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A Meta-analysis

Anita L. Kozyrskyj, BScPhm, MSc; G. Elske Hildes-Ripstein, MD; Sally E. A. Longstaffe, MD; J. Leigh Wincott, MD; Daniel S. Sitar, BScPhm, PhD; Terry P. Klassen, MD, MSc; Michael E. K. Moffatt, MD, MSc

JAMA. 1998;279:1736-1742.

Objective.— To conduct a meta-analysis of randomized controlled trials of antibiotic treatment of acute otitis media in children to determine whether outcomes were comparable in children treated with antibiotics for less than 7 days or at least 7 days or more.

Data Sources.— MEDLINE (1966-1997), EMBASE (1974-1997), Current Contents, and Science Citation Index searches were conducted to identify randomized controlled trials of the treatment of acute otitis media in children with antibiotics of different durations.

Study Selection.— Studies were included if they met the following criteria: subjects aged 4 weeks to 18 years, clinical diagnosis of acute otitis media, no antimicrobial therapy at time of diagnosis, and randomization to less than 7 days of antibiotic treatment vs 7 days or more of antibiotic treatment.

Data Extraction.— Trial methodological quality was assessed independently by 7 reviewers; outcomes were extracted as the number of treatment failures, relapses, or reinfections.

Data Synthesis.— Included trials were grouped by antibiotic used in the short course: (1) 15 short-acting oral antibiotic trials (penicillin V potassium, amoxicillin [-clavulanate], cefaclor, cefixime, cefuroxime, cefpodoxime proxetil, cefprozil), (2) 4 intramuscular ceftriaxone sodium trials, and (3) 11 oral azithromycin trials. The summary odds ratio for treatment outcomes at 8 to 19 days in children treated with short-acting antibiotics for 5 days vs 8 to 10 days was 1.52 (95% confidence interval [CI], 1.17-1.98) but by 20 to 30 days outcomes between treatment groups were comparable (odds ratio, 1.22; 95% CI, 0.98 to 1.54). The risk difference (2.3%; 95% CI,-0.2% to 4.9%) at 20 to 30 days suggests that 44 children would need to be treated with the long course of short-acting antibiotics to avoid 1 treatment failure. This similarity in later outcomes was observed for up to 3 months following therapy (odds ratio, 1.16; 95% CI, 0.90-1.50). Comparable outcomes were shown between treatment with ceftriaxone or azithromycin, and at least 7 days of other antibiotics.

Conclusion.— This meta-analysis suggests that 5 days of short-acting antibiotic use is effective treatment for uncomplicated acute otitis media in children.

From the Department of Community Health Sciences (Ms Kozyrskyj and Dr Moffatt), Manitoba Centre for Health Policy and Evaluation (Ms Kozyrskyj), the Department of Pediatrics and Child Health (Drs Hildes-Ripstein, Longstaffe, Wincott, Sitar, and Moffatt), and Clinical Pharmacology Section (Dr Sitar), University of Manitoba, Winnipeg, Manitoba; and Department of Pediatrics, Research Institute, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario (Dr Klassen).

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