Antibiotic treatment of acute otitis media in children: to wait or not to wait?

Acute otitis media, the most common bacterial infection in early childhood, is caused in the majority of cases by four bacterial pathogens: Streptococcus pneumoniae, nontypeable Haemophylus influenzae, Moraxella catarrhalis and group A Streptococcus [1,2]. The pendulum on the controversial topic of treating acute otitis media with antibiotics has swung back and forth during the last 50–60 years. The use of antibiotics in the treatment of this condition seems logical, because the role of these agents is to eradicate the causative organisms from the middle ear fluid of infants and children with acute otitis media and, indeed, recent studies showed that failure to eradicate the bacteria early during treatment increases the clinical failure rates in children younger than 2 years of age [3,4]. Of course, in general, the efficacy of the antibiotic therapy is measurable, and may be reported by assessing the improvement in acute otitis media symptoms in children treated with antibiotics and by showing that the percentage of patients with a clinical cure is higher at a certain time point in treated patients when compared with placebo [4,5]. However, a spontaneous cure is common in patients with acute otitis media and previous studies showed that between seven and 20 children must be treated with antibiotics in order for one to derive benefit from the treatment [6,7]. Since broad and sometimes unskilled antibiotic therapy is responsible for the selection of increasingly resistant bacteria, the observation option (‘watchful waiting’) in the treatment of acute otitis media, a strategy already used in Holland, the UK and other European countries since the beginning of 1980s, was reconsidered during the last years [8,9]. The diagnostic keys essential for the management of acute otitis media via the observation method are the certainty of the examining physician on the diagnosis of acute otitis media, patient age and severity of illness. An additional and crucial factor is represented by the ability of the treating physician to see and recheck the patients during the next 24–48 h in order to decide if they are improving or deteriorating and if there is need for initiating the antibiotic treatment during a second visit. The American Academy of Pediatrics recommends the observation option in children older than 6 months of age who do not present with severe illness or in whom the diagnosis is uncertain, and in patients older than 2 years of age without severe illness [10]. In contrast, immediate antibiotic therapy is recommended for children younger than 6 months of age and for all those with a severe form of the disease, due to the association with increased risk of failure when using the ‘watchful waiting’ policy. The broad implementation of the ‘watchful waiting’ policy is still controversial, and the evidence presented in many studies supporting the broad use of this method in the treatment of acute otitis media in children is problematic,