Acute otitis media: do not hesitate to treat

Recently, two randomised, double-blind, placebo-controlled trials published in The New England Journal of Medicine have stirred up discussion about the use of antibiotics in the treatment of acute otitis media (AOM). In the Netherlands, the practice guideline of the Dutch College of General Practitioners recommends withholding antibiotics in most cases and that antibiotics can be considered when a child under the age of 2 years has bilateral AOM, otorrhoea, or persistent symptoms for 3 days or more. These recommendations are mostly based on a meta-analysis published in 2006. Previous studies on AOM had important limitations such as varying diagnostic criteria and biased patient selection. The new trials, which are of high methodological quality, investigated only 'real' AOM and the results show the same efficacy as the aforementioned meta-analysis. We therefore feel it is justified to consider prescribing antibiotics for a young child with manifest symptoms and evident AOM on otoscopic examination.     

Is co-morbidity taken into account in the antibiotic management of elderly patients with acute bronchitis and COPD exacerbations?

BACKGROUND: Guidelines on acute lower respiratory tract infections recommend restrictive use of antibiotics, however, in patients with relevant co-morbid conditions treatment with antibiotics should be considered. Presently, it is unknown whether GPs adhere to these guidelines and target antibiotic treatment more often at patients with risk-elevating conditions. OBJECTIVES: We assessed whether in elderly primary care patients with acute bronchitis or exacerbations of chronic pulmonary disease (COPD), antibiotics are more often prescribed to patients with risk-elevating co-morbid conditions. METHODS: Using the Utrecht GP research database, we analysed 2643 episodes in patients of 65 years of age or older with a GP-diagnosed acute bronchitis or exacerbation of COPD. Multivariable logistic regression analysis was applied to determine independent determinants of antibiotic use. RESULTS: Antibiotic prescribing rates were high in both acute bronchitis (84%) and in exacerbations of COPD (53%). In acute bronchitis, only age was an independent determinant of antibiotic use [odds ratio (OR) 1.03, 95% confidence interval (CI) 1.003-1.048], whereas in exacerbations of COPD antibiotics were more often prescribed to male patients (OR 1.3, 95% CI 1.0-1.5), patients with diabetes (OR 1.7, 95% CI 1.1-2.4) and heart failure (OR 1.3, 95% CI 1.0-1.7). CONCLUSION: Dutch GPs prescribe antibiotics in the majority of elderly patients with acute bronchitis and in half of the episodes of exacerbations of COPD. Tailoring their antibiotic treatment according to the presence or absence of high-risk co-morbid conditions could help GPs in improving antibiotic use in patients with respiratory tract infections in primary care.     

Acute otitis media: do not change the Dutch practice guideline

Two recent clinical trials have again shown that antibiotics are effective in the management of young children with acute otitis media (AOM). Should this change our reserved attitude towards the use of antibiotics? According to the rules for evidence-based medicine, we cannot ignore the vast body of evidence already existing unless new trials are methodologically better and their results differ from previous trials. This does not seem to be the case. The patient characteristics of these trials are similar to those of a previously published individual patient data meta-analysis. The primary outcome 'symptom scores' reported by Hoberman et al. is also comparable, but T?htinen et al. may have overestimated the effect of antibiotics. Their primary outcome 'time to treatment failure' does not take later improvement or recovery into account. In both trials, the greatest benefit is related to otoscopic recovery of AOM, which is clinically not the most relevant outcome. For now, there is no reason to adapt the current AOM practice guideline of the Dutch College of General Practitioners.     

Socially responsible antibiotic choices in primary care: a qualitative study of GPs' decisions to prescribe broad-spectrum and fluroquinolone antibiotics

BACKGROUND: There is considerable variation within and between countries in general medical practitioners' (GPs') prescribing of broad-spectrum antibiotics such as fluroquinolones, and resistance to these agents is increasing worldwide. Urgently promoting cautious fluroquinolone prescribing in primary care may limit increase in resistance. OBJECTIVE: We therefore interviewed 40 GPs in order to explore the reasons for their choice of prescribed antibiotic, in particular their decision to prescribe fluroquinolones. METHODS: We used a grounded theory approach to data collection and analysis, incorporating purposive and theoretical sampling, based on high and average fluroquinolone prescribing. Interviews were conducted with 26 GPs from practices known to be high prescribers of fluroquinolone antibiotics and 14 from average fluroquinolone prescribing practices. RESULTS: Chosing to prescribe a broad-spectrum antibiotic such as a fluroquinolone, rather than a narrow-spectrum antibiotic, related to a number of clinical considerations, perceptions of patient expectations and organizational influences. GPs from high fluroquinolone prescribing practices were more likely to prioritize patients' immediate needs, whereas GPs from average prescribing practices were more likely to consider longer term issues. GPs from both high and average fluroquinolone prescribing practices justified their antibiotic choices on the basis of a desire to do their best for their patients and society. CONCLUSION: Choosing to prescribe powerful, broad-spectrum antibiotics such as fluroquinolones, as well as choosing to keep these agents in reserve, was justified on the basis of social responsibility. Strategies to change fluroquinolone and broad-spectrum antibiotic prescribing will need to take into account clinicians' perceptions of social responsibility.     

Penicillin for acute throat infections. Are there arguments for modifying the guidelines of the Dutch College of General Practitioners?

A recent study concludes that a 7-day penicillin treatment for a sore throat is superior to a 3-day treatment or a placebo, because the symptoms are resolved two days earlier. Prior to this study, the difference--based on the conclusions of a Cochrane review--was thought to be just 8 hours. The total number of patients included was too small to conclude that penicillin could reduce the number of short-term and long-term complications. In the guidelines of the Dutch College of General Practitioners, a 7-day penicillin treatment for a sore throat is only recommended in severe cases. It is still quite acceptable for Dutch GPs to discuss the treatment options for a sore throat with their patients. A change to the current guidelines is not necessary.     

The practice guideline 'Otitis media with effusion' (second revision) from the Dutch College of General Practitioners; a response from the perspective of general practice

The usefulness of tympanotomy tubes in children with otitis media with effusion who also have speech and language retardation is doubtful in view of the natural development. The second revision of the practice guideline 'Otitis media with effusion' from the Dutch College of General Practitioners is still not in complete agreement with this. The indications for performing an adenoidectomy are now more limited. Pneumatic otoscopy and tympanometry are diagnostic aids that may deserve a permanent place in the general practitioner's medical practice in the future.     

The practice guideline 'Otitis externa' (first revision) from the Dutch College of General Practitioners; a response from the perspective of otorhinolaryngology

The first revision of the practice guideline 'Otitis externa' from the Dutch College of General Practitioners describes diagnostic, therapeutic and preventive aspects of care and focuses mainly on the acute form of the disease. In comparison with the previous guideline, some modest but valuable improvements have been made with regard to diagnosis and medical treatment. For acute otitis externa, treatment with acid and corticosteroid eardrops is considered the treatment of choice, rather than treatment with acid eardrops only. The guideline clearly discusses indications for referral of patients with otitis externa to an otorhinolaryngologist. Hypersensitivity and more severe pathology should be excluded in persistent cases. For chronic otitis externa, an otorhinolaryngologist can provide surgical treatment with a good chance of success and a low recurrence rate.