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New guidance on antibiotic use for childhood acute otitis media

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With acute otitis media (AOM) being one of the most common childhood diseases for which antibiotics are prescribed, new step-by-step RACGP guidance has been released to help GPs best treat their patients.
 
The latest released topic in the RACGP’s First do no harm: A guide to choosing wisely in general practice is the GP and accompanying patient resource for ‘Antibiotic use for acute otitis media in children’.
 
A new ‘Expansion of disease definitions‘ has also been released.
 
First do no harm was launched in 2022, born out of an understanding that overdiagnosis, interventions with insufficient evidence, and overused tests can lead to patient harm, wasted resources and misunderstandings around health literacy.
 
Each topic, including MTHFR gene testing, vitamin D testing, and opioids to treat chronic non-cancer pain, offers practical guidance for GPs as well as a patient-facing resource which explains why GPs are making their recommendations.
 
Launched this month, the latest guidance for GPs states that doctors should not routinely commence antibiotics for AOM in children aged six months or older ‘who do not have clinical features that place them at increased risk’.
 
‘Do not routinely use decongestants, antihistamines or oral prednisolone for AOM,’ it adds.
 
However, it does say that ‘under specified circumstances’, GPs can adopt a watchful waiting or delayed prescribing approach, with follow-up within 48–72 hours as a ‘reasonable alternative to antibiotics’.
 
GPs are given a ‘green light’ to:

• complete a targeted examination to exclude other conditions, particularly meningitis and mastoiditis
• treat ear pain with age- and weight-appropriate therapeutic doses of oral analgesia
• explain that the usual course of AOM is about three days but can be up to one week
• prescribe antibiotics for patients with high risk factors
• consider prescribing antibiotics for children who have conditions such as a history of recurrent AOM, craniofacial abnormalities, or only one hearing ear
• use a shared decision-making approach where the GP and the patient/carer discuss and consider the benefits and harms of treatment options.

Professor Mark Morgan, Chair of RACGP Expert Committee – Quality Care and of the First Do No Harm Expert Steering Group, told newsGP the release comes as AOM continues to be a common presentation for children in general practice.
 
‘A child screaming in the night with ear pain and fever is distressing,’ he said.
 
‘Patient, parent and carer concerns should never be lightly dismissed. This resource ensures the conversation is backed by evidence to aid shared decision making.
 
‘We know when people get home from a GP consultation there is often a need for one carer to explain what happened to others. The patient-resource is particularly helpful for that further conversation at home.’
 
In response to this need, Professor Morgan said the patient-facing resource has been carefully designed to provide information in a balanced way.  
 
He added that the latest guidance is particularly important as there is a ‘widespread belief in the ability of antibiotics to rapidly cure ear pain and fever’.
 
‘This leads to expectations that GPs will automatically prescribe antibiotics,’ he said.
 
‘There is a risk of decisional conflict if a GP chooses not to prescribe.
 
‘This resource helps GPs and patients and carers to have respectful conversation with important facts highlighted.’
 
The new guidance also runs through the several serious conditions which may cause, or be masked by, AOM such as acute mastoiditis, meningitis, intracranial abscess, sinus thrombosis and facial nerve paralysis.
 
The resource designed specifically for patients explains in simple terms what middle ear infections are, why GPs do not recommend antibiotics in most cases, antibiotic side effects, and answers common questions.
 
The guidance comes as antibiotic overprescribing continues to be a global concern.
 
Pharmaceutical Benefits Scheme data shows that the highest rate of antibiotic dispensing for patients aged less than 65 years is for children aged 2–4 years.
 
Research from the Australian Commission on Safety and Quality in Health Care found that for every 100 children treated with antibiotics only five additional children will be better at 2–3 days as a result of taking antibiotics and the duration of symptoms is shortened by an average of only 12 hours.
 
This month’s release also includes the new ‘Expansion of disease definitions’ resource.
 
This explains that when the definition of a disease expands as the result of emerging clinical evidence, it can result in changes to the thresholds and criteria for a diagnosis of the disease and an increase in the number of people with a diagnosis.
 
‘Although changes to a definition are sometimes required to ensure patients receive the treatment they need (e.g. for a fast-developing condition that requires early diagnosis), they can sometimes lead to low-value care or harm to patients, their families and the health system,’ it states.
 
It goes on to list factors that can contribute to an expansion of a disease’s definition, the possible concerns relating to each factor, and how GPs can manage expanding disease definitions.
 
Overall, Professor Morgan said the guidance was created to be a quickly accessed resource that pulls the latest evidence together, to be used ‘across Australia and beyond’.
 
‘The First do no harm guide is designed to help communicate with patients and carers in a balanced way based on the best evidence,’ he said.
 
‘Each guide has a matching patient resource that is printable or accessed by QR code from the GP’s guide.
 
‘First do no harm is also an excellent learning resource for GP registrars.’
 
The new resources, alongside existing ones, are all available now on the RACGP website.
 
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acute otitis media antibiotics First do no harm overdiagnosis quality care

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