National Trends in Emergency Department

Antibiotic Prescribing for Children with Acute

Otitis Media, 19962005
Thomas Fischer, MD, Adam J. Singer, MD, Christopher Lee, MD, Henry C. Thode Jr., PhD

Abstract
Objectives: Withholding antibiotics in nontoxic children with acute otitis media (AOM) is now recommen-
ded to reduce bacterial resistance rates. Using the National Hospital Ambulatory Medical Care Survey
(NHAMCS), the authors describe the national trends for prescribing antibiotics in children with AOM pre-
senting to emergency departments (EDs) in the United States over the past decade. The authors hypothe-
sized that the rates of prescribing antibiotics would decline over time.
Methods: This was a retrospective study of NHAMCS databases. A national sampling of ED visits for 1996
2005 was used to identify trends in ED prescription of antibiotics to patients with AOM. The National Drug
Code Directory Drug Classes were used to identify type of antibiotic prescribed. Frequency and type of
antibiotic prescription patterns over time were evaluated.
Results: There were 2.6 million and 2.1 million ED visits for AOM during the first and last years of the
study. Children ages 212 years accounted for about 40% of all ED visits for AOM, with another 40% in
the younger than 2 years age group and 20% in the older than 12 years of age group. During the first
and last year of the study, 79.2% and 91.3% of the patients with AOM were prescribed antibiotics, respec-
tively. There was a slight increasing trend in the proportion prescribed antibiotics over time (p = 0.02). The
rates of use of antibiotics for AOM were similar in all three age groups.
Conclusions: There was a slight increase in the percentage of children with AOM who were prescribed
antibiotics in the ED between 1996 and 2005. There was also no change in the patterns of prescribing
antibiotics.
ACADEMIC EMERGENCY MEDICINE 2007; 14:11721175 2007 by the Society for Academic Emergency
Medicine
Keywords: acute otitis media, antibiotics, selective, prescriptions

T
he most common diagnosis for which antibiotics
are prescribed for children in the United States
remains acute otitis media (AOM).1,2 At least 15
million prescriptions for antibiotics are written every
year.3 AOM, however, is a disease with a high rate of
spontaneous resolution.47 For more than 20 years, phy-
sicians in The Netherlands have used a treatment strat-
egy for selected patients with AOM that withholds
antibiotics for an initial observation period of two to
three days, during which time treatment is restricted to
analgesics and antipyretics. Antibiotics are only given
From the Department of Emergency Medicine, Stony Brook Uni-
versity Medical Center (TF, AJS, CL, HCT), Stony Brook, NY.
Received May 1, 2007; revision received June 26, 2007; accepted
July 9, 2007.
Presented at the SAEM NY Regional Conference, New York, NY,
March 28, 2007.
Contact for correspondence and reprints: Adam J. Singer, MD;
e-mail: adam.singer@stonybrook.edu.
to those patients who fail to improve at the end of the ob-
servation period or whose condition worsens during the
observation period. As a result of this policy, the percent-
age of patients given antibiotics for AOM in The Nether-
lands is approximately 31%.8
Excessive and inappropriate use of antibiotics has
been linked to a rising prevalence of penicillin-resistant
Streptococcus pneumoniae.8 Rates of penicillin-resistant
S. pneumoniae increased from 27.5% in 1995 to 43.8% in
1997.9 In contrast, in The Netherlands, the rate of penicillin
resistance to S. pneumoniae still remains less than 1%.10,11
Although historically the standard of care for the treat-
ment of AOM in the United States has been to administer
antibiotics for all cases, concern over the rising rates of
bacterial resistance and the success of the Dutch experi-
ence with initial antibiotic withholding has led to a shift
in the treatment paradigm for AOM. In the late 1990s,
the New York State Department of Health assembled a
committee of physicians whose purpose was to formu-
late a more judicious approach to the use of antibiotics
for AOM. The culmination of the committees work was

ISSN 1069-6563 2007 by the Society for Academic Emergency Medicine

1172 PII ISSN 1069-6563583 doi: 10.1197/j.aem.2007.07.011
ACAD EMERG MED  December 2007, Vol. 14, No. 12  www.aemj.org
a treatment strategy called the observation option that
was based closely on the Dutch model.12 The observation
option has been endorsed by the American Academy of
Pediatrics (AAP) and the American Academy of Family
Physicians (AAFP) and can be found on their Web sites.13
We hypothesized that, given the changes in treatment
strategies for AOM, we would see a gradual decline in
antibiotic prescribing for cases of AOM seen in the emer-
gency department (ED). Antibiotic prescribing patterns
for AOM have been analyzed before, but to our knowl-
edge, this is the first study to analyze antibiotic prescrib-
ing patterns for AOM in patients presenting to the ED.
METHODS
Study Design
We analyzed the ED component of the 19962005 Na-
tional Hospital Ambulatory Medical Care Survey
(NHAMCS).14 The study was ruled exempt from in-
formed consent by our institutional review board.
Study Setting and Population
Briefly, NHAMCS encompasses a national probability
sample of visits to U.S. hospital emergency and outpa-
tient departments by the Division of Health Care Statis-
tics of the National Center for Health Statistics, Centers
for Disease Control and Prevention; only the ED data
were used in these analyses. The survey uses a four-stage
sampling design, covering geographic primary sampling
units, hospitals with EDs within primary sampling units,
emergency service areas within EDs, and patient visits
within emergency service areas. Patient visits are re-
corded using a systematic random sample selected over
a randomly assigned four-week reporting period.
Study Protocol
Visit sampling and data collection were recorded on
patient record forms by hospital staff or by field represen-
tatives from the U.S. Census Bureau. Data collection
methods do not indicate that data recording by hospital
staff was performed prospectively; data recording by
field representatives was performed as a medical chart re-
view. Therefore, this study should be considered (conser-
vatively) as a retrospective chart review. Data processing
and coding were performed by an external source.
We identified an AOM case if it had International Clas-
sification of Diseases, Ninth Revision, Clinical Modifica-
tion (ICD-9-CM) code 382.9 in the primary diagnosis
field. Over the ten annual surveys, between six (1996
2002) and eight (20032005) medications were recorded
per encounter; all recorded medications were considered
in the analyses. Up to three National Drug Class codes
were provided for each medication.15 Antibiotic use
was identified on the basis of any of the following drug
class codes: penicillins, cephalosporins, lincosamids or
macrolides, polymyxins, tetracyclines, chloramphenicol
or derivatives, aminoglycosides, sulfonamides or related
compounds, antibacterials miscellaneous, or quinolones
or derivatives.
Data Analysis
Population visits and visit rates were computed by
using the population weights used by NHAMCS to
1173
calculate national estimates of number of ED visits. An-
tibiotic use was determined within age groups for the
pediatric population (younger than 2 years, 212 years,
1317 years) and the adult population (18+ years of
age) for comparative purposes. We calculated the age-
specific percentages of AOM visits resulting in a pre-
scribed antibiotic overall and stratified by gender,
race, and geographic region. Estimates included the
number of visits and the percentage of visits with anti-
biotics. Confidence intervals (CIs) were calculated for
percentages using standard errors, which were esti-
mated using the methods described by NHAMCS sur-
vey documentation. Trends were computed across all
years using weighted linear regression to account for
the sampling scheme used in the NHAMCS survey;
weights were the inverse of the variance estimates cal-
culated from the standard errors. Analyses were per-
formed using SPSS for Windows 13.0 (SPSS Inc.,
Chicago, IL).
Although the 2005 NHAMCS data were accessible at
the time of this writing, the documentation necessary to
calculate standards errors and weights used in analyses
was not available, so data from 2005 were only partially
included in these analyses. Results for 2005 that did not
require testing or CIs are presented here.
RESULTS
There were 2.6 million and 2.1 million ED visits for AOM
during the first (1996) and last (2005) years of the study.
Children aged 212 years accounted for approximately
40% of all ED visits for AOM during our study period,
with another 40% in the younger than 2 years age group;
5% of all ED visits for AOM were in the age group 1317
years, and 15% were adults. The age distribution of
patients with AOM was similar across years during
the ten-year period (Figure 1).
During the first and the next to last (2004) years of the
study, 79.2% (95% CI = 74.9 to 83.5) and 85.7% (95% CI =
81.8 to 89.6) of all pediatric patients (younger than 18
years) with AOM were prescribed antibiotics, respec-
tively. There was a slight increasing trend in the propor-
tion of pediatric patients prescribed antibiotics over time
(p = 0.02; Figure 2); in 2005, the percent of pediatric pa-
tients receiving antibiotics was consistent with this trend,
because 91.3% received antibiotics. The rates of use of
antibiotics for AOM were similar in patients younger
than 2 years, 212 years, and older than 12 years; most
age-year specific rates were between 79% and 89% in
the pediatric age groups over the study period. Patients
older than 18 years generally were prescribed antibiotics
at a rate about ten percentage points lower than that of
pediatric patients (Figure 3). There was no change in an-
tibiotic use by patient gender, race, or geographic region
in pediatric patients across years.
Types of antibiotics prescribed were similar for each
year over the study period. Approximately two thirds
of patients received prescriptions for penicillins, another
15% received prescriptions for erythromycins, and 12%
received prescriptions for cephalosporins. Some patients
were prescribed more than one antibiotic (e.g., amoxicil-
lin and amoxicillin clavulanate).
1174 Fischer et al.
Figure 1. Age distribution of ED patients with acute otitis
media by year, 19962005. (Color version of this gure avail-
able online at www.aemj.org.)
DISCUSSION
The results of the current study clearly demonstrate that
the majority of patients presenting to the ED with AOM
are prescribed antibiotics, regardless of age. Further-
more, there has been a slight increase in the proportion
of patients with AOM who are prescribed antibiotics.
The study also demonstrates that most patients with
AOM are prescribed a penicillin. The obvious question
is this: why has there been no decline in the ED antibiotic
prescribing rates for AOM over the ten years of our
study period? Several possibilities seem likely.
Despite the fact that the concept of initial withholding
of antibiotics for AOM is a legitimate treatment strategy,
it is unknown how widely accepted this concept is within
the emergency medicine community. As previously men-
tioned, the observation option has been officially en-
dorsed by the AAP and the AAFP. However, the
American College of Emergency Physicians has made
Figure 2. Percentage of pediatric (younger than 18 years)
patients with acute otitis media who received antibiotics
in the ED by year, 19962005. (Color version of this gure
available online at www.aemj.org.)
 TRENDS IN ED ANTIBIOTIC RX FOR ACUTE OTITIS MEDIA IN CHILDREN
Figure 3. Percent of patients within age group receiving
antibiotics in 2004. (Color version of this gure available on-
line at www.aemj.org.)
no such endorsement to date. Furthermore, many physi-
cians may not have been familiar with the observation
option during the study period, because it was only en-
dorsed by the AAP and the AAFP in 2004, toward the
end of the study period. While the observation option
recommended by the AAP is only for children ages 6
months to 2 years with an uncertain diagnosis, the obser-
vation option should be considered even for nonsevere
certain cases of AOM in children aged 2 years or older.
Another possible explanation for our failure to show a
decline in antibiotic prescribing rates is that even if emer-
gency physicians are aware of the observation option as
a treatment strategy, they may not believe it is an appro-
priate strategy for the ED setting. A critical element of
the observation option is that close follow-up must be en-
sured so that intervention with antibiotic therapy can be
initiated in the event that the patients condition worsens
or fails to improve at the end of the observation period.
Herein lies a caveat that is of unique concern to the emer-
gency physician. Doubts regarding patient follow-up in
general often lead to more cautious diagnostic and ther-
apeutic plans of action than would otherwise be followed
in a different setting. Furthermore, it is possible that a
patient with AOM presenting to the ED represents a
more severe form of the disease than one who presents
in the primary care setting, thereby making initial obser-
vation a less attractive option for the emergency physi-
cian. Therefore, one must fairly ask the question: is
there any evidence that initial observation without pre-
scribing antibiotics is a safe and effective treatment strat-
egy in the ED setting? In fact, there are two recent
studies addressing this very question.
Spiro et al. studied children with AOM aged 6 months to
12 years who presented to the ED and found that 62%
of these patients recovered uneventfully without requir-
ing antibiotics.16 In addition, Spiro et al. observed no inci-
dence of suppurative complications (i.e., mastoiditis or
meningitis) in those patients not given antibiotics and
found overwhelming parental cooperation with this strat-
egy of initially withholding antibiotics.16 We have also
conducted a small observational study in which a conve-
nience sample of 144 children aged 217 years with AOM
presenting to our ED were treated with analgesics and
given a prescription for antibiotics. The parents were
instructed not to fill the prescription for 4872 hours unless
ACAD EMERG MED  December 2007, Vol. 14, No. 12  www.aemj.org
the childs condition worsened. Of all patients, 105 (73%)
recovered without complications without ever receiving
oral antibiotics.17
It would seem, therefore, that a treatment strategy for
AOM using the initial withholding of antibiotics can, in
fact, be safely and effectively implemented in the ED in
patients with nonsevere infections and good follow-up
and will likely result in a significant decrease in the num-
ber of antibiotic prescriptions given.
Over the study period, the number of patients present-
ing with AOM declined by roughly half a million per
year. While we have no clear explanation for this decline,
this finding might also influence the interpretation of our
data. It may be possible that practitioners changed their
diagnosis (and resultant coding) practices to take into ac-
count their treatment patterns. That is, physicians may
have given patients who they treated with antibiotics
the diagnosis otitis media (unspecified) (382.9), while
giving patients who they did not treat with antibiotics
the diagnosis acute serous otitis media (381.01). Thus,
it is possible that over the study period, coding improved
and antibiotic therapy was, indeed, better targeted to the
patients who more clearly needed antibiotics.
Although we did not observe a downward trend in the
rate of antibiotic prescribing for AOM over the years we
studied, it is entirely possible that a downward trend may
be detected in future years as the treatment paradigm for
AOM more firmly shifts toward the direction of initial
observation without antibiotics.
LIMITATIONS
A significant limitation of our study was that the docu-
mentation of antibiotics in the visit form does not trans-
late necessarily to the actual filling of the prescription
by the patient. It is entirely possible that some emergency
physicians already aware of the concept of initially with-
holding antibiotics may have, in fact, chosen a delayed
prescription strategy. However, it was not possible to de-
termine this distinction from the NHAMCS data forms,
which were completed at the point of care. We also can-
not determine the severity of the clinical presentation.
Thus, the rates of antibiotic prescription may be higher
in the ED than in other clinical settings, because mostly
children with more severe infections present to the ED.
CONCLUSIONS
The rate of antibiotic prescribing for cases of AOM seen
in the ED slightly increased between 1996 and 2005. Al-
though there is evidence that initial observation without an-
tibiotics is both safe and effective in selected patients, this
evidence has not been recognized or endorsed by any na-
tional professional body of emergency medicine and has
only recently been endorsed by the AAP and the AAFP.
Any detectable decrease in ED antibiotic prescribing pat-
terns for AOM as hypothesized will likely have to await a
broader national consensus endorsing such a policy.
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