Adherence to clinical guidelines in the diagnosis and management of acute otitis media: a retrospective study in a rural emergency department

Introduction

Acute otitis media (AOM) is a common paediatric presentation with almost 50% of all children having at least one infection before reaching 2 years of age (1). Children in high-income countries can generally be managed without antibiotics, as most cases will spontaneously resolve with low rates of complications. Unnecessary antibiotic usage poses risk of adverse events to children and anti-microbial resistance at a community level (2). However, identification and treatment of children at a high risk of developing chronic suppurative otitis media (CSOM) is necessary due to the long-term impacts of the condition (3). Clinical practice guidelines (CPGs) have been developed to assist clinicians with the diagnosis and management of AOM (3,4). Previous Australian studies have found poor compliance with guidelines (5,6).

Dubbo Hospital is a major rural referral hospital situated in Western New South Wales with an Ear, Nose and Throat service. In 2022–2023, there were approximately 40,000 presentations to the Emergency Department (ED) (7). The health district has an Aboriginal and/or Torres Strait Islander population that is over 11% of the total population (8).

The primary objective of this study was to analyse presentation, diagnosis, and management of children with AOM in a rural ED. The secondary objective was to compare diagnosis and management to established CPGs.

Methods

A retrospective cohort study was performed on children under the age of 16 presenting to Dubbo Base Hospital ED with a diagnosis of AOM. Patient presentations from January 1^st, 2022 to December 31^st, 2023 were searched using the Cerner Discern Analytics 2.0 program, as part of the Cerner Powerchart electronic medical record (EMR). Search terms for discharge diagnoses were “acute otitis media”, “acute bilateral otitis media”, “acute left otitis media”, “acute right otitis media”, “acute otitis media with effusion”, “ear infection”, “otitis media”, “acute suppurative otitis media”, “acute non-suppurative otitis media”, “acute purulent otitis media”, “discharge from ear”, “ear ache”, “disorder of the ear”, “earache of right ear” and “earache of left ear”. The study is reported according to the STROBE reporting guidelines (available at https://www.theajo.com/article/view/10.21037/ajo-24-76/rc).

Inclusion criteria were all patients less than 16 years of age and a documented diagnosis of AOM. Encounters were reviewed on EMR and ineligible patients with alternate diagnoses were removed. Data were collected from patient records on presentation, diagnosis, and management. Presentation variables measured included residential distance from Dubbo, age, sex, presenting symptoms, temperature on arrival, unilateral or bilateral symptoms, duration of symptoms, previous tympanostomy tube insertion, Cochlear implant, immunocompromised, craniofacial abnormalities, Trisomy 21, and previous complications of AOM. Diagnostic variables measured included examination and otoscopy findings. Management variables were total time spent in the ED, experience of the treating doctor, whether the patient was discussed with paediatrics or ear, nose, and throat (ENT) teams, analgesia prescribed, whether the patient was already on antibiotics, antibiotic prescription, delayed prescriptions and re-presentation, or subsequent complications of AOM.

The diagnosis and management were compared to guidelines from the Australian Therapeutic Guidelines (eTG) and Otitis Media Guidelines for Aboriginal and Torres Strait Islander children (3,4). Diagnostic criteria used for the purpose of this study were acute onset of symptoms with bulging of the tympanic membrane or otorrhoea, provided acute diffuse otitis externa was excluded. Management with antibiotics was consistent with the guidelines if patients were younger than 6 months, younger than 2 years with bilateral AOM, systemically unwell (lethargy, pallor, very irritable, inability to tolerate oral intake), had otorrhoea or perforation, high risk of complications (immunocompromised, craniofacial abnormalities, cochlear implant, trisomy 21) and symptoms greater than 72 hours. Management of children who identified as Aboriginal and Torres Strait Islander with antibiotics was considered appropriate due to high rates of CSOM in rural and remote communities.

Data were analysed using R studio (9). Comparison for continuous variables that were not normally distributed on Kolmogorov-Smirnov test was performed using Mann-Whitney U-test. Categorical variable associations were analysed using Pearson’s Chi-squared test or Fisher’s exact test for count data less than 10. Univariate analysis presented as odds ratios (ORs) and 95% confidence intervals (CIs) was used when comparing multiple variables. Missing data were highlighted and excluded from statistical analysis. A P value less than 0.05 was considered statistically significant.

The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This study was reviewed by the Executive Officer of the Greater Western Human Research Ethics Committee (HREC) and advised that no ethical risks requiring submission to an HREC were identified in accordance with NSW Health Policy (GL2007_020) and individual consent for this retrospective analysis was waived.

Results

There were 286 encounters over the search period, with 46 having alternate diagnoses documented, leaving 240 for review. The median age was 3 years [interquartile range (IQR), 1 year 8 months to 6 years], with a slight male predominance (n=133, 55.4%) and 16.3% (n=39) lived more than 50 km from Dubbo Base Hospital. One in ten (n=25, 10.4%) had a previous tympanostomy tube insertion, one patient had a Cochlear implant, four had craniofacial abnormalities, and 5% (n=12) had a previous tympanic membrane perforation as a complication of AOM.

Presentation

Presenting symptoms included otalgia (n=157, 65.4%), being generally unwell (n=97, 40.4%), otorrhoea (n=33, 13.8%), and fever (n=29, 12.1%), with more than one symptom possible. Three-quarters (n=180, 75%) had symptoms for 72 hours or less, and 81.7% (n=196) reported unilateral as opposed to bilateral (n=44, 18.3%) symptoms. Twenty-three (9.6%) children were already on antibiotics prior to presentation, and 35 (14.6%) had a previous ED presentation with AOM. The median temperature on arrival was 36.9 ℃ (IQR, 36.5–37.9 ℃).

Diagnosis

Otoscopy findings included injected tympanic membrane (n=143, 59.6%), middle ear effusion (n=83, 34.6%), discharge in external auditory canal (n=42, 17.5%), bulging tympanic membrane (n=33, 13.8%), and tympanic membrane perforation (n=11, 4.6%) with more than one finding often present (n=119, 49.6%). Otoscopy findings were not documented in 5 (2.1%) of cases and 4 (1.7%) had a normal ear exam. Thirty-one children (13%) were considered systemically unwell. Almost one-quarter (n=54, 22.5%) did not meet diagnostic criteria for AOM. Of these 54 cases, 31 (57.4%) were prescribed antibiotics (Figure 1). Interns and residents were less likely to satisfy diagnostic criteria (OR 0.4, 95% CI: 0.2–1, P=0.029) than registrars (OR 0.8, 95% CI: 0.3–2.1, P=0.434) when compared to emergency specialists and general practitioners. The remainder of the patients were seen by career medical officers and nurse practitioners.

Figure 1 Diagnosis of AOM and corresponding prescribing patterns in a rural emergency department. AOM, acute otitis media.

Management

There were 179 (74.6%) children who met criteria for antibiotics, and of this group, most of them (n=157, 87.7%) were managed with antibiotics. Of the children who did not meet criteria for management with antibiotics (n=61, 25.4%), half (n=31, 50.8%) were prescribed antibiotics (Figure 2). There were 8 children (3.3%) who were treated with intravenous antibiotics, while the rest were prescribed courses of oral antibiotics. Of these eight children who received intravenous antibiotics, four were not tolerating any oral intake and four had a diagnosis of mastoiditis. Factors that were associated with higher likelihood of management with antibiotics included symptoms for greater than 72 hours (OR 4.4, 95% CI: 1.7–15.4, P=0.003), bilateral symptoms (OR 6.7, 95% CI: 2.0–45.4, P=0.001), higher temperature on arrival (median 37 vs. 36.75 ℃, P=0.006), previous tympanostomy tube insertion (OR 6.5, 95% CI: 1.3–158.4, P=0.021), otorrhoea (OR 3.4, 95% CI: 1.3–12.1, P=0.017) and meeting diagnostic criteria for AOM (OR 4.7, 95% CI: 2.3–9.5, P<0.001).

Figure 2 Comparing appropriateness of antibiotic prescribing based on clinical practice guidelines for children with a diagnosis of acute otitis media in a rural emergency department.

There were 4 (1.7%) children who developed mastoiditis as a complication of AOM. Two of the children with mastoiditis were previously on oral antibiotics. Twelve children (5%) were referred to the ED after the initial review. Of the children that were represented, four were not prescribed antibiotics initially, and one child represented with a rash following prescription of antibiotics. Management with or without antibiotics was not associated with representation (OR 0.8, 95% CI: 0.2–3.9, P=0.726) or complication of AOM (OR 0.4, 95% CI: 0.1–6.5, P=0.588).

Of the 188 children who were managed with antibiotics, 159 (84.6%) were prescribed appropriate antibiotics based on guidelines. In terms of analgesia, 140 (58%) were prescribed a combination of paracetamol and ibuprofen, 12 (5%) were prescribed paracetamol alone, 5 (2%) were prescribed ibuprofen alone, and 83 (35%) were not prescribed any analgesia (Figure 3). Children who were not managed with antibiotics were more likely to be prescribed analgesia (OR 4.3, 95% CI: 1.9–10.9, P<0.001).

Figure 3 Analgesia prescribed to children with acute otitis media in a rural emergency department.

Discussion

A high proportion of children in this cohort (74.6%) met the CPG criteria for management with antibiotics and most of them were prescribed antibiotics. Of those children not meeting CPG criteria for management with antibiotics, half were prescribed a course of antibiotics. Almost a quarter of the children did not meet the diagnostic criteria of AOM, and more than half of these children were prescribed a course of antibiotics. Factors associated with antibiotic prescriptions were consistent with the CPGs. Over a third of children were not given any analgesia.

There were several limitations for this retrospective cohort study. Firstly, the retrospective nature of the study poses the risk of selection bias as data were collected from medical records with a high likelihood of missing or inaccurate documentation. This is particularly pertinent as diagnosis and management were assessed based on clinical documentation with no verification of accuracy. In addition, pneumatic otoscopy and tympanometry were not used as diagnostic tools, likely leading to under diagnosis in the cohort. Furthermore, patients were screened and included based on the diagnosis documented in the ED, meaning inaccurate documentation could be a further source of selection bias. In addition to this, comparison to the CPGs for diagnosis and management does not allow for the clinical nuances often required when working in the ED, such as assessment of a patient’s ability to access appropriate follow-up and be safety-netted. Finally, appropriateness of diagnosis and management was derived from our understanding of the CPGs, and certainly there is a degree of interpretability, representing a source of information bias.

Many of the children included in this cohort met CPG criteria for management with antibiotics. This highlights the importance of accurate diagnosis of AOM, particularly in a setting with many high-risk children. A prior Australian study examining management of AOM in urban Queensland found 62% of children received antibiotics, with half of these unlikely to have a diagnosis of AOM (6). Similar results were reflected in our study, with half of the children not meeting diagnostic criteria for AOM being given a prescription for antibiotics. An Australian survey-based study demonstrated variable rates of compliance with CPGs, with overuse of antibiotics being more common than underuse (5). Our study had similar findings, with most children requiring antibiotics being appropriately prescribed antibiotics. The factors associated with antibiotic use were reflective of the current CPGs. Appropriate counselling of parents is required, particularly involving them in shared decision making to ensure that antibiotics are not being inappropriately prescribed. An Australian study found that many parents still believe antibiotics to be the best course of treatment for AOM (10). Particular challenges of working in a rural setting include poorer access to primary care for appropriate follow-up to ensure resolution of AOM, increased reliance on the ED for medical care and vast travel distances required of patients to access appropriate health care (11).

In our cohort, doctors with less experience were less likely to satisfy appropriate diagnostic criteria. AOM can be challenging to diagnose and in cases of diagnostic uncertainty, senior medical review may be required to prevent the prescription of unnecessary antibiotics (12). In our cohort, there was an under-prescription of analgesia. A study of General Practitioners in the Netherlands found that many doctors were unaware of the need to manage symptoms with analgesia and not rely on antibiotics alone (13). Patients managed with antibiotics in our cohort were significantly less likely to be prescribed analgesia (OR 4.3, 95% CI: 1.9–10.9, P<0.001), possibly reflecting a need to increase education about the importance of supportive measures. Overall, there were low rates of complications and representations with no significant difference between children managed with or without antibiotics. Similar findings were elicited in a meta-analysis, which demonstrated high number needed to treat to prevent serious complications of AOM (14).

There is limited generalisability of our study to the general population. Our study was representative of a high-risk cohort where most children required treatment with antibiotics. However, it does offer valuable insights into the need for adaptability when working in rural environments.

Conclusions

Overall, there was reasonable compliance with CPGs in the cohort. This study highlights the uniqueness of working in rural settings and the management of children at high risk for complications of AOM. Further education on otoscopy and diagnosis of AOM for junior doctors is required, as well as the role of analgesia in the management of AOM.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://www.theajo.com/article/view/10.21037/ajo-24-76/rc

Data Sharing Statement: Available at https://www.theajo.com/article/view/10.21037/ajo-24-76/dss

Peer Review File: Available at https://www.theajo.com/article/view/10.21037/ajo-24-76/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://www.theajo.com/article/view/10.21037/ajo-24-76/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This study was reviewed by The Executive Officer of the Greater Western Human Research Ethics Committee (HREC) and advised that no ethical risks requiring submission to an HREC were identified in accordance with NSW Health Policy (GL2007_020) and individual consent for this retrospective analysis was waived.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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