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Wait-and-See Prescription for the Treatment of Acute Otitis Media
A Randomized Controlled Trial
David M. Spiro, MD, MPH;
Khoon-Yen Tay, MD;
Donald H. Arnold, MD, MPH;
James D. Dziura, PhD;
Mark D. Baker, MD;
Eugene D. Shapiro, MD
JAMA. 2006;296:1235-1241.
Context Acute otitis media (AOM) is the most common diagnosis for which antibiotics are prescribed for children. Previous trials that have evaluated a "wait-and-see prescription" (WASP) for antibiotics, with which parents are asked not to fill the prescription unless the child either is not better or is worse in 48 hours, have excluded children with severe AOM. None of these trials were conducted in an emergency department.
Objectives To determine whether treatment of AOM using a WASP significantly reduces use of antibiotics compared with a "standard prescription" (SP) and to evaluate the effects of this intervention on clinical symptoms and adverse outcomes related to antibiotic use.
Design, Setting, and Patients A randomized controlled trial conducted between July 12, 2004, and July 11, 2005. Children with AOM aged 6 months to 12 years seen in an emergency department were randomly assigned to receive either a WASP or an SP. All patients received ibuprofen and otic analgesic drops for use at home. A research assistant, blinded to group assignment, conducted structured phone interviews 4 to 6, 11 to 14, and 30 to 40 days after enrollment to determine outcomes.
Main Outcome Measures Filling of the antibiotic prescription and clinical course.
Results Overall, 283 patients were randomized either to the WASP group (n = 138) or the SP group (n = 145). Substantially more parents in the WASP group did not fill the antibiotic prescription (62% vs 13%; P<.001). There was no statistically significant difference between the groups in the frequency of subsequent fever, otalgia, or unscheduled visits for medical care. Within the WASP group, both fever (relative risk [RR], 2.95; 95% confidence interval [CI], 1.75 - 4.99; P<.001) and otalgia (RR, 1.62; 95% CI, 1.26 - 2.03; P<.001) were associated with filling the prescription.
Conclusion The WASP approach substantially reduced unnecessary use of antibiotics in children with AOM seen in an emergency department and may be an alternative to routine use of antimicrobials for treatment of such children.
Trial Registration clinicaltrials.gov Identifier: NCT00250900
Author Affiliations: Departments of Pediatrics (Drs Spiro, Tay, Dziura, Baker, and Shapiro), Epidemiology and Public Health (Dr Shapiro), and Medicine (Dr Dziura), Yale University School of Medicine, New Haven, Conn; and Departments of Emergency Medicine and Pediatrics, Vanderbilt University School of Medicine, Nashville, Tenn (Dr Arnold). Dr Spiro is now with the Departments of Emergency Medicine and Pediatrics, Oregon Health and Science University, Portland.
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