Antibiotic Prescription Policy for Acute Otitis Media: Do We Follow the Guidelines?

Background: Acute otitis media (AOM) is a common cause for antibiotic prescription. Most guidelines endorse abstaining from immediate antibiotic treatment ('watchful waiting', WW) in mild-moderate episodes. We studied adherence rates to the latest AOM guidelines (2013), in terms of antibiotic type and prescription options. Methods: In this population-based study, AOM episodes were identified in Clalit Health Services-insured children aged 0-10years between 2011 and 2018, using a data-sharing platform. After identifying the index, prescription and issuing dates for antibiotics for each AOM episode, treatment was categorized as immediate (<= 2days after diagnosis) or WW (antibiotic not prescribed/issued; prescribed <= 2days after diagnosis but issued on Days 2-7; or prescribed/issued on Days 2-7). Guideline adherence was measured according to age. Results: Of the 491106 episodes, 361518 (73.6%) were treated with antibiotics. Following the 2013 guidelines, the ratio of episodes in children aged <= 6months that were adherent (immediate treatment) was higher (OR=1.22; 95% CI 1.15-1.29; P<0.001), whereas the adherent episode ratio for children aged 6-24months and 2-10years (WW) was lower (OR=0.87; 95% CI 0.85-0.88 and OR=0.94; 95% CI 0.92-0.96, respectively; P<0.001). Antibiotic prescription rates after 2013 for children aged <= 6months were not different (OR=1.03; 95% CI 0.96-1.1; P=0.4), but were higher in children aged 6-24months and 2-10years (OR=1.07; 95% CI 1.05-1.09; P<0.001 and OR=1.02; 95% CI 1.01-1.04; P=0.015, respectively). Amoxicillin was the most common antibiotic, administered in 75.6% of episodes. Azithromycin was most commonly associated with treatment failure (6.6%). Conclusions: Improved adherence to the 2013 guidelines was observed only in children aged <= 6months and over-treatment with antibiotics was still high.