On the Shoulders of Giants
Allowing parents the option to wait and see if their child did not improve or worsened in 48 hours after the diagnosis of acute otitis media in the ED vs. filling the prescription right away resulted in a dramatic reduction in antibiotic use with little downside in this RCT.
Why does this matter?
Antibiotic stewardship matters. Antibiotics are not without side effects, and antibiotic resistance is ever increasing. Most cases of otitis media get better with or without antibiotics. A wait-and-see approach in children reduced antibiotic use by over 50%.
Wait and see...
This was a RCT of almost 300 children 6 months to 12 years in the ED with acute otitis media. Half were told to wait and see (wait-and-see-prescription - WASP) if the child was not better or was worse in 48 hours before filling the prescription. The others were just given the prescription. 62% vs. 13% chose to not fill the prescription in the WASP group vs standard. This represents a dramatic reduction in antibiotic usage. An increase in rare adverse outcomes, like mastoiditis, could have been missed in this small study. Children with immunocompromise, unclear follow up, perforation, toxic appearance, as well as a few other variables were excluded. Be careful if you choose this approach and don't be too cavalier.
Wait-and-see prescription for the treatment of acute otitis media: a randomized controlled trial JAMA. 2006 Sep 13;296(10):1235-41.