Friday, January 8, 2016

The Antibiotic Mandatory Waiting Period?

It has become generally accepted within the medical community the vast majority of cases of pediatric otitis media will resolve without antibiotics.  However, the tradition of treating OM with antibiotics is slow to wane, fueled by momentum and parental expectations.  Some success has been achieved with delayed-prescription strategies, where parents are provided with antibiotics, but encouraged to wait a few days and observe for spontaneous improvement.

These authors applied the same school of thought to benign upper respiratory tract infections – sinusitis, pharyngitis, and bronchitis.  They randomized 398 patients with common URTI-spectrum symptoms to one of four treatment strategies:  immediate antibiotic initiation; antibiotics provided immediately, but patient encouraged to wait-and-see a few days for spontaneous improvement; antibiotics available for pick-up three days later, if desired; and no antibiotics.  The primary outcome was duration and severity of symptoms, with various secondary outcomes of absenteeism, satisfaction, and antibiotic utilization.

The results of this study are a little bit mixed.  The patients initiating antibiotics immediately had shorter symptoms duration than any other strategy.  The sample sizes are small, and the standard deviation of symptoms in each cohort is huge, but it’s probably reasonable to estimate antibiotic use truncated moderate or severe symptoms by about a day or a day and a half from a 5-6 day illness duration.  Twelve of 98 randomized to no prescription ultimately crossed over to antibiotics.

But the remainder, despite their randomization to benign neglect, improved regardless, without any detectable difference in safety outcomes.  After all, the majority of these infections are either viral, or self-limited bacterial infections handled by the body’s natural immune system without complications.

The interesting outcomes, however, were the two delayed-antibiotic strategies.  Compared to the 91% antibiotic usage rate of the immediate antibiotic group, the patient-initiated and delayed-collection strategies resulted in 33% and 23% antibiotic usage rates, respectively.  Symptom duration, as to be expected, was mildly attenuated, falling between immediate antibiotic use and no antibiotics.

Is this the happy medium strategy needed to finally divorce ourselves from our addiction to unnecessary care for URTI disease?  “Choosing Wisely” as a general philosophy doesn’t seem to have had the desired effect – how about an executive action to mandate the same waiting period for antibiotics as we have for guns?

“Prescription Strategies in Acute Uncomplicated Respiratory Infections: A Randomized Clinical Trial”
http://www.ncbi.nlm.nih.gov/pubmed/26719947

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