Antibiotic Management and Health Disparities in Acute Otitis Media: Implications for Pediatric Care and Pharmacy Practice

Acute otitis media (AOM) is defined as the rapid onset of signs and symptoms of inflammation in the middle ear.¹ It is the most common indication for antibiotics in children, affecting over 5 million children and resulting in greater than 10 million antibiotic prescriptions annually in the United States.²

According to the American Academy of Pediatrics, antibiotic therapy or observation with close follow-up can be offered in children 6 months to 23 months of age with non-severe unilateral AOM, defined as the presence of mild otalgia and a temperature below 39℃.^1,3 The observation period is the initial management of AOM and is limited to symptomatic relief due to a possible viral etiology. Observation is also offered for children 2 years and older with non-severe unilateral or bilateral AOM.^1,3 Commencement of antibiotic therapy is only initiated if the child’s condition worsens at any time or does not show clinical improvement within 48 to 72 hours of diagnosis, which is known as delayed antibiotic prescribing.

A model ear shows how infections can affect the outer and middle ear, leading to conditions such as otitis media. Image Credit: © Arzu - stock.adobe.com

Initial antibiotic therapy, which is treatment of AOM with antibiotics prescribed at the time of diagnosis with intent to start antibiotic therapy as soon as possible, is indicated for children 6 months and older with severe bilateral or unilateral AOM. Severe AOM is the presence of moderate to severe otalgia, otalgia for at least 48 hours, or fever equal to or higher than 39℃.^1,3 First-line initial immediate or delayed antibiotic treatment for AOM is high-dose amoxicillin or amoxicillin-clavulanate (Augmentin; USAntibiotics) 90 mg/kg/day for a 10-day duration for children younger than 24 months, a 7-day duration for children 2 to 5 years of age, and a 5-day course for children older than 5 years of age with mild symptoms.¹ For patients with a history of penicillin allergy, second and third-generation cephalosporins, including cefdinir (Omnicef; Abbvie), cefuroxime (Ceftin; GlaxoSmithKline), cefpodoxime (Vantin; Pfizer), and ceftriaxone (Rocephin; Hoffmann-La Roche Inc) are appropriate options for initial immediate or delayed antibiotic treatment due to the negligible cross-reactivity between penicillins and the second- andthird-generation cephalosporins.⁴ Macrolides, such as erythromycin and azithromycin, have limited efficacy against Haemophilus influenzae and Moraxella catarrhalis.¹ In addition, routine use of azithromycin has been associated with increased resistance to Streptococcus pneumoniae (S pneumoniae).⁵

Differences in antibiotic prescribing by patient’s race and ethnicity, sex, age, socioeconomic factors, geography, clinician’s age and specialty, and health care setting can represent health care inequities.⁷ In a retrospective cohort study that assessed racial differences in antibiotic prescribing, it was concluded that Black children were less likely to receive an antibiotic prescription from the same clinician per acute visit than non-Black children despite adjustment for age, gender, comorbid conditions, insurance, and stratification by practice.⁸ In addition, Black children were also less likely to receive a diagnosis of AOM than non-Black children.⁸ In a cross-sectional study that analyzed children with AOM and commercial insurance, patient populations with a lower social deprivation index score were associated with lower odds of treatment for recurrent otitis media.⁹ Social deprivation index is defined as a composite measure of area level deprivation based on 7 demographic characteristics collected in the American Community Survey, including percent living in poverty, percent with less than 12 years of education, percent of single-parent households, percentage living in rented housing units, percent living in the overcrowded housing unit, percent of households without a car, and percent of unemployed adults under 65 years of age.¹⁰ Inequities in antibiotic prescribing result in increased antibiotic resistance, adverse events (AEs), treatment failures, and complications from AOM.⁷

Overprescribing of antibiotics for AOM can lead to the development of antimicrobial resistant organisms, including penicillin-resistant S pneumoniae, which increases risk of treatment failure.¹¹ In addition, the overuse of antibiotics for AOM is estimated to result in 2.5 million patient-reported AEs annually and increases risk of Clostridioides difficile infections.¹² Undertreatment of AOM can lead to complications regarding AOM, including tympanic membrane perforation, mastoiditis, labyrinthitis, petrositis, meningitis, brain abscess, and hearing loss.¹²

Within pharmacy practice, knowledge and perception of health disparities have been identified as playing an important role in pharmacists’ practice across various settings.¹³ This is significant as pharmacists play a crucial role in antimicrobial stewardship efforts to reduce unnecessary antibiotic use, optimize therapy, and enhance outcomes.¹⁴

REFERENCES

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2. Keith A, Jenkins TC, O'Leary S, et al. Reducing length of antibiotics for children with ear infections: protocol for a cluster-randomized trial in the USA. J Comp Eff Res. 2023;12(11):e230088. doi:10.57264/cer-2023-0088

3. Jamal A, Alsabea A, Tarakmeh M, Safar A. Etiology, Diagnosis, Complications, and Management of Acute Otitis Media in Children. Cureus. 2022;14(8):e28019. doi:10.7759/cureus.28019

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8. Gerber JS, Prasad PA, Localio AR, et al. Racial differences in antibiotic prescribing by primary care pediatricians. Pediatrics. 2013;131(4):677-684. doi:10.1542/peds.2012-2500

9. Qian ZJ, Rehkopf DH. Association Between Social Disadvantage and Otitis Media Treatment in US Children With Commercial Insurance. JAMA Otolaryngol Head Neck Surg. doi:10.1001/jamaoto.2022.3560

10. Griggs S, Al-Kindi S, Hardin H, et al. Socioeconomic deprivation and cardiometabolic risk factors in individuals with type 1 diabetes: T1D exchange clinic registry. Diabetes Res Clin Pract. 2023;195:110198. doi:10.1016/j.diabres.2022.110198

11. Frost HM, Hersh AL. Rethinking Our Approach to Management of Acute Otitis Media. JAMA Pediatr. 2022;176(5):439-440. doi:10.1001/jamapediatrics.2021.6575

12. Jamal A, Alsabea A, Tarakmeh M, Safar A. Etiology, Diagnosis, Complications, and Management of Acute Otitis Media in Children. Cureus. 2022;14(8):e28019. doi:10.7759/cureus.28019

13. Hurley-Kim K, Unonu J, Wisseh C, et al. Health Disparities in Pharmacy Practice Within the Community: Let's Brainstorm for Solutions. Front Public Health. 2022;10:847696. doi:10.3389/fpubh.2022.847696

14. Dighriri IM, Alnomci BA, Aljahdali MM, et al. The Role of Clinical Pharmacists in Antimicrobial Stewardship Programs (ASPs): A Systematic Review. Cureus. 2023;15(12):e50151. doi:10.7759/cureus.5015