不用抗生素處置急性中耳炎並未增加
作者：Laurie Barclay, MD
出處：WebMD醫學新聞
January 25, 2010 — 根據線上發表於1月25日且將登載於2月號小兒科(Pediatrics)期刊的研究結果，在美國兒科學會(AAP)以及美國家庭醫師學會(AAFP)於2004年發表AOM的臨床實務指引允許「追蹤觀察(暫不予治療；watchful waiting)」之後，不用抗生素處置急性中耳炎(acute otitis media，AOM)並未增加。
賓州蘭開斯特綜合研究中心的Andrew Coco醫師等人寫道，在美國兒科學會以及美國家庭醫師學會於2004年提出的臨床實務指引中，觀察而無初步的抗生素治療是可接受的AOM處置選項，該指引也建議以amoxicillin作為多數孩童的第一線治療，如果有疼痛時則使用止痛劑。我們的目標是比較在2004年發表該指引之後的AOM處置。
使用2002-2006年的「National Ambulatory Medical Care Survey」資料，研究者分析了經美國醫師診斷有AOM的1114名6個月到12歲孩童資料，他們也比較了在2004年發表該指引前後各30個月的情況。研究的主要終點是，病患沒有處方抗生素的比率，次級終點是沒有處方抗生素之病患的預測因子，以及抗生素處方與止痛藥處方的比率。
指引公佈之後，發生AOM而無抗生素處方的比率並未顯著改變(11% - 16%；P = .103)，沒有耳朵痛、沒有發燒、收到止痛藥處方等，與預測沒有處方抗生素的病患無關。
指引公佈之後，amoxicillin處方率增加(40% - 49%；P = .039)、amoxicillin/clavulanate複方的處方率降低(23% - 16%；P = .043)、cefdinir處方率增加(7% - 14%；P = .004)、止痛藥處方率增加(14% - 24%；P = .038)。
研究作者們寫道，在美國兒科學會以及美國家庭醫師學會於2004年提出臨床實務指引之後，AOM不用抗生素的處置並未增加，未接受抗生素的孩童比較可能有輕微感染，與該指引相符的是，amoxicillin和止痛藥的處方增加，與該指引相反的是，amoxicillin/clavulanate複方的處方降低，而cefdinir的處方增加。
研究限制包括，資料的回溯本質、指引公佈後立即納入資料(可能沒有足夠時間讓指引建議被採用)、排除以電話和電子郵件聯絡資訊、無法分辨高劑量和標準劑量的amoxicillin處方。
研究作者們結論表示，在指引公佈之後，令人鼓舞的是，amoxicillin處方增加且與AOM相關的疼痛比較有被治療。
俄亥俄州辛辛那提兒童醫院醫學中心的Robert M. Siegel醫師在編輯評論中指出，教育病患和家屬有關抗生素的使用以及確保孩童的耳朵疼痛有被適當治療，將可以減少抗生素使用且有更佳的病患滿意度。
Siegel醫師寫道，現代病患和家屬比上一代更具醫療知識，因為他們有較多管道如透過網路和維基百科或部落格等獲得資訊，健康照護提供者應接受並鼓勵之，並納入患者參與是否使用抗生素治療中耳炎的決策，藉由兒科醫師的保證，處方止痛藥將可以消除孩童的疼痛，病患將對於開立AOM的抗生素處方時得以一起參與決定感到感謝。
研究作者們皆宣告沒有相關財務關係，Siegel醫師是Atkins Nutritionals公司的科學諮詢委員會成員。
Pediatrics. 線上發表於2010年1月25日。
Management of Acute Otitis Media Without Antibiotics Has Not Increased
By Laurie Barclay, MD
Medscape Medical News
January 25, 2010 — The management of acute otitis media (AOM) without antibiotics has not increased after publication of the 2004 American Academy of Pediatrics (AAP) and the American Academy of Family Physicians (AAFP) clinical practice guideline on AOM allowing "watchful waiting," according to the results of a study reported Online First January 25 and to be published in the February issue of Pediatrics.
"Observation without initial antibiotic therapy was accepted as an option for ...AOM management in the 2004 American Academy of Pediatrics and American Academy of Family Physicians clinical practice guideline," write Andrew Coco, MD, MS, from Lancaster General Research Institute in Lancaster, Pennsylvania, and colleagues. "The guideline also recommended amoxicillin as the first-line treatment for most children, and analgesic treatment to reduce pain if it was present. Our objective was to compare the management of AOM after publication of the 2004 guideline."
Using the National Ambulatory Medical Care Survey from 2002 to 2006, the investigators analyzed data from 1114 children aged 6 months to 12 years who were diagnosed with AOM in US physicians' offices. They also made comparisons for the 30-month periods before and after the guideline was released in 2004. The main endpoint of the study was the rate of encounters with no reported antibiotic-prescribing, and secondary endpoints were predictors of encounters at which no antibiotic-prescribing was reported and rates of antibiotic- and analgesic-prescribing.
After guideline publication, the rate of AOM encounters at which no antibiotic prescribing was reported did not change significantly (11% - 16%; P = .103). Absence of ear pain, absence of reported fever, and receipt of an analgesic prescription independently predicted encounters at which no antibiotic-prescribing was reported.
Changes after guideline publication were increased rate of amoxicillin-prescribing (40% - 49%; P = .039), decreased rate of amoxicillin/clavulanate-prescribing (23% - 16%; P = .043), increased rate of cefdinir-prescribing (7% - 14%; P = .004), and increased rate of analgesic-prescribing (14% - 24%; P = .038).
"Although management of AOM without antibiotics has not increased after the publication of the 2004 American Academy of Pediatrics and American Academy of Family Physicians clinical practice guideline, children who did not receive antibiotics were more likely to have mild infections," the study authors write. "In accordance with the guideline, the prescribing of amoxicillin and analgesics has increased. Contrary to the guideline, the prescribing of amoxicillin/clavulanate has decreased, whereas the prescribing of cefdinir has increased."
Limitations of this study include retrospective nature of the data, inclusion of data immediately after the release of the guideline (which may not have allowed sufficient time for adopting the guideline recommendations), exclusion of telephone and email contact information, and inability to distinguish between the prescribing of high-dose vs standard-dose amoxicillin.
"It is encouraging that after the publication of the guideline, amoxicillin-prescribing has increased and the pain associated with AOM is more frequently being treated," the study authors conclude.
In an accompanying editorial, Robert M. Siegel, MD, from Cincinnati Children's Hospital Medical Center in Cincinnati, Ohio, notes that educating patients and families regarding antibiotic use and ensuring that the child's ear pain is adequately managed will lead to decreased antibiotic use and better patient satisfaction.
"Today's patients and families are more medically sophisticated than the last generation, because they have greater access to information through the Internet and its educational resources such as wikis and blogs," Dr. Siegel writes. "Health care providers should embrace and encourage this empowerment and involve patients in shared decision-making regarding whether to use antibiotics for otitis media. With the assurance of a pediatrician that prescribed analgesics will probably remove their child's pain, patients will appreciate being asked to participate in the decision as to when to fill an antibiotic prescription for AOM."
The study authors have disclosed no relevant financial relationships. Dr.?Siegel is a member of the Scientific Advisory Board of Atkins Nutritionals, Inc.
Pediatrics. Published online January 25, 2010.
