC-ASSOCIATED DIARRHEA IN AN OUTPATIENT PEDIATRIC POPULATION. J Ped Gastroent Nutr 2003; 37(1):22-26

Methodology  Children aged 1 month to 15.4 years treated with oral antibiotics for a proven or suspected infection were enrolled from an ambulatory pediatric practice during an 11-month period. Parents recorded the daily frequency and characteristics of stools using a diary during the antibiotic treatment and for 1 week after it was stopped. An episode of diarrhea was defined by at least 3 soft or liquid stools/d for at least 2 consecutive days. Risk factors for AAD-age, type of antibiotic treatment, type of combined treatment, and site of infection-were analyzed.

Results  Of 650 children included, 11% had an episode of AAD, lasting a mean of 4.0 +/- 3.0 days, beginning a mean of 5.3 +/- 3.5 days after the start of antibiotic treatment. No child was hospitalized because of AAD. The incidence of AAD was higher in children less than 2 years (18%) than in those more than 2 years (3%; P < 0.0001). The mean age of the children in the study was 34.1 months and the mean duration of antibiotic therapy was 8.6 days (range 5-18 days).  The most common diagnoses were tonsillitis or rhinopharyngitis (48%), acute otitis media or sinusitis (30%) and chest infection (16%).  Prescribed antibiotics included penicillins G and V (9%), amoxicillin and ampicillin (32%), amoxicillin-clavulanate (9%), cephalosporins (22%) and macrolides (12%).  Other medications were commonly prescribed, most often theophylline, mucolytics, antitussives, antipyretics and analgesics. The incidence of AAD was particularly high after administration of certain antibiotics (amoxicillin/clavulanate, 23%; P = 0.003 compared with other antibiotics). The type of combined treatment and site of infection did not influence the onset of AAD.

Q2: Do physicians follow the CDC-P guidelines for the diagnosis of acute otitis media (AOM)?

A: In this study, overall compliance was about 40%.

Citation
Garbutt J, Jeffe DB, Shackelford P. DIAGNOSIS AND TREATMENT OF ACUTE OTITIS MEDIA: AN ASSESSMENT Pediatrics 2003;112(1):143-149.

Background  CDC-P guidelines for the diagnosis of acute otitis media (AOM) specify that middle ear otorrhea, or middle ear fluid or effusion (MEE) plus signs or symptoms of acute local or systemic illness should be documented, and recommend the use of pneumatic otoscopy to confirm MEE. Treatment guidelines specify a short course (5-7 days) of antibiotics for children over age two with mild disease, and a ten-day course for younger children and those with tympanic membrane perforation, comorbidity or recurrent AOM.  Amoxicillin at a dose of 40-45mg/kg/day is recommended for initial treatment in patients at low risk for infection with penicillin- resistant S. pneumoniae, while 80-90mg/kg/day is recommended for those at increased risk for such infection.  Broader spectrum agents are recommended if initial amoxicillin treatment is ineffective. 

Methodology The authors, from Washington University in St. Louis, MO, and funded by SmithKline Beecham, reviewed the charts of 573 children treated by one of 29 pediatricians in 14 practices to assess compliance with these recommendations, and the physicians were surveyed to determine their self- reported usual behavior for the management of AOM. 

Results  Overall compliance with diagnostic criteria was about 40% by both chart review and physician self-report.  Compliance was particularly poor for diagnostic recommendations, but was also suboptimal, by chart review though less so by self-report, with regard to treatment recommendations.  Physicians rarely utilized pneumatic otoscopy or objective tests to document MEE, and overuse of broad-spectrum antibiotics, underuse of effective treatments for treatment failures or recurrence, and subtherapeutic amoxicillin dosing were common sources of noncompliance with treatment recommendations.
 
Q3: Does treatment of Acute otitis media (AOM) using a “wait-and-see prescription” (WASP) significantly reduce use of antibiotics compared with a “standard prescription” (SP)? Also, what are the effects of this intervention on clinical symptoms and what are the adverse outcomes related to antibiotic use?

A: The WASP approach substantially reduced unnecessary use of antibiotics in children with AOM seen in an emergency department and may be an alternative to routine use of antimicrobials for treatment of such children

Citation
Spiro D, Tay KY, Arnold DH et al. WAIT-AND-SEE PRESCRIPTION FOR THE TREATMENT OF ACUTE OTITIS MEDIA .JAMA 2006: 296(10):1235-1241

Context  Acute otitis media (AOM) is the most common diagnosis for which antibiotics are prescribed for children. Previous trials that have evaluated a “wait-and-see prescription” (WASP) for antibiotics, with which parents are asked not to fill the prescription unless the child either is not better or is worse in 48 hours, have excluded children with severe AOM. None of these trials were conducted in an emergency department.

Methodology  A randomized controlled trial conducted between July 12, 2004, and July 11, 2005. Children with AOM aged 6 months to 12 years seen in an emergency department were randomly assigned to receive either a WASP or an SP. All patients received ibuprofen and otic analgesic drops for use at home. A research assistant, blinded to group assignment, conducted structured phone interviews 4 to 6, 11 to 14, and 30 to 40 days after enrollment to determine outcomes. The main outcome measure was the filling of the antibiotic prescription and clinical course.

Results  Overall, 283 patients were randomized either to the WASP group (n = 138) or the SP group (n = 145). Substantially more parents in the WASP group did not fill the antibiotic prescription (62% vs 13%; P<.001). There was no statistically significant difference between the groups in the frequency of subsequent fever, otalgia, or unscheduled visits for medical care. Within the WASP group, both fever (relative risk [RR], 2.95; 95% confidence interval [CI], 1.75 - 4.99; P<.001) and otalgia (RR, 1.62; 95% CI, 1.26 - 2.03; P<.001) were associated with filling the prescription.

Q4: Can antibiotic use with radiologic findings of sinusitis improve outcomes and resolve symptoms when compared to placebo?

A: In this study, a 10-day course of cefuroxime wasn’t superior to placebo in children with symptoms of acute respiratory infection and sinusitis, and evidence of maxillary sinusitis on imaging studies.  These findings also question the utility of radiologic maxillary sinusitis as a criterion for antibiotic therapy.

Citation
Kristo A, Uhari M, Luotenen J et al. CEFUROXIME AXETIL VERSUS PLACEBO FOR CHILDREN WITH ACUTE RESPIRATORY INFECTION AND IMAGING EVIDENCE OF SINUSITIS Acta Paed 2005: 94:1208-1213.

Background  Antibiotics are often recommended for the treatment of acute bacterial sinusitis in children and  X-rays showing maxillary sinusitis have been considered to be diagnostic of bacterial etiology.

Methodology  In this double-blind, controlled Finnish study, 82 children aged 4-10 with acute respiratory symptoms suggestive of sinusitis with maxillary sinusitis on ultrasonography were randomized to a ten-day course of cefuroxime (125mg twice daily) or placebo.  Diaries were maintained listing the presence or absence of six symptoms and the use of other medications (analgesics, nose drops, cough preparations). 

Results  Fourteen-day follow-up information was available for 72 children. There were no significant differences between the study groups in the percentage who were clinically cured (63% in the cefuroxime group [22/35] and 57% in controls [21/37]), or in the percentage who were cured or improved without complications (91% [32/35] vs. 84% [31/37]).  Similar findings were observed in children who were younger or older than six years.  There were no significant differences between the groups in patterns of symptom resolution or use of other medications, or in the percentage with radiological sinusitis on day 14 (69% in the cefuroxime group vs. 64% in controls).  There was no correlation between clinical outcomes or imaging findings.   

Q5: What is the relationship between the time a physician spends in an office encounter with the prescribing of antibiotics for pediatric patients with presumed viral respiratory infections?

A: Prescribing antibiotics for children with upper respiratory infections or bronchitis is not associated with a reduction in the time that a physician spends with a patient in an office encounter. The impact on physician productivity of injudicious antibiotic prescribing for upper respiratory infections and bronchitis may not be as great as previously believed.

Citation
Coco A, Mainous AG. RELATION OF TIME SPENT IN AN ENCOUNTER WITH THE USE OF ANTIBIOTICS IN PEDIATRIC OFFICE VISITS FOR VIRAL RESPIRATORY INFECTIONS Coco, A., et al, Arch Ped Adol Med 2005; 159:1145

Methodology  Cross-sectional analysis of the 2000 National Ambulatory Medical Care Survey in physician offices in the United States. Participants consisted of Children and adolescents (aged ≤ 18 years) with a diagnosis of upper respiratory infections or bronchitis. The main outcome measure was the time spent by a physician with a patient in an office encounter.

Results  Analysis of 269 office encounters representing 12,366,162 annual office visits for upper respiratory infections and bronchitis. The mean (SE) number of minutes a doctor spent with a patient in encounters for colds or bronchitis that resulted in an antibiotic prescription was 14.24 (0.85) minutes while 14.18 (1.03) minutes were spent in encounters without antibiotics prescribed. In multivariate analysis, the likelihood that the time spent by a physician was above or below the median visit time of 15 minutes was not associated with the use of antibiotics when controlled for patient age, race, sex, participation in a prepaid plan, or whether the encounter was with the patient’s primary care physician.

Q6: How do parents communicate their preferences for antibiotics to their child’s physician? Also, how can physicians communicate why antibiotics are not being prescribed in a way that maintains satisfaction with the visit?

A: According to the study below, physicians should consider providing a contingency plan to parents who expect antibiotics for their children when there is no clinical indication. Further study is needed to determine how parents indirectly communicate their desire for antibiotics and what additional communication techniques physicians can use to resist the overprescribing of antibiotics

Citation
Mangione-Smith R, McGlynn EA, Elliot MN et al. Parent expectations for antibiotics, physician-parent communication, and satisfaction. Arch Pediatr Adolesc Med. 2001 Jul;155(7):800-6

Methodology  Design: pre-visit survey of parents, audiotaping of the study encounters, and a post-visit survey of parents and physicians. Setting: two private pediatric practices. Participants comprised ten physicians (response rate = 77%) and a consecutive sample of 295 eligible parents (response rate = 86%) who attended acute care visits for their children between October 1996 and March 1997. The main outcome measure was physician-perceived pressure to prescribe antibiotics and parental visit-specific satisfaction.

Results  Fifty percent of parents expressed a pre-visit expectation for antibiotics. Among these parents, only 1% made a direct verbal request for them. Even when no direct requests for antibiotics were made, physicians still perceived an expectation for antibiotics 34% of the time. Among parents who did not receive expected antibiotics, those offered a contingency plan from the physician (i.e., the possibility of receiving antibiotics in the future if their child did not get better) had a higher mean satisfaction score than parents not receiving a contingency plan (76 vs. 58.9; P<.05).

Commentary
No parents like dealing with diarrhea, so the first article is a great one to share with families that insist on antibiotics for mild otitis media or viral illnesses. It is imperative that we all follow the guidelines for treatment of ear infections and correctly diagnose otitis media. If you are not using an insufflator, this is something that you should put into immediate practice. Ears can be red from crying and from fever; however, if there is no mobility on insufflation, it is difficult to doubt your examination skills.

The wait and see prescription concept has gained increasing popularity in the US as a way to decrease immediate antibiotic use and still give parents some autonomy, especially when they do not have access to healthcare. If patients have proper follow-up, then an ear recheck in 48-72 hours is sufficient and the provider does not need to write a prescription. The use of antibiotics and imaging is not routinely indicated in patients with acute upper respiratory tract infections. It is important to keep in mind that patients with a persistent cough for more than 2 weeks may have pertussis and this necessitates further evaluation.

Finally, we often feel that it is quicker to give a prescription for antibiotics and make the caregiver happy than to explain why antibiotics are not warranted. Coco et al’s study confirmed that writing a prescription for an antibiotic was NOT associated with a decrease in physician time spent with the patient. Therefore, every effort should be made to resist the urge to “just write the prescription” as this behavior contributes to the era of antibiotic resistance. Often the provider feels pressured to prescribe antibiotics even when no direct request is made of them.
The final article further demonstrates the importance of giving the parents a “contingency” plan if antibiotics are not prescribed. The term “best interest” is often used to describe the provider’s responsibility when caring for patients. At times, the physician may have to refuse the parent’s demands in order to accomplish the goal of maximizing what is truly better for the patient.

Ghazala Sharieff, MD is the Director of Pediatric Emergency Medicine at the Palomar-Pomerado Health System/California Emergency Physicians



 

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